PNHP

Obamacare adding to crisis of confidence in government

Obamacare adding to crisis of confidence in government

Majority in U.S. Say Healthcare Not Gov’t Responsibility

By Joy Wilke
Gallup, November 18, 2013 Poll: Do you think it is the responsibility of the federal government to make sure all Americans have healthcare coverage, or that it is not the responsibility of the federal government? Year   Yes No
2001   62  34
2002   62  35
2003   59  39
2004   64  34
2005   58  38
2006   69  28
2007   64  33
2008   54  41
2009   47  50
2010   47  50
2011   50  46
2012   44  54
2013   42  56
(Polls were taken in November each year) The 56% of U.S. adults who now say it is not the federal government’s responsibility to make sure all Americans have healthcare coverage continues to reflect a record high. Prior to 2009, a clear majority of Americans consistently had said the government should take responsibility for ensuring that all Americans have healthcare. The most recent data were collected in Gallup’s annual Health and Healthcare poll, conducted Nov. 7-10. The percentage of U.S. adults who said it is the federal government’s responsibility to ensure all Americans have healthcare coverage peaked at 69% in 2006. Attitudes began to shift significantly in 2007, and continued to change through the time President Barack Obama took office in 2009. Americans who feel healthcare coverage is not the federal government’s responsibility have been in the clear majority the past two years. Attitudes across all three partisan groups have shifted away from the view that ensuring healthcare coverage is a proper role of government, but most significantly among Republicans and independents. In September 2000, 53% of Republicans believed the government should not be responsible for ensuring all Americans had health coverage; today, 86% feel that way, an increase of 33 percentage points in 13 years. Over the same period, the percentage of Republicans believing the government should ensure healthcare coverage for all has fallen from 42% to 12%. Fifty-five percent of independents currently say the government should not be involved with healthcare — an increase of 28 points since 2000. The percentage of Democrats who hold this view is now 30%, its highest level since Gallup first asked the question and an 11-point increase since 2000 — with the largest change in opinion occurring between 2006 and 2008. Implications Americans’ attitudes toward the government’s role in ensuring all Americans have access to affordable healthcare have changed substantially over the past decade. These changes began before the Affordable Care Act was passed in 2010, and concurrently with the financial crisis of 2008 and Obama’s first presidential campaign and election. Although Democrats are now somewhat more likely compared with 2000 to say the government should stay away from healthcare, much of the shift in attitudes against government intervention has stemmed from changes among Republicans and independents. It is possible that this sharp change has been caused by a politicization of the issue as it became a major part of Obama’s campaign platform, and as he and other Democratic leaders pressed for and passed the ACA, sometimes called “Obamacare,” in 2010. The continuing implementation of the ACA over the coming months and years will surely continue to shape Americans’ attitudes toward the federal government’s role in this area. It is not clear how the ACA’s troubled rollout to date will affect attitudes over the next year. But as the debate about the implementation of the new healthcare law has unfolded, Americans have become less likely than ever to agree that the federal government should be responsible for making sure that all Americans have healthcare. http://www.gallup.com/poll/165917/majority-say-healthcare-not-gov-responsibility.aspx Link for graph of trend since 2000: http://content.gallup.com/origin/gallupinc/GallupSpaces/Production/Cms/POLL/fplxc0ofzkq4zsfgrlrtka.png

Obama’s Gift to the Republicans

By Robert Kuttner
Huff Post Politics, November 17, 2013 The Affordable Care Act, as a government mandate for people to purchase private insurance with an array of possible subsidies, had too many moving parts. It was an accident waiting to happen. As many of us wrote at the time, Medicare for All would be simpler to execute, easier to understand, and harder for Republicans to oppose. But this was not to be. Instead we got a program that was poorly understood by the public because it was almost impossible to explain and even harder to execute. At the time the law was passed, administration leaders and many commentators compared the Affordable Care Act to Social Security and Medicare. The analogy was never apt. These great achievements are public programs, efficient to administer and testament to the fact that government can serve social objectives far more effectively than the private sector. Obamacare, by contrast, is the inefficiency of “public-private partnerships” at its worst. It is a public subsidy for the private insurance industry. No fewer than 55 separate contractors were hired to design the software. Yet though it is not a true public program worthy of the name, Obamacare is being used to discredit government. http://www.huffingtonpost.com/robert-kuttner/obamacare-republicans_b_4293314.html?wpisrc=nl_wonk

Comment:

By Don McCanne, M.D Although we always have to be careful that we don’t read too much into polls, this particular result showing that a majority of Americans have decided that health care is not the responsibility of the federal government does provide support to Robert Kuttner’s statement, “Obamacare is being used to discredit government.” Looking at the graph (link above, or use the columns of numbers above), in November of 2009 opinions shifted. This was close to the completion of the enactment of the Affordable Care Act, following a summer of vicious, partisan and tea party “death panel” attacks on the proposed reform legislation. In the past two years, as opponents kept up their shrill attack on Obamacare, the divide became even greater. The last poll showing a 14 percent margin for those believing that health care coverage should not be a responsibility of the federal government was taken one month after the bungled rollout of Healthcare.gov. Many have suggested that once the computer glitches are ironed out, people will be very pleased with Obamacare, and the surge in anti-government views will subside. Anyone who has followed the reform process knows that couldn’t be true. Anger will increase when people find out that their deductibles are unaffordable, that some of their hospitals and physicians have been shut out of the provider networks, and that costs will continue to escalate for lack of adequate policies to contain costs. For us to remain on the sidelines to let this play out can only intensify the view of the public that the federal government should not be involved, considering how badly our leaders have screwed up this effort. Especially at this time of intense anger and disgust over the botched rollout, it is imperative that we immediately intensify our efforts to get the public to understand that they are right when they critique Obamacare. Much more importantly, we need for them to understand the differences between good governance, bad governance, and too little governance, when it comes to health care. Decades of too little governance is why our health care system is in the mess it is. Further reducing the role of government can only compound the problems of high co sts, poor quality, and impaired access. We need government to be involved, but in the right way, not the wrong way. Since the neo-liberals took over the Democratic party, “the era of big government is over.” They rejected a model based on the most popular health care program this nation has seen – Medicare. They decided that we needed a public/private solution – private insurance with a welfare program for those who couldn’t financially support the insurance industry. The progressives lost their spine and joined in, realizing that the neo-liberals controlled their party. This set us up for bad governance. The blame does not lie with the institution of government, but it lies with bad decisions made by the people we selected to run the government. So what should our message be to those who say that it is not government’s responsibility? The private insurers have had over half of a century to prove their worth, and they’ve failed us miserably. We need the government, but it needs to be OUR government. We need to demand Medicare for all from our politicians, or, failing that, we need to replace them. We need the support of the people – the majority who now believe that the government isn’t the solution. Our most intensive efforts must be directed to educating people that they are spending far too much on the private insurers for too little in return. In contrast, Medicare offers us a much better deal, but it can be improved. After all, it is our government, and we should have control. The responsibility lies with the people. We need to exercise that responsibility through a government that is of the people, by the people and for the people. We need to dump the anti-government rhetoric because we’re talking about ourselves.

]]>

Medicaid expansion focus of rally at Statehouse

By Dann Denny
Herald-Times (Bloomington, Ind.), Nov. 19, 2013
 
Physician Rob Stone is among a group of Medicaid-expansion advocates who are gathering from 1 to 2 p.m. Tuesday at the Statehouse to urge Gov. Mike Pence and the Indiana Legislature to expand Medicaid in the Hoosier state.

“We’re aiming for 1,000,” said Stone, a Bloomington physician and director of Hoosiers for a Commonsense Health Plan. “I’d be surprised if we get that many, but I’ve love to see several hundred show up.” It was several weeks ago that Stone suggested having the Statehouse rally, phoning in the idea to a gathering of a statewide coalition called Cover Indiana at the AARP headquarters in Indianapolis. Hoosiers for a Commonsense Health Plan is a member of Cover Indiana, as are groups such as the AARP, United Way of Indiana, League of Women Voters and Indiana Hospital Association. When Stone suggested the grassroots gathering take place in February, Indiana state Rep. Ed Clere — a Republican from New Albany representing District 72 — suggested Nov. 19 because that is the day Indiana lawmakers meet to organize the legislative session. Others at the meeting concurred. “I’m excited,” Stone said. “I don’t plan on pulling out Kryptonite and chaining myself to the governor. I just want to talk to some people and urge them to really think about this issue, because we have to find a way to make this happen.”

Stone said he’s been encouraged by the actions of Clere, who’s been traveling around the state for the past few months telling different groups that his party has it wrong on Medicaid expansion. “I think the political landscape may be changing,” Stone said. “Last year, the governor said he did not like Medicaid expansion and his party had a supermajority in the House and Senate, so it appeared as if nothing would happen. But now, with Ed Clere going all over the state saying his party has it wrong, and Republican governors in Ohio and Michigan expanding Medicaid even though they’re not fond of the Affordable Care Act, there may be a chink in the Republican Party’s armor.” Stone and his wife, Karen, are leaving Tuesday morning for Indianapolis, where they will have a face-to-face meeting at 8:45 a.m. in the Statehouse with District 60 state Rep. Peggy Mayfield to talk about Medicaid expansion. Stone said he’s hoping Pence will follow the lead of Republican John Kasich, governor of Ohio, who found a way to expand Medicaid despite stiff resistance from the Ohio Legislature. “He tried to convince the Republicans who control the House and Senate to expand Medicaid, but ran into a brick wall,” Stone said. “But he found a way to free up some funds and expand the program without the full cooperation of the Legislature. He said when he’s at the Pearly Gates, he will not be asked what he did to make government smaller but what he did to take care of the people in his state.” Stone said if Indiana, which now has about 800,000 uninsured residents, would expand Medicaid to include adults living at or below 133 percent of the federal poverty level — which states have the option of doing under the Affordable Care Act — it would provide coverage for 300,000 to 400,000 more Hoosiers. The federal government would cover 100 percent of the cost of expanding the program during the first three years, and then Indiana would have to begin paying a gradually increasing share that tops out at 10 percent of the cost. “That will cost Indiana taxpayers between $50 million and $150 a million a year, which is certainly not chicken feed,” he said. “But it would bring an estimated $1.7 billion a year in federal money into Indiana’s Medicaid program. That would mean more than $11 of federal funds for every $1 of Indiana taxpayers’ money.”
He said the added cost to Hoosier taxpayers could be largely offset with a $121 million cigarette tax earmarked for the Healthy Indiana Plan, and $48 million in a high-risk insurance pool. “Basically, Medicaid expansion is a deal too good to refuse,” he said.

Stone said when hospitals voluntarily endorsed the Affordable Care Act in 2009, they did so with the understanding that cuts to their Medicare reimbursements would be offset by an expansion of Medicaid. “Now many hospitals, particularly small county hospitals, in the 20-some states that have not expanded Medicaid are at risk,” he said. “If Indiana does not expand Medicaid, there may be 20 to 30 small hospitals that may go out of business, and these hospitals are often the largest employer in the town with the highest-quality jobs.” Healthy Indiana Plan Gov. Pence has said he wants to use the state’s up-and-running Healthy Indiana Plan as a vehicle for Medicaid expansion. “The Healthy Indiana Plan now covers about 38,000 of the 800,000 uninsured Hoosiers, so it would have to grow much larger,” Stone said. “And to meet the requirements of the ACA, it would have to undergo some big changes. For example, it would have to cover pregnancies, which it currently does not cover.” http://www.heraldtimesonline.com/news/local/medicaid-expansion-focus-of-rally-tuesday-at-statehouse/article_132c4d50-1059-53f7-87c8-c95d3b19c535.html

]]>

Obamacare is the Trojan horse for what!?

A Conservative Cure for Obamacare

By Paul Howard & Yevgeniy Feyman
Bloomberg View, November 18, 2013 The Patient Protection and Affordable Care Act is floundering. Conservatives who take satisfaction in that should be careful not to get ahead of themselves. The rollout problems – however serious and continuing – shouldn’t be confused with the law’s outright collapse. The reality is that large constituencies are in place to work to preserve Obamacare. What strategy, then, would move us closer to the patient and consumer-focused health-care system that conservatives desire while also recognizing the facts on the ground? The answer might be simple: Propose changes that will make plans more affordable and drive enhanced competition among insurers and providers. In other words, make Obamacare a Trojan horse for conservative health-care reform. The administration of President Barack Obama has quietly introduced regulatory decisions that have made the exchanges a viable market for high-deductible, health-savings-account-eligible health plans. Shortly after the law passed, it looked like the administration would use regulatory rule-making to kill health savings accounts. But subsequent rules clarified that HSA-qualified plans were actually the default structure for bronze plans on the exchanges. (Some silver plans qualify, too.) Far from being driven to extinction, high-deductible, HSA-eligible plans have an opportunity to capture significant new market share on the exchanges. Conservatives aren’t going to repeal or replace Obamacare anytime soon. But they can propose smart fixes that build on the HSA-friendly exchange architecture to make the law more consumer- and patient-friendly. Reform from the inside can set the stage for even bigger changes in the not-too-distant future. http://www.bloomberg.com/news/2013-11-18/a-conservative-cure-for-obamacare.html

Comment:

By Don McCanne, M.D. In recent months, many conservatives have been attacking Obamacare as being a Trojan horse that will open up health care to single payer, even though actually it has taken us further in the wrong direction to a private insurance-dominated market. This article from the Manhattan Institute more accurately describes Obamacare as a Trojan horse taking us to high-deductible, health-savings-account-eligible health plans, often referred to as consumer-directed health plans. But let me clarify that. The low actuarial value plans that will dominate the Obamacare exchanges are high-deductible plans that already are or with very little tweaking will be eligible for associated health savings accounts (HSAs). HSAs work well for wealthier people who can take advantage of the tax incentives, and who remain healthy so that they can use the accumulated tax-advantaged funds in retirement. But families with more modest incomes will be selecting the low-actuarial value bronze and silver plans only because of the lower premiums. They will receive little or no tax benefit, and if major illness strikes, they may not be able to afford the out-of-pocket expenses, even if qualified for subsidies. From a health policy perspective, the HSA component can be ignored. Except for tax incentives for the rich, the HSA is really only cash to be used for out-of-pocket payments. Even if funded by the employer, it is still paid by the employee in the form of forgone wage increases. So it is the high-deductible and not really the HSA that has such perverse consequences – patients forgoing care because of not having the money to pay the deductible, – whether having an empty pocket or an empty HSA. What is particularly disconcerting is that it always was intended that the exchange plans be high-deductible plans, simply to control premium costs. Also, employers are now rapidly converting to high-deductible plans for the same reason. The consumer-directed advocates no longer need to hide in a Trojan horse since the deductibles are already highly visible. Right before our eyes, it has been the Trojan army of deductibles that has been conquering our health security, placing those with health care needs in servitude. The Trojan horse came, and the neo-liberals pretend they didn’t even see it.

]]>

Obamacare or Medicare for All?

By Jerome P. Helman, M.D.
Los Angeles Times, Letters, Nov. 16, 2013 Re “Obamacare’s dismal stats,” Editorial, Nov. 14: With federally fabricated smoke and mirrors, and with the persistent use of unintended consequences as excuses, Obamacare is truly a sinking ship. No amount of spin can save it now. We must look to reparation. The Times’ editorial could have noted that many people who are leaving the individual insurance market or who are being dumped by their carriers have policies that conform to the Affordable Care Act. Health insurers have relentlessly increased the individual policy premiums to the point of being unaffordable. The Times also mentions that the insurance options on the exchanges for small businesses have been narrowed. This “narrow network” tactic is nothing new; it has been used by health insurers since preferred provider organizations in the 1970s began to discount reimbursements to physicians and hospitals. This had nothing to do with quality or efficiency, but it did limit access to care and effectively rationed care to the individual. We should not sit idly by. The time has come to eliminate the complicit health insurers, place price controls on medications and medical equipment, and make hospitalization affordable to all. We need single-payer now: Medicare for all. Jerome P. Helman, M.D., resides in Venice, Calif. http://www.latimes.com/opinion/la-le-1116-saturday-obamacare-20131116,0,1961427.story#axzz2l1Xrg4dG

]]>

Two years later: Reflections on Occupy

Truthout, Nov. 16, 2013 PNHP note: Here are three items of special interest to single-payer supporters who were involved with, or followed, the Occupy Wall Street movement.

Two Years After the Eviction of OWS, Here’s 5 People Keeping the Movement Alive

By Kathleen Ann Bradley
Yes! Magazine It was a cold night in late January 2012. The New York subway doors opened and a tall, dark-haired, 30-ish young man dressed entirely in black—leather jacket, jeans, and boots—stepped into the car. Hanging from his backpack were an orange plastic bullhorn and a small drum; tied on top was a thin sleeping mat. He was one of the small army of Occupy Wall Streeters who had been driven from the park on November 15—two years ago today. He and some friends had been camping out in a vacant house to prevent the bank from foreclosing on it, he told us, but the winter weather had forced them to leave. After protesters like him were evicted, no one knew where the movement was going and what it was going to do next. Two years later, though, the answers to those questions are beginning to become clear. One way to get a handle on what became of the Occupy movement is to track the continuing work of its participants, five of whom we’ve profiled here. All of them were active in Occupy encampments, and now they are focused on channeling the energy and commitment to direct social action that fueled the movement into ensuring that Occupy groups born in the parks will continue to grow and work for lasting change. Laurie Wen: Healthcare for the 99% Just a week or so into the occupation, Laurie Wen and other members of Physicians for a National Health Program joined a solidarity march and then camped out overnight in Zuccotti Park to advocate for single-payer, publicly financed universal health insurance. “That is still the mission of the group,” she says. At the group’s speak-outs and teach-ins in parks around the city, doctors and patients talked about what is wrong with the nation’s healthcare system and how to fix it. “The doctors would talk about how painful it is to see their patients suffering because they don’t have enough insurance or have the wrong kind,” Wen says. During “99 Doctors Give Flu Shots to the 99%,” an event the group held on November 13, 2011, members gave a couple hundred flu shots to people in Zuccotti Park. They also held rallies and marches—some targeting private insurance companies “because their mission is profit, not necessarily to provide care,” Wen says. “And that very much jibes with the central tenet of OWS—corporate greed versus human need.” Physicians for a National Health Program continues to advocate for putting human needs first, she says. Right now they’re working on a bill that would provide universal single payer healthcare in New York state, and pushing for its passage. “We have majority co-sponsorship in the New York State Assembly—enough legislators to pass the bill if Speaker Sheldon Silver would just bring it to the floor.” The group also supports the proposed “Robin Hood tax” on financial speculation. “That money could very well fund a lot of human needs,” she notes, “including health care.” Full: http://truth-out.org/news/item/20084-two-years-after-the-eviction-of-ows-heres-5-people-keeping-the-movement-alive *****

Reflections on Occupy

By Katie Robbins
At the Heart of an Occupation blog, Oct. 14, 2013 I started showing up at Liberty Square a few days after the occupation began. I was living in New York and working on single-payer universal health care and had been doing that for about four years. I had basically come to the realization that the political process was broken, that in order to have any sort of fair debate about how to provide health care to people in this country we would have to have some serious change in the political process and in the influence that corporations have over that process. I had followed the debate of the biggest players—the pharmaceutical companies, the hospitals, the insurance companies making a law that would benefit their interest and not the people or the people’s health. Anytime we tried to insert our message, we ran into brick walls. I was actually arrested in Congress in 2009 trying to get Max Baucus to let doctors and nurses testify on behalf of the need for a universal health care system. The tactic of camping out and occupying a space had been used in New York City and other places before Occupy Wall Street started. There was the Bloombergville demonstration at City Hall a year prior. I was excited to see people coming together, but I didn’t quite see how I fit in until there was a movement happening. It was so exciting. I showed up with friends of mine, and we started to navigate through the aspects of what it would look like to have a specific working group around healthcare, and we started Health Care for the 99%. We supported the work of the medic tent. We helped with supplies. When we did engage people who were medical professionals or had some kind of training, we would make sure that they knew that the medic tent was always looking for volunteers. We also worked on the more political aspect of the health care system that’s dominated by corporate interests. We raised awareness around that.Just looking at the signs people had at Zuccotti Park showed how important health care was to people there. I remember a woman holding a sign that said, “The dogs I walk have health insurance, but I don’t.” We had a pretty tremendous response from the beginning on the issue of health care. We had a really active working group that met weekly, sometimes more than weekly for more than a year. We’re still around, but there aren’t regular meetings. We will come together as Health Care for the 99% when we can. We had founded the group in late September of 2011. A few weeks later, we called for a demonstration on health insurance companies to protest their greed and their denial of care to people, and we had five hundred people show up for this demonstration, and we marched for a while. Across the street from Liberty Square is a Blue Cross Blue Shield office, which is a subsidiary of the largest private health insurance company in the country, so we started there and marched up to St. Vincent’s Hospital. It had been closed a few years ago to be turned into luxury condos, leaving the lower west side without a hospital, which is really a public health crisis in New York City—to have that much space without an emergency room to help people. That hospital had such a long history of being a part of the community. It was really devastating to see that kind of decision made, seeing something people so desperately need to have in their community taken away from them, turned into the last thing that we need more of in this city, which is more condos. The hospital closing issue is still going on, and people in our group are still very involved with that. There are hospitals being closed in Brooklyn illegally. In addition to that, we had speak-outs for consciousness-raising.  We would come together, and people would step forward and share their health care testimonial. It was such a powerful process. We still have this network of people that continue to work in some capacity with health care. Doctors, nurses and health professional have been involved. There have been existing groups in New York for some time, like the New York State Nurses Association and National Nurses United, who are hugely important for getting energy going. There’s also Physicians for a National Health Program and Health Care Now. They’ve all been working on this issue, but Occupy helped to solidify and bring a lot of people together that hadn’t been working together. It was an important time. Occupy helped to bring attention to the deep inequality in the country. The majority of the people have been so left out of the process and so marginalized. Anytime we can model and put into motion alternative ways of living or organizing ourselves is a really important exercise in thinking about developing another world, which is probably going to be a reality for us at some point. A lot of people talk about the unsustainability of our lifestyle. There are probably going to be some big changes because it’s not possible to continue our way of life forever. I think it’s really important that people come together and really imagine alternative ways of existing that don’t rely on capitalism. In the United States, unlike any other developed industrialized countries, we rely on a totally commoditized health care system. We have rationing based on if you can pay for health care. If you can’t pay for it, then you’re not going to get it. We do have programs to assist people who might have trouble paying, but they are very limited. It’s very hard to be eligible. There’s inconsistency and restrictions in care. The kind of profits being made off of health care, off of sick people, are huge, and that in and of itself is a totally moral crisis. Just the morality of the health care system, the fact that it’s based on requiring payment in order to receive care from the individual to the provider is immoral, but there’s also the economic crisis, which is that we spend twice as much as any other country on health care, but we get so much less. We have huge numbers of people who are totally uninsured. Even after the Affordable Care Act or Obamacare is implemented, they are estimating around 30 million people will remain uninsured. In addition, we will have a new growing concept of underinsured, which is people who have insurance and pay a lot of money for this insurance but still can’t afford to use that insurance because of the financial barrios—co-pays, huge deductibles. All of those things really add up, and people are going to have a really difficult time making ends meet even though they supposedly have this insurance, which is supposed to protect you from bankruptcy and guarantee that you get the health care you need when you need it, but private health insurance doesn’t do either. About 60% of bankruptcies are due to medical debt. When most of those people filed for bankruptcy, they had health insurance. That problem isn’t going to go away, unfortunately, even with the changes that we’re seeing to the health care system through Obamacare. There’s an increase in consolidation of corporate power within the health care system. I hear the expression that patients are treated more and more like widgets as electronic medical records are utilized. The way it’s being implemented is that the doctor or the nurse is so engrossed in a database and entering information into a computer that they’re not even looking at the patient to see what’s going on with them. That’s not good health care. People will have to think about alternative means of caring for themselves, quite frankly. We just won’t be able to get it form the system. We need to think creatively about how we make sure it’s still available to people. For me personally, I have a $15,000 annual deductible for my family, so we ration care all of the time, and it resets every year. We are so on the brink of bankruptcy should we ever have a serious illness. Our insurance works best for us when we don’t use it, so we just try to avoid using it as much as possible. I’m a student in Public Health, so I don’t do a lot of direct care service, but I know that there are a lot of doctors and nurses who can tell you a new story everyday about how the lack of insurance or the restrictions of a private health insurance company have hurt the patient, either by delaying the care that they need, costing too much or lack of insurance preventing them the care that they need totally. I would like to see a world that meets human needs, where we think logically about how to use our resources collectively, where we can imagine a way of exchanging services not based on a monetary foundation, where we realize that there are other ways to measure human experience and enhance our lives and make us be full human beings living with dignity. For me, what it would feel like is the energy that I put in, the work that I do would be rewarded by society. I wouldn’t have to choose between rent or health insurance. I wouldn’t have to make a decision to skip a meal, so that I can pay my electric bill. These kinds of choices would be eliminated, and there would be a fair system rewarding people on the work they do. That includes things that we consider work now and things that we don’t. Women, for example, raise up an entire generation of people in this country for free. I imagine that there would be a more fair social contract with the people around us, and that could take a lot of different shapes. It’s more about the principles of fairness and not ignoring the work we do to exist and be part of a society. For me, it would mean that I would have more time and less stress. Maybe I could create things. I love to paint. I like to garden, and I rarely get to do the things that I most want to do. People would be able to pursue their actual interests. Occupy made me realize that I should value the parts of my life in ways that society may not. Another world IS possible. http://attheheartofanoccupation.blogspot.com/2013/10/katie-robbins.html *****

Occupy’s ‘Strike Debt’ buys debt cheaply… then forgives it

RT America, Nov. 14, 2013 (video) http://www.youtube.com/watch?v=VaFGC8jGS3k Jacques LaRoche of Strike Debt talking about the Rolling Jubilee’s recent purchase of medical debt.

]]>

Insurer Cuts Medicare Plan Doctors — Patients Left In Lurch

By Miranda Rosenberg
The Hartford Courant, Nov. 15, 2013 While most Americans have been focusing on the recent problems surrounding the rollout of the new healthcare.gov website, another health insurance story has been largely overlooked. Last month, just as Medicare’s open enrollment period was set to begin, UnitedHealthcare dropped thousands of physicians nation-wide, including thousands in Connecticut, from its Medicare Advantage programs without an explanation. Who are these physicians and why were they dismissed from United’s Medicare Advantage plans en masse without being dropped from any of United’s commercial programs? Company executives remain notably tight-lipped despite public inquiries from physicians, newspapers and lawmakers. Connecticut’s five-member congressional delegation and attorney general have become involved. Based on the information available, it is clear that the company’s end goal is to unload its sickest, costliest patients. Typically insurance companies entice patients to join by including large networks of highly regarded providers. United’s doctor drop, however, accomplished almost the exact opposite, wiping out entire services in some areas and removing the most talented physicians from the network. Many of the physicians in question carry United’s premium designation, the company’s official recognition of excellence in “quality of care and cost efficiency.” In Florida, United dropped an estimated 45 percent of its Medicare Advantage provider network, including the nationally renowned Moffitt Cancer Center in Tampa. United also dropped the only nephrologists in Connecticut’s greater New Britain area as well as the entire Yale Medical Group, which represents more than 1,000 physicians on the faculty of the Yale School of Medicine. It is not only specialists that United is targeting — more than a third of the 2,250 physicians dropped in Connecticut are primary care providers. What does this mean for patients? Thousands of senior citizens now must either find new in-network physicians, enroll with a different company’s Medicare Advantage plan, or go back into traditional Medicare before open enrollment ends on December 7th. Finding a new doctor can be challenging because many doctors, especially primary care physicians, either do not accept new patients or have long waiting times for new patient appointments. Many of our nation’s seniors have complicated, ongoing health problems and complex medical histories — they cannot afford to wait months to see a new doctor. Their current physicians are familiar with their health needs; abruptly changing doctors only serves to disrupt their care. The healthiest patients who rarely need medical care are more profitable for United; these patients may not have developed strong physician-patient relationships. Patients undergoing costly, long-term treatments such as dialysis and chemotherapy, however, are more likely to choose to leave United’s Medicare Advantage programs in order to stay in the care of their current physicians. When Medicare Advantage programs debuted, they tended to attract younger, healthier patients. Now that those patients are getting older and sicker, the cost of their care is increasing, pushing United to look for a way to remove them selectively from their coverage programs. If managed care is meant to represent successful health maintenance, however, then the patients United has been covering for the past decade should be healthier than average. United should enact policies that aim to retain these policyholders rather than drop physicians in order to encourage the patients to go elsewhere for coverage. Getting expensive patients to leave the United network enables United to maximize its own revenue and protect its 2014 projected earnings, but it comes at the expense of the other insurers and traditional Medicare which will be forced to absorb this high-cost patient population. Ultimately, what United has done is enact a back door plan to unload the sickest, costliest patients and put the financial burden back onto traditional Medicare and other health insurance companies. Miranda Rosenberg of Philadelphia is a first year student at the Perelman School of Medicine at the University of Pennsylvania with a research focus on health policy. http://www.courant.com/news/opinion/hc-op-rosenberg-insurer-cuts-doctors-patients-left-20131115,0,4306559.story

]]>

The United States is worse in access, affordability and insurance complexity

Access, Affordability, And Insurance Complexity Are Often Worse In The United States Compared To Ten Other Countries

By Cathy Schoen, Robin Osborn, David Squires, and Michelle M. Doty
Health Affairs, December 2013 (online November 13, 2013) The United States is in the midst of the most sweeping health insurance expansions and market reforms since the enactment of Medicare and Medicaid in 1965. Our 2013 survey of the general population in eleven countries — Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States — found that US adults were significantly more likely than their counterparts in other countries to forgo care because of cost, to have difficulty paying for care even when insured, and to encounter time-consuming insurance complexity. Signaling the lack of timely access to primary care, adults in the United States and Canada reported long waits to be seen in primary care and high use of hospital emergency departments, compared to other countries. Perhaps not surprisingly, US adults were the most likely to endorse major reforms: Three out of four called for fundamental change or rebuilding. Insurance Design And Affordability In this study, US adults — both the insured and the uninsured — were more likely than adults in other countries to report going without care because of costs, having high out-of-pocket costs, and having difficulty paying medical bills. Reforms scheduled under the Affordable Care Act provide for subsidies to lower cost sharing for those with incomes below specified thresholds as well as reductions in premiums for people with low or modest incomes. However, by international standards, cost-sharing exposure will remain high for those with low incomes. Also, states will have considerable leeway in insurance design for middle- and high-income families, with annual out-of-pocket maximums and deductibles that will continue to be high compared to those in other countries. For people with chronic, ongoing conditions, the result could be continued high medical cost burdens. Insurance And Primary Care Insurance design and payment policies also matter for access and countries’ primary care infrastructure. The high rates of ED use associated with long waits for primary care in the United States (including among insured patients) and several other countries underscore the importance of 24/7 primary care coverage in terms of overall system cost and resource allocation. Insurance Complexity The experiences of patients and physicians in other countries regarding the time-consuming complexity of insurance also provide potential insights for the United States. A recent Institute of Medicine study estimated that administrative layers throughout the US health insurance and care system add as much as $360 billion per year to the cost of health care — and much of that sum was deemed to be wasted, with little or no return in value. Evidence from other countries suggests opportunities to reduce such costs. Cost Control A key challenge for the United States is its already high level of health spending, which is 50–167 percent higher per capita than in the other study countries. These costs undermine the financial protections offered by insurance and drive premiums up. Support For Reform Polls in the United States show mixed public support and lack of knowledge about the provisions of the Affordable Care Act. Yet in the survey most US adults called for major change, with a minority preferring the status quo. People who had experienced problems with access to or affordability of care or who had time-consuming insurance problems had more negative views than people who had not had such problems. http://content.healthaffairs.org/content/early/2013/11/12/hlthaff.2013.0879.full.pdf+html?ijkey=7LvT

Comment:

By Don McCanne, M.D. This 2013 survey sponsored by the Commonwealth Fund is very helpful during the Affordable Care Act transition because it tells us how the United States is doing compared to ten other industrialized nations with universal systems. Our results are terrible, and when we look ahead at the changes yet to be implemented, it is clear that they will have an almost negligible impact on correcting the serious deficiencies in the United States. Our per capita costs will remain far higher than those of other nations. Our insurance products will remain very expensive yet highly flawed in design since they leave those individuals who have significant health care needs with high medical cost burdens. The excessive complexity of our insurance products will continue to waste hundreds of billions of dollars that could be used on health care. Measures intended to provide much needed reinforcement of our primary care infrastructure are all too meager, so timely access to care will remain impaired for too many. Three-fourths of Americans believe that we need fundamental changes or complete rebuilding of our health system. We have a far greater percentage dissatisfied than are in the other developed nations. Although it will be several weeks before the exchange plans and the Medicaid expansions will be in effect, most Americans will not be able to detect any improvements in their health care financing and access. In fact, many will have greater out-of-pocket costs because of increased shifting of costs to patients through measures such as high deductibles, and others will lose access to their current health care professionals and institutions because of the greater use of narrow provider networks – further reducing choices in health care. In spite of the noble intentions of the Affordable Care Act, most of us will not see any correction of the serious flaws demonstrated in this international survey which shows how costly and dysfunctional our system is, and too many of us will be even worse off. As we watch the 2014 implementation unfold, we have to keep in mind that it didn’t have to be this way. We could have had and still can have a single payer national health program – an improved Medicare covering everyone. With what we spend, we should be at the top in these international comparisons. Single payer would get us there.

]]>

AHIP statement on consumers keeping their current coverage

AHIP Statement on Consumers Keeping Their Current Coverage

America’s Health Insurance Plans (AHIP), November 14, 2013 America’s Health Insurance Plans’ (AHIP) President and CEO Karen Ignagni released the following statement on today’s announcement by the administration related to policy cancellations: “Making sure consumers have secure, affordable coverage is health plans’ top priority.  The only reason consumers are getting notices about their current coverage changing is because the ACA requires all policies to cover a broad range of benefits that go beyond what many people choose to purchase today. “Changing the rules after health plans have already met the requirements of the law could destabilize the market and result in higher premiums for consumers.  Premiums have already been set for next year based on an assumption of when consumers will be transitioning to the new marketplace.  If due to these changes fewer younger and healthier people choose to purchase coverage in the exchange, premiums will increase in the marketplace and there will be fewer choices for consumers.  Additional steps must be taken to stabilize the marketplace and mitigate the adverse impact on consumers.” http://www.ahipcoverage.com/?p=12831

Comment:

By Don McCanne, M.D. President Obama’s decision today to allow individuals to keep the insurance they have has devastating policy implications. It is no wonder that AHIP released this statement only minutes after the President’s announcement. The insurance plans that were to be cancelled are plans that have fewer benefits than are now required by the Affordable Care Act. If the replacement plans have more comprehensive benefits, then why would people want to keep their old plan? Individuals place a high priority on the premium to be paid when they select their plans. They will almost always select the plan with the lowest premium that at least superficially seems to meet their needs. If they have major health care needs, they will select plans with more comprehensive benefits, even if they are more expensive. On the other hand, healthy individuals who are watching their budgets will often select the cheapest plan – their old plan in this case, even though it has fewer benefits. So what will happen when people are allowed to keep their old plans? Younger, healthier individuals will stay with those plans whereas older individuals with greater heath care needs will move into the new plans available in the exchanges. This adverse selection that concentrates expensive patients in the new plans will drive premiums up. When the premiums go up, more will drop out, causing the premiums to go up even further – so high that the plan has to be pulled from the market – the death spiral of adverse selection. Karen Ignagni is right when she says that allowing people to keep the insurance they have will destabilize the insurance market and cause premiums to rise, but only for the new insurance marketplaces (exchanges) that the insurance industry is counting on for their expanded business opportunities, made possible by the insurance-industry-designed Affordable Care Act. Although the spinmeisters are busy trying to discredit the President and his administration for the false promise of allowing you to keep your insurance, and for the rollout of the exchange website before it was ready, this noise is a distraction from the real problem here. The Affordable Care Act is an irreparably flawed model of financing health care, and no amount of patching is going to fix it. It is and always will be an unstable, expensive and inequitable model of financing health care. You know what is stable? Medicare. And it is less expensive and more equitable. Yes, it needs continual oversight and refinements, but it has the support of the public. If it were our only health care financing program, in an improved single payer version, virtually all of us would be demanding to keep the insurance that we would then have – an Improved Medicare for All.

]]>

Health reform’s problems run deeper than a glitchy website

By Philip Caper, M.D.
Bangor (Maine) Daily News, Nov. 14, 2013 Serious problems with the websites created by the Affordable Care Act continue, and probably will for a long time. Although frantic efforts at incrementally improving them are being made by the Obama administration, and some sites are working better than others, they are a long way from working well. As I’ve written before, the causes of the website’s problems are far more serious than poor software design. They are baked into the law by its extreme complexity. There is growing frustration and anger at the administration in Congress from both Democrats and Republicans. Much of it is being expressed by the same people whose hypocrisy and obstructionism is responsible for a failure to do the right thing in the first place. Calls from members of Congress to delay the ACA’s implementation or to repeal it entirely will intensify. Instead of expanding our existing Medicare program, which has been working well for almost 50 years and is our country’s most efficient and least intrusive health care financing program, the ACA creates complex new law that perpetuates and reinforces the chaos and confusion of our hodgepodge of public and private insurance programs. Coverage and financial assistance continue to depend on an individual’s employment status, income, place of residence, age, conjectures about future health status, and many other factors, some of them subject to change with little or no warning and many impossible to predict. Smooth implementation of the ACA depends upon the ability of many parts of government and thousands of insurance companies to seamlessly communicate with one another and agree on data drawn from myriad different public and private sources. Some in the health insurance field believe such a task will be difficult or impossible to achieve. We have to ask ourselves, who are the winners from requiring us to go through the expense and confusion inherent in trying to implement a law of over 2,000 pages? The answer is clear. It’s a health insurance industry that profits from complexity and confusion, and providers of pharmaceuticals, medical supplies, devices and services who benefit excessively from the very weak cost controls inherent in our fragmented system of paying for services. The losers are all the rest of us. The ACA’s objective, access to health care for all Americans, could have been accomplished much more easily with far less confusion, expense and complexity. I talk to a lot of people from across the political spectrum about health care reform. There is a growing consensus that improved Medicare for all is the necessary first step in repairing our badly broken health care system. During a trip to California last week, I ran into House Minority Leader Nancy Pelosi. When I explained to her that while I admired her efforts to reform our health care system, I remain an advocate for “Improved Medicare for All,” she responded, “Yes, we should have done single payer.” Perhaps there’s still hope. Between Harry Reid’s recent comments and Pelosi’s epiphany, there seems to be a growing understanding of the problem, and its solution, in some parts of Congress. But first, we will have to get rid of the obstructionist politicians whose only interest seems to be in preserving a health insurance industry that has become one of the most destructive forces in American society. That task is up to us. Physician Philip Caper of Brooklin is a founding board member of Maine AllCare, a nonpartisan, nonprofit group committed to making health care in Maine universal, accessible and affordable for all. He can be reached at pcpcaper21@gmail.com. http://bangordailynews.com/2013/11/14/health/health-reforms-problems-run-deeper-than-a-glitchy-website

]]>

Expanding Medicare to all can solve health care disaster

By Caroline Poplin, M.D.
Newsday, Nov. 14, 2013 Republicans can hardly believe their good luck. The Obama administration has once again snatched defeat from the jaws of victory. After successfully holding off Republican efforts to destroy Obamacare by shutting down the government and threatening default, the administration badly bungled the rollout of the crown jewel of health reform: the insurance exchanges. (No surprise to those of us who wrestle with computers daily.) Somehow administration leaders also failed to anticipate the predictable response of insurance companies to a perfect opportunity to raise premiums wholesale, while blaming someone else. Nevertheless, we need to keep in mind that even as they gleefully tear into the ACA, Republicans have not offered an alternative. On reflection, however, this is no surprise. Republicans don’t see a problem with health care in America. Insurers can sell what they chose to whom they chose; people can select policies they like and can afford, or save their money for other things. This is how markets work. The only change Republicans would make is deregulation, so insurers and good prospects can find one another more easily across state lines. As Ronald Reagan said: “Government is not the solution to the problem, government (in this case, the ACA) is the problem.” For conservatives, health insurance and health care are ordinary commodities to be traded in the marketplace, just like automobile insurance and automobiles. But health care is not just another item in the shopping cart. As the African-American spiritual observed, “If living were something that money could buy, the rich would live and the poor would die.” And that is where we are in the 21st century. Health care is a matter of life and death. Our medicine is highly effective. Today, we can cure, or treat, diseases that were once fatal – heart attacks, many cancers, even HIV. That is, if you have the money. Today rich Americans live, on average, five years longer than poor citizens. Nor is health insurance an ordinary insurance product. Illness today is not evenly distributed across the population. Some 10 percent of people are responsible for 60 percent of health-care costs in the United States. Because most illness continues for many years after diagnosis, these people are easy to identify: patients with multiple sclerosis, congestive heart failure, lymphoma. No one wants to pay for the sick people – not the insurance companies (particularly if they cannot recover their costs by charging the sick higher premiums), and not healthy customers. We hear this now, as single men and older people complain that to comply with the ACA, they have to pay for maternity benefits that they will never use. A free market with lots of choices among multiple insurers, risk pools, policies with all sorts of benefits and price structures, allows insurers and healthy individuals to avoid the sick. The less affluent healthy can gamble on inexpensive policies with spotty coverage (useless to the chronically ill): since most people are healthy most of the time, few of them will ever need to test their insurance. (Or they can join large groups of other healthy people working for large employers who provide insurance.) Insurers can charge sick people thousands of dollars a month to cover the cost of their claims, and then some. The result? The people who need health care the most have the most difficulty getting insurance that covers it. Doesn’t this defeat the whole purpose of the exercise? That, however, is the Republican alternative to the ACA. And remember, even before the ACA, things were not stable, but deteriorating: as health costs rose, premiums, co-pays and deductibles were going up, employers were cutting back. Without the ACA, those trends will continue. The ACA was an effort to preserve a private health insurance market, using regulation to achieve a better result. As we see, this is very complicated. There is a third option. If everyone is in the same, large, pool, everything medically necessary is covered, insurers are paid merely to process claims, and premiums are scaled to income, there is enough money to cover everyone at reasonable cost without elaborate, expensive, error-prone computer programs and geniuses to run them. People will be able to choose their doctors and hospitals. (And the rich can always buy more if they want.) A crazy, wild-eyed socialist nightmare? No, this is Medicare, a familiar, popular, competently-run public insurance system that everyone’s parents or grandparents rely on. Person-for-person, disease-for-disease, Medicare is the cheapest, most efficient health insurance program in the country. (There is virtue in simplicity.) Medicare already controls health care costs better than private insurers, and with a few tweaks, could do much more, forcing prices down to the level citizens of every other advanced democracy pay, with no sacrifice in quality. Given the alternatives, maybe Medicare-for-all deserves a second look. Caroline Poplin is a physician, attorney and policy analyst in Bethesda, Md. This article has been distributed by the McClatchy-Tribune News Service. http://www.newsday.com/opinion/oped/poplin-expanding-medicare-to-all-can-solve-health-care-disaster-1.6435431

]]>

Support HR 676, for a single-payer health care system

By Richard Damon, M.D.
The Montana Standard (Butte, Mont.), Letters, Nov. 14, 2013 If you had choices, would you keep the health care insurance coverage you have if you had comprehensive, accessible, affordable, quality, insurance from birth to death, free choice of physician and hospital, no co-pays, no deductibles, no monthly premiums, no more hassle with private insurers, no more threat of medical bankruptcy, and the security that comes with knowing that you will not be one of the thousands who die needlessly because of health rationing imposed by private insurers who provide insurance based on age, gender, health history, or what health care costs have been paid out because of your chronic condition? Would you choose insurers that focus on profits as their primary objective instead of covering care? Would you choose to not worry that your sick asthmatic child has to repeatedly end up in the ER? Would you be willing to pay a modest increase in your taxes to know that whatever health condition you may develop in the future, it would be covered? Would you choose a program of health care that provides preventive care to prevent illness, and readjusts the distribution of health care providers so care is available to both rural and urban folks? Would you like to rest at night and not worry about the symptoms that are growing in frequency and intensity that keep you awake? Would you like to rid yourself of the worrying that your employer might cut your insurance previously provided to you? Well, you have choice of a single-payer healthcare system, HR 676. The challenge is to speak out, joining a loud national voice to demand it be done. Write or call your congressional members now. If you do nothing you are acting like Congress. You will choose to not make a choice. Your voice can change things. Dr. Richard Damon resides in Bozeman. http://mtstandard.com/news/opinion/mailbag/ourreadersspeak-support-hr-it-provides-single-payer-healthcare-system/article_c24b2de8-4ccd-11e3-ae1c-001a4bcf887a.html

]]>

Kip Sullivan on the policy community's compromised work on ACOs

Accountable care organization formation is associated with integrated systems but not high medical spending.

By David I. Auerbach, Hangsheng Liu, Peter S. Hussey, Christopher Lau, and Ateev Mehrotra
Health Affairs, October 2013
 
“[P]roponents hope that ACOs will deliver better quality and outcomes … and have lower costs. Independent analysts have projected savings for ACOs [endnote 3], and a recent evaluation of an ongoing private prototype has found evidence of savings and quality improvement [endnote 4].”
 
Endnote 3: “Congressional Budget Office, Budget options, volume 1: health care: CBO;2008 Aug…..”
 
Endnote 4: “Song Z, …, et al. The “Alternative Quality Contract,” based on a global budget, lowered medical spending and improved quality. Health Aff (Millwood). 2012;31:1885-94.”
 
http://content.healthaffairs.org/content/32/10/1781.abstract

Comment:

By Kip Sullivan, J.D. The “accountable care organization” is the latest health policy fad to captivate lawmakers. The term was invented at a meeting of the Medicare Payment Advisory Commission on November 9, 2006. Despite the vague definition of ACO, and despite the absence of any evidence supporting claims made for ACOs, Congress included in the Affordable Care Act provisions authorizing the Centers for Medicare and Medicaid Services to initiate an ACO program. CMS has designated some 250 entities as Medicare ACOs.
 
The two sentences quoted above indicate that even as of mid-2013, seven years after the ACO label was invented and four years after Democrats inserted ACO provisions into the legislation that was to become the Affordable Care Act, ACO proponents must either leave their praise for ACOs undocumented or misrepresent the research on ACOs. The authors of these two sentences chose the latter approach. They cited a study by the Congressional Budget Office which found that ACOs would have almost no impact on Medicare spending, and they cited a study of an ACO-like entity in Massachusetts which found the entity is generating higher, not lower, total health care spending.
 
The two sentences quoted above are from a paper by David Auerbach and colleagues designed to determine where the 250 Medicare ACOs are forming. They reported they are more likely to form where provider consolidation is higher, notably the Midwest and the Northeast. Because the paper simply asked where ACOs are forming, there was no need for the authors to praise ACOs. However, as the quote above indicates, the authors chose to do so. And, given the state of the research on ACOs, they were reduced to exaggerating one study and misrepresenting another in order to “document” their praise.
 
The first study cited by Auerbach et al. was the 2008 report to Congress by the Congressional Budget Office. In that report, the CBO analyzed 115 health care reform proposals or “options.” Option number 37 was the ACO, although CBO didn’t label it that way. CBO called it a “bonus-eligible organization.”  The CBO stated: “Under this option, groups of providers meeting certain qualifications would have the opportunity to participate … in Medicare as bonus-eligible organizations (BEOs). The concept of BEOs is similar to the accountable care organization models proposed by some researchers” [p. 72]. After describing the BEO in the terms CMS would use several years later when it announced its definition of an ACO, the CBO concluded: “This option would reduce Medicare spending … by $5.3 billion over the 2010-2019 period” [p. 73].  http://www.brookings.edu/~/media/events/2009/3/11%20aco/cbohealthoption37.pdf
 
Auerbach et al. should have known that five billion dollars is a minuscule portion of a decade of Medicare spending. The 2010 National Health Expenditure Accounts estimated total Medicare spending over the 2010-2019 period would be more than 7 trillion dollars — $7,135,000,000 to be more precise (my calculation using the numbers shown for Medicare in Table 3
http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/proj2009.pdf)  If we divide $5.3 billion into $7.135 trillion, the savings CBO said ACOs would achieve turns out to be less than one-tenth of one percent of Medicare spending.
 
The second paper Auerbach et al. cited – a 2012 paper published in Health Affairs by Song et al. – has already been the subject of two letters published in Health Affairs as well as a comment by Don McCanne on this blog https://www.pnhp.org/news/2013/june/academyhealths-ill-judged-choice-of-the-2013-article-of-the-year. The letter writers (I was one of them) pointed out an extremely obvious defect in the Song paper: The title of the paper claimed the ACO-like entity was saving money when the text stated it wasn’t. Despite the two letters and Don’s comment, Auerbach et al. chose to misrepresent the Song paper, and the editors of Health Affairs let them do it.
 
Auerbach et al.’s misuse of research is not an isolated example. Over the last several decades, a culture of permissiveness has developed within the US health services research community. This culture tolerates exaggeration and misrepresentation, especially when the exaggeration or misrepresentation promotes the managed care ideology that dominates the health policy debate in this country. As we contemplate how President Obama and the Democrats find themselves burdened by an Affordable Care Act that is not affordable, we should begin our analysis with this question: What role did the US health policy community play in causing policy-makers to think ACOs would make the ACA affordable?

]]>