fivethirtyeight--2019-05-13--Democrats Have No Safe Options On Health Care

Even though most of the candidates have committed to some form of universal health care, the Democratic primary is turning into a debate about the future of the country’s health care system. Presidential hopefuls have proposed policies ranging from an ambitious four-year plan to transform Medicare into a universal single-payer system, in which the government pays for everyone’s health care and private insurance plans are effectively eliminated, to a more modest scheme that would leave the existing health care system intact but create a government-administered public insurance plan people could choose to purchase. But some of the candidates have been light on policy specifics, so it’s likely that health care will be a big topic at the debates and beyond.  In the abstract, focusing on health care makes a lot of political sense for Democrats. It was a top issue among Democratic voters in the 2018 midterms, and the Trump administration recently renewed its efforts to strike down the Affordable Care Act in the courts, which means the law could be hanging in the balance throughout the primaries and into the general election. A recent ABC News/Washington Post poll also found that Americans, by a 17-point margin, say that President Trump’s handling of health care makes them more likely to oppose him than to support him in 2020. By a similar margin, an Associated Press/NORC poll found that Americans trust Democrats more than Republicans on health care.  All of this means that Democrats are heading into the 2020 election cycle with a serious edge on an issue that has the potential to mobilize their base. But if the candidates pitch big, sweeping changes to the health care system without addressing voters’ concerns about cost and access, that advantage won’t necessarily hold up. And trying to sell Americans on a completely new system carries risks, even in the primaries.  First, it’s important to understand how health care has morphed over the past decade from just another issue to one of the issues voters care most about. In the 2018 exit polls, 41 percent of voters said health care was the most important issue facing the country, up from 25 percent in 2014 and 18 percent in 2012. (It wasn’t asked about in 2016.) And although Democrats are more likely to prioritize health care than Republicans, a Pew Research Center poll from January found that a majority of Republicans say health care costs should be a top priority for Congress and the president.  The reason? Health care is becoming more of a financial burden, according to Mollyann Brodie, executive director for public opinion and survey research at the Kaiser Family Foundation. Specifically, Americans’ out-of-pocket health care costs have risen significantly over the past decade, even for workers who get insurance through their jobs. In an economy that by many measures is doing well, health care — rather than something like taxes — is becoming one of voters’ most important pocketbook issues, she said. “If you’re worried about whether you or your loved ones can afford your next health care bill, that’s really a matter of life or death, so you can understand why this issue is moving to center stage politically.”  And Americans are increasingly likely to say that the government has an important role to play in ensuring access to health care. In November, Gallup found that 57 percent of Americans said they think it’s the federal government’s responsibility to ensure that everyone has health care coverage, up from a low of 42 percent in 2013. Support for the Affordable Care Act rose over the same period, too. But, notably, support for government intervention in the health care system was even higher before President Obama was elected and the ACA passed — in 2006, 69 percent of Americans thought the government should guarantee health care coverage.  While support for government involvement in health care is rebounding, it’s not clear how much change voters are really asking for. “The average American is first and foremost concerned about the financial problems facing their family,” said Robert Blendon, a professor of health policy and political analysis at Harvard. “They’re less worried about system-level concerns like health care spending and inequality. They want their existing coverage to be better and more affordable.”  Americans aren’t opposed to the idea of government-run health care, but there’s not a lot of consensus on what that would mean. For example, a recent Kaiser Family Foundation poll found that a majority (56 percent) of Americans favor a national “Medicare for All” plan. But according to a March Morning Consult poll, Americans are more likely to favor a plan that offers some kind of public option — a government-sponsored health insurance plan available in addition to existing private plans — over a system where everyone is enrolled in the same plan.  But this apparent contradiction makes sense, according to Brodie, because Americans are risk-averse when it comes to health care, and the switch to single-payer would affect far more people than the ACA did. Tens of millions of previously uninsured people received coverage under the ACA, but that number would be dwarfed by the 156 million people who get their insurance through their employers and could see their coverage change if the country switched to a single-payer plan. “Even if the current system isn’t working, transitions are scary,” Brodie said. “And people aren’t necessarily aware of what a national plan really means. When you start telling people that there might not be any more private insurance companies, that’s actually not a popular position.” For example, a January Kaiser Family Foundation poll found that support for a national Medicare for All plan dropped significantly when respondents were told it would mean eliminating private insurance companies.  And when asked what health care policies they want Congress to prioritize, Americans don’t list Medicare for All first. Instead, according to a recent Kaiser Family Foundation poll, they want Congress to pass targeted measures that would lower prescription drug costs, continue the ACA’s protections for preexisting conditions and protect people from surprise medical bills. Only 31 percent of Americans say that implementing Medicare for All should be a top priority for Congress, compared to 68 percent who want lowering drug prices to be a top priority. Moreover, prioritizing Medicare for All is politically polarizing: Only 14 percent of Republicans support putting that kind of plan at the top of the to-do list, compared to 47 percent of Democrats.  However, smaller policy steps like lowering prescription drug costs and protecting people from surprise medical bills get more bipartisan support. Overall, Americans seem to be more concerned with fixing the current health care system than creating a sweeping new replacement — even if that replacement could address the issues they most want fixed in the current system.  The complexity of Americans’ views on health care doesn’t change the fact that Democrats have a big advantage over Republicans on this issue, but it does mean that the individual candidates are in a tough spot because there’s no obvious unifying message they can adopt for the primary. And embracing a single-payer plan now could hand the GOP a weapon for the general election, allowing Republicans to frame the health care discussion around the Democrats’ controversial plan while glossing over Trump’s efforts to dismantle the ACA.  “The safest bet for a Democrat in the general election is to emphasize Trump’s track record on health care and say you’re going to make the ACA work,” Blendon said. The problem is that while that kind of argument might appeal to moderates, it’s likely to fall flat among a significant sector of the Democratic base that supports prioritizing a national Medicare for All plan over improving and protecting the ACA.  Democrats arguably still have an opening to make a case for a more ambitious health care overhaul, since voters still have relatively little information about what something like Medicare for All means. “It’s fine to support single-payer if you think that’s where the country needs to go, but you can’t just lean on principles like fairness or equality when you’re selling it,” said David Cutler, an economist at Harvard who advised Obama’s campaign on health care strategy. “You also have to tell voters, very specifically, what you are going to do to lower their costs and improve their coverage next year — not in 10 years.”  Even though Americans mostly prefer Democrats’ health care positions to the GOP’s, Democrats still risk alienating voters if they emphasize bumper-sticker slogans over concrete strategies for reducing the financial burden of health care. This is particularly important because their base of support for a single-payer system may be shallower than it appears, even within the party — especially when it comes to getting rid of private insurance. Big changes to the status quo are always politically challenging, but they may be especially risky when many Americans are concerned about losing the protections they already have.


foreignpolicy--2019-05-24--Good Health Supports Good Governance

Good Health Supports Good Governance

International aid is once again becoming a political flash point. Boosters say that aid can support development. Detractors argue that it instead promotes dependency and undermines good governance. The renewed battle could spell trouble for global efforts to tackle some of the biggest health problems of our time, including AIDS, tuberculosis, and malaria. It is also unnecessary: The evidence suggests we do not have to trade health for governance.  For a time, it seemed that the debate over aid was over. Focus had shifted away from whether aid was bad or good to prioritizing the types of aid that seem to be working, including key global health programs. But in December 2018, U.S. National Security Advisor John Bolton unveiled the Trump administration’s new Africa strategy. He decried a “longstanding pattern of aid without effect, assistance without accountability” and announced a shift to a “new path” for aid that would focus on securing stable and transparent governance on the continent.  Taking things a step further, in March, President Donald Trump’s budget proposal for 2020 slashed foreign aid, including for some of the world’s most effective global health programs. The multilateral Global Fund to Fight AIDS, Tuberculosis, and Malaria and a range of bilateral efforts including the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), global health at the Centers for Disease Control and Prevention, and family planning at the U.S. Agency for International Development all came in for steep cuts. The administration said its budget would support “reducing the long-term need for foreign assistance” and support countries “to solve their own development challenges.”  Democrats and Republicans in Congress are prepared to come together to reject the cuts. Rep. Nita Lowey, a Democrat, said that the budget changes would “diminish America’s global standing.” Senate Republican leaders have also opposed them, with Senate Foreign Relations Committee Chairman James Risch criticizing cuts to programs that he believes “support the growth of healthier, more stable societies with whom we can trade.”  The Trump administration is not the only aid skeptic. In the United Kingdom, Penny Mordaunt, the international development secretary the beginning of this month, hit similar notes when she laid out the Conservatives’ vision for aid in April. To help countries “stand on their own feet and build sustainable health and education systems,” she said, the country’s Department for International Development would refocus on tackling “man-made crises” like corruption. Another faction of Conservatives, led by her replacement as development secretary, has argued that her vision misses the point of aid.  The idea that providing aid to tackle health problems such as AIDS or malaria might undermine good governance makes some intuitive sense. “We do want to be able to hold our governments accountable but we can’t do that if, actually, Oxfam is going to solve the health care problem,” Dambisa Moyo, the economist and aid pessimist, recently opined. The argument is that funding for public goods should come from citizens via taxes. When citizens have a stake in financing public goods, they’ll work to ensure that governments perform well.  There is plenty of research showing that countries that succeed in building effective health systems rely on strong governance institutions—those that distribute power, ensure transparency, check corruption, and provide strong legal systems. These same institutions are critical for economic growth and development. It would seem, then, that there is good reason to focus on building strong institutions first in order to ensure better health in the future.  But we don’t have to choose. Well-designed global health aid can have beneficial effects on governance as well.  The Global Fund to Fight AIDS, Tuberculosis, and Malaria is a clear example. The fund, widely lauded for saving millions of lives, was created in 2002 at the height of the AIDS pandemic as a health financing agency to pool contributions from wealthy nations, foundations, and the private sector.  From the start, the Global Fund worked hard to ensure that its programs would promote transparency and good governance. Before receiving money, a recipient nation must create a Country Coordinating Mechanism to oversee the funds. The mechanism is required to include representatives from government, nongovernmental organizations, community groups, and the private sector. The fund also contracts an independent professional agent in each country to conduct audits of financial and programmatic progress.  At the global level, meanwhile, each application is reviewed by an independent panel of experts, which makes recommendations to the fund’s board. And the inspector general has repeatedly identified and exposed misallocation of aid and worked through local courts and legal systems to recover it. The fund has also invested millions of dollars in programming intended to strengthen the rule of law and management of national health systems.  In a recent study, Georgetown University’s Lixue Chen and I used data from 112 countries to test whether aid from the Global Fund had any effect on governance. We found that increased aid from the fund was associated with better control of corruption, government accountability, political freedom, regulatory quality, and rule of law (the relationship with effective policy implementation was not statistically significant). This relationship held true even when we controlled for other factors that might explain the difference like a country’s wealth, relative political stability, and level of corruption at the start of funding.  We can see this kind of governance in action, for example, in Malawi, where the fund has invested over $1.3 billion. With among the highest HIV rates in the world, Malawi has made some of the fastest progress against the disease—cutting AIDS deaths and new HIV infections in half through highly effective use of donor money. At a broader level, financing from the fund has supported the growth of new NGOs that have monitored government budgets, promoted human rights, and campaigned against corruption. Recently, for example, when the government tried to transfer money budgeted for health to an organization run by the first lady to beautify Malawi, advocates found out through the transparency of the Global Fund, exposed the move to the media, and held protests in the capital leading to defunding of the AIDS commission.  Good governance doesn’t mean there is never fraud or abuse. Indeed the U.S. government recovered $2.6 billion in fiscal 2017 from health care fraud. Good governance means that there are institutions in place to respond to bad actors, effective rule of law to adjudicate disputes, and ways for people to hold their government accountable. These factors are critical not just for protecting health budgets but also for building strong economies. In Malawi, rather than undermining the ability of citizens to hold government accountable, money from the Global Fund also helped improve transparency and provided the tools to fight corruption.  Not all aid is created equal. Last year, through the Bipartisan Policy Center, two former Senate majority leaders and I collaborated on a study that showed that the PEPFAR program was associated with similar positive trends in governance. Other studies have linked more general foreign aid to poorer governance. This suggests that there may be something particularly beneficial about aid for global health. First off, health aid is targeted to need. Although the political interests of aid-sending nations play a role, health aid flows primarily to low- and middle-income countries to address specific needs. Second, the structures and processes associated with good global health work are related to improving governance, including the strong participation of activists, NGOs, and doctors. Finally, health aid is often pegged to specific program targets like getting a certain number of people access to HIV treatment or distributing a particular number of bed nets to fight malaria. These are tangible goals, visible to the population, and the focus on results can help set citizen expectations that promised public goods will, in fact, be delivered.  In this context, the Trump administration’s moves to cut aid for global health as a way to improve governance are indefensible. The Global Fund is preparing for a major donor conference to be hosted by French President Emmanuel Macron this fall. But the Trump budget proposes to cut the three-year U.S. pledge by over $1 billion—a disaster since U.S. funding is matched two-to-one by other countries. The PEPFAR program, UNICEF, and a variety of other aid programs come in for similar cuts. Of course, it is the U.S. Congress that really has the power to set U.S. funding levels, and members of Congress have voiced their intentions of ignoring Trump’s budget proposal. Nonetheless, it is worrying that the old debate over whether aid is good or bad has been reopened.  Improving health is not possible in a vacuum. We do need strong institutions. And just as the United Nations Sustainable Development Goals link improved health with improved governance, our research on the Global Fund to Fight AIDS, Tuberculosis, and Malaria shows that aid, when it flows through well-designed mechanisms, can be a key part of doing both.


fortune--2019-07-31--Legislating Social Media Addiction Brainstorm Health

Legislating Social Media Addiction: Brainstorm Health

There's a presidential primary debate on tonight (and I imagine at least a few readers will be checking in on it, given an expected focus on health care).  But let's check in on a more low-key, and likely quixotic, policy quest aligned with the digital health space. A freshman U.S. Senator (Josh Hawley, a Missouri Republican), has proposed legislation that would ban "addictive" features on social media platforms.  The Social Media Addiction Reduction Technology Act (or, well, the SMART Act) would prevent some of the big tech names like Facebook, YouTube, and Twitter from using algorithmic means to feed on their very human users' propensity for spending hours upon hours on said platforms (behavior that hasn't exactly been linked with great mental health outcomes).  This might include the use of auto-play videos, or "infinite scrolling" (wherein your digital wormhole literally has no end), or programmable behavior encouraging users to constantly engage.  Whether such a piece of legislation has a snowball's chance in passing - and even if it does, whether it would pass constitutional muster - well, that's a whole different story. But perhaps one that will appear in the endless social media loop.  Read on for the day's news.  A meditation app with a twist. My colleague Ellen McGirt has a typically insightful-yet-fun piece up today about a meditation app that’s specifically geared towards people of color in an era of violence and divisiveness centered on minorities. The Liberate Meditation app includes “talks and meditations [that] are all offered by Buddhist people of color, and you don’t have to be a practitioner to enjoy the emotional safety the teachings provide,” Ellen writes. (Fortune)  Merck continues to crush on strength of Keytruda. I’ve written before (and recently) about the failings of big, legacy pharmaceutical companies. One standout appears to be Merck, which absolutely obliterated Wall Street expectations on the strength of its star cancer immunotherapy Keytruda. Keytruda brought in about $2.6 billion in sales in just a single quarter, placing it far ahead of competitors like Bristol-Myers Squibb’s rival Opdivo. That figure is a stunning 58% increase in sales for the quarter. Keytruda has succeeded where many of its competitors have failed, particularly in the massive lung cancer space.  Expect health care fireworks at tonight’s Democratic debate. Debate night is underway (part one of two, anyways). This evening, look out for some fireworks between Sens. Elizabeth Warren and Bernie Sanders, two candidates generally considered to be on the left side of the spectrum who may be compelled to lay out exactly what their differences are on “Medicare for All” and universal health coverage policies.  Recruiting Scams Are ‘Prolific,’ Experts Say, by Alyssa Newcomb


fortune--2019-10-03--What Trumps Executive Order Means for Healthcare

What Trump’s Executive Order Means for Healthcare

President Donald Trump signed an executive order this afternoon in Florida, pushing for further privatization of Medicare.  The ‘Executive Order on Protecting and Improving Medicare for Our Nation’s Seniors’ focuses on expanding Medicare Advantage. It will expand the role of private insurers to offer benefits rather than the government.  “The Executive Order will improve upon privately-run Medicare Advantage plans, and provide seniors with more benefit choices,” says Lindsay Bealor Greenleaf, director of policy at the global healthcare consulting firm ADVI Health.  In a speech to supporters, Trump also called for a drug importation plan.  “We will soon allow the safe and legal importation of prescription drugs from other countries including Canada,” the president said. The Administration has signaled a growing interest in a drug importation plan in recent months.  In June, Trump directed Health and Human Services Secretary Alex Azar to work with Florida on a state level bill that authorizes importation of prescription drugs from other countries. Colorado and Vermont recently passed similar laws.  In the speech, Trump took the opportunity to attack Democratic healthcare plans.  “Medicare is under threat like never before. Almost every major Democrat has backed a massive government take over that would totally obliterate Medicare,” he said.     However, Democrats have pointed out for months that President Trump’s 2020 budget calls for a $845 billion cut to Medicare.  Progressives like Senator Bernie Sanders’ (I-Vt.) single-payer proposal would essentially create a universal Medicare program that would cover all through a government-run healthcare plan, rather than a privatized alternative.  Recent polling from the Kaiser Family Foundation found that 51% of Americans would prefer a single-payer system, suggesting that voters are more in favor of the Democrats’ plan.


foxnews--2019-04-17--Medicare chief says Medicare-for-all is biggest threat to American health care system

Medicare chief says 'Medicare-for-all' is ‘biggest threat to American health care system’

The nation’s top Medicare official said on ‘Fox & Friends’ Wednesday that Democrats' “Medicare-for-all” proposal amounts to “the biggest threat to the American health care system,” claiming the policy would lead to worse care and longer wait times.  “I’ve been saying that Medicare-for-all is the biggest threat to the American health care system,” Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma said. “What we’re talking about is stripping people of their private health insurance, forcing them into a government-run program.”  Sen. Bernie Sanders, I-Vt., unveiled his latest Medicare-for-all plan last week -- legislation that was endorsed by other 2020 Democratic hopefuls Sens. Kirsten Gillibrand, N.Y., Kamala Harris, D-Calif., Cory Booker, D-N.J., and Elizabeth Warren, D-Mass. A similar bill has been introduced in the House.  Such plans would abolish almost all private coverage. Proponents have said such plans would give access to health care to all, recognizing it as a human right.  Some estimates put the 10-year cost of the plan at more than $32 trillion. Sanders said at a Fox News town hall on Monday that it would mean many Americans would "pay more in taxes." But he also argued the plan's costs would replace premiums and deductibles already being paid by American families, claiming many would pay less in the end.  "I am concerned about the debt. That's a legitimate concern," Sanders said. "But we pay for what we are proposing. In terms of Medicare for All, we are paying for that by eliminating as I said before, deductibles and premiums. We are going to save the average American family money."  An informal poll of the audience on Monday showed most in attendance indicating they could support such a plan.  But Verma noted that socialized health care systems in other countries have problems of their own -- including long wait times and poor care -- leading citizens to travel to the U.S. for drugs and care they can't access at home.  “So this is a bureaucracy that’s going to be making decisions about everybody’s healthcare, what kind of benefits they can have, what kind of medications that they can have access to,” she said. “And if we look at other socialized countries that have tried this approach, what do we see there? Long wait times, poor quality health care and that’s why those people are flying to the United States to get their health care.”  “The reality is we’re having problems today paying for the Medicare program and the trustees have warned about solvency, so adding more people to the program is only going to exacerbate it,” she said.  CLICK HERE FOR THE FOX NEWS APP  The plan has also seen skepticism from Democrats in Congress. House Speaker Nancy Pelosi, D-Calif., said in February that "Medicare-for-all” may not be “as good a benefit as the Affordable Care Act.”  “It doesn’t have catastrophic [coverage] -- you have to go buy it. It doesn’t have dental. It’s not as good as the plans that you can buy under the Affordable Care Act,” she told Rolling Stone in an interview. “So I say to them, come in with your ideas, but understand that we’re either gonna have to improve Medicare — for all, including seniors — or else people are not gonna get what they think they’re gonna get. ... And by the way, how’s it gonna be paid for?”


foxnews--2019-06-30--DNC Chair Perez defends free healthcare for illegal immigrants This is not a handout

DNC Chair Perez defends free healthcare for illegal immigrants: ‘This is not a handout’

A key issue that has come up during the Democratic primary season is whether those who enter the United States illegally should be eligible for free healthcare, and Democratic National Committee Chairman Tom Perez is fully endorsing it.  During Thursday’s Democratic debate, when asked who would support this, all ten of the participating candidates raised their hand. Perez joined them, defending the policy by claiming that illegal immigrants would be paying for their health benefits with tax dollars.  TOP MOMENTS AND KEY TAKEAWAYS FROM FIRST DEMOCRATIC PRESIDENTIAL DEBATES  “This is not a handout,” Perez told Chris Wallace on Fox News Sunday.  “Immigrants, including undocumented immigrants, pay billions of dollars in taxes,” he claimed. “Democrats believe that you should be able to buy into a health insurance system ... this is allowing people to buy into an insurance program, people who pay billions of dollars in taxes."  LINDSEY GRAHAM IMPRESSED WITH KAMALA HARRIS AFTER PUTTING PRESSURE ON BIDEN: 'SHE'S GOT GAME'  Earlier in the conversation, Wallace grilled Perez on former vice president Joe Biden’s performance during Thursday’s debate, where California Senator Kamala Harris put him on the defensive when it comes to his record on school integration. Biden had opposed federally mandated busing as a way to integrate schools, while Harris said she herself benefited from busing.  When asked how Biden’s chances in the primary race will be affected by this, Perez simply said, “That’ll be up for the voters to decide.”


foxnews--2019-11-27--Federal judge blocks Trump health insurance rule for immigrants

A federal judge in Portland, Ore., has granted a nationwide preliminary injunction disallowing a Trump administration rule requiring immigrants prove they will have health insurance or can pay for medical care before they can get visas.  U.S. District Judge Michael Simon, as The Oregonian reported, halted the directive requiring applicants have plans to be covered by health insurance within 30 days of entering the nation, or have enough financial resources to cover the cost.  President Trump had issued a proclamation in early October requiring immigrants, seeking visas from abroad — not those in the U.S. already, applying for U.S. visas to prove they can afford health care. It didn’t affect lawful permanent residents. It didn’t apply to asylum-seekers, refugees or children.  Hospitals have spent more than $35 billion, or an average of $7 million per hospital, on “unreimbursed services” over the last 10 years, according to the White House.  Under the proposed rule, the required insurance can be purchased individually or provided by an employer, and it can be short-term coverage or catastrophic. Medicaid doesn't count. And an immigrant will not be able to obtain a visa if using ObamaCare subsidies when buying insurance.  “This decision is an important check on the Trump administration’s effort to rewrite our nation’s immigration and health care laws in violation of the boundaries set out in the Constitution,” said Esther Sung, an attorney with the Justice Action Center.  Seven U.S. citizens and a nonprofit organization sued to prevent the rule from taking effect, saying it would block nearly two-thirds of all prospective legal immigrants.  The lawsuit also said the rule would greatly reduce or eliminate the number of immigrants who enter the U.S. with family-sponsored visas.  According to the Migration Policy Institute, a nonpartisan immigration think tank, 57 percent of U.S. immigrants had private health insurance in 2017, compared with 69 percent of U.S.-born, and 30 percent had public health insurance coverage, compared with 36 percent of native-born.  The uninsured rate for immigrants dropped from 32 percent to 20 percent from 2013 to 2017, since the implementation of the Affordable Care Act, according to Migration Policy.  There are about 1.1 million people who obtain green cards each year.  The new restrictions came as immigration and health care are at the forefront of the 2020 presidential race. Democratic candidates repeatedly have decried Trump’s strict immigration policies, and most have touted "Medicare-for-All" or at the very least a public option for health care. Most have even taken it a step further and supported providing health care for undocumented immigrants.


freedombunker--2019-04-09--The Medicare for All Push Is an Admission of Governments Failed Health Care Experiment

The Medicare for All Push Is an Admission of Government’s Failed Health Care Experiment

According to President Trump, the GOP will soon be “the party of health care.” Yet the “repeal and replace” approach to Obamacare is no longer on the table, so we’re not sure what’s coming next.  The Democrats, on the other hand, have a plan: Medicare for All. Popularized by 2016 presidential hopeful Bernie Sanders, this proposal has since won the support of many on the left. Democratic Rep. Pramila Japaypal’s new House bill to establish Medicare for All boasts over 100 cosponsors, making the party’s transformation clear. Yet the consequences of this proposed policy are somber. Medicare for All effectively tells citizens that health care quality can’t get better, that the system is broken beyond repair, and that they should just take one for the team—even if it results in a tragic ending.  Medicare for All would freeze the healthcare system as we know it, preventing further innovation and development.  For years, health care’s progression has sped along at a steady clip. Artificial intelligence and wearable technology, for instance, can now provide information that can be used for diagnostics and customized treatments which improve health care outcomes. Some doctors have moved to provide direct primary care, a Netflix-like subscription model with unlimited access to basic services against a monthly fee. Hospitals are building a reputation by voluntarily posting prices in an effort to increase transparency. Meanwhile, major companies are teaming up with telemedicine providers to make health services conveniently accessible to employees around the clock.  But little change or innovation is happening in areas under government control.  This is seen nowhere more clearly than in drug development. FDA drug approval times average 12 years. Hospitals also exemplify this inefficiency because physicians spend over 50 percent of their time on administrative tasks due to burdensomePatients have already paid more than their fair share, and they will continue to overpay through huge tax increases if the Democratic policy is implemented. ACA regulations. Turning the government into the only provider of health care would prevent innovative products and business structures from improving the quality of care because the profit incentives to outdo competitors would disappear. In the long run, the health of future generations would suffer.  Medicare for All is merely the government’s admission that it has failed to build a system that works. Federal policies have wreaked breathtaking damage—high prices, burned-out doctors, and a whopping 250,000 deaths due to medical errors every year—yet now, some feel that the government ought to take full ownership over the problem it created.  In truth, no one knows exactly how health care became the regulatory monster that it is today, let alone how to craft policies that will allow it to run smoothly for generations to come. Of course, politicians can’t admit to that, but they can always propose pie-in-the-sky solutions like Medicare for All and ignore the fact that patients will have to pay for their mistakes. Needless to say, patients have already paid more than their fair share, and they will continue to overpay through huge tax increases if the Democratic policy is implemented.  Medicare for All leaves the door open for the government to assume a decisive role in people’s lives—and deaths. While patients would no longer transfer money to insurance and providers, health care bills would continue to be due, and the government would have to pick them up. With this financial power, the state would act as the ultimate decision-maker in granting access to treatment—with potentially tragic consequences.  We saw a devastating example of this in the case of a British couple whose baby, Alfie Evans, was refused hospital admittance by the UK government due to high treatment costs and a high probability of failure. Sure—economically, the decision makes sense. But many parents would rather lose a home than a child, and that tradeoff can’t reasonably be expected from a bureaucratic government entity that works under budget constraints. So Alfie Evans died. This isn’t the kind of controversy we should want to bring stateside, but it could potentially happen here if we hand the reins over to big government.  Medicare for All promises that the burden of cost will be lifted—but it doesn’t guarantee that health care quality and access will be maintained.  After all, Medicare for All presents parallels with Barack Obama’s 2012 re-election campaign ad “The Life of Julia.” Julia, a cartoon character meant to represent all of us, was introduced via an online slideshow that followed her from birth to death, her life punctuated by the government’s actions under the candidate’s would-be policies—free college tuition, subsidized health care, and social security through retirement. People across the political spectrum denounced the portrait as unrealistic, decrying the meaninglessness of Julia’s existence, the woman’s reliance on the state, and the manifest ways in which the promises couldn’t hold.  "The Life of Julia” promised the average American that she would be happy, healthy, and well off until death thanks to the support afforded to her by the government. At the end of Obama’s presidency, this rosy picture didn’t describe the situation of many Americans who had been fed false promises.  Today, Medicare for All promises that the burden of paying for healthcare will be lifted from patients—but it doesn’t guarantee that health care quality and access will be maintained. In fact, the opposite will happen. It’s high time for concerned citizens to realize the consequences of the proposal that too many already see as the future of healthcare.


freedombunker--2019-06-26--Marylands Health Care Price Controls Arent Solving ProblemsTheyre Creating Them

Maryland’s Health Care Price Controls Aren’t Solving Problems—They’re Creating Them

The 2020 Democratic field, as with much of the Democratic party, is currently fighting about whether to expand Obamacare, allow more people into Medicare, or pursue the more radical option of full-fledged single-payer. But should a Democrat win the White House next year, it's likely that left-leaning wonks will make a push for a somewhat different, lesser-known idea: "all-payer rate setting"—or, as it is more colloquially known, price controls.  The basic idea behind all-payer is that the government sets prices for hospital services in a given region, offering transparency and eliminating the sort of maddening price differentials that frustrate patients, outrage politicians, and make headlines when they are revealed.  In theory, all-payer should hold down health care costs by making it impossible to mysteriously jack up prices for health care services. In practice, however, all-payer ends up captured by the hospitals it is supposed to constrain, adds new layers of confusion to the already complex process of health care pricing, and, although it helps control spending on certain particular metrics, doesn't serve as a meaningful overall check on health care costs.  Those are the main takeaways from Manhattan Institute scholar Chris Pope's new study of rate regulation in Maryland, which has maintained an all-payer system for about four decades. State-based price setting was common in the 1970s and 1980s, but largely disappeared by the 1990s; Maryland is the only state which continued the policy. And it continues, Pope concludes, because the state's hospitals like it, since it effectively guarantees them a large additional income stream from the federal government.  Maryland's all-payer system historically operated under a unique waiver from the federal government that ends up granting the state's hospitals about $2.3 billion a year more than they would get otherwise. The reason this extra pot of money exists is that in Maryland, Medicare rates are much higher than in other states. Typically, the rates Medicare pays hospitals are far lower than the rates paid by private insurers; nationally, private rates are about 67 percent higher than Medicare, a differential that has increased considerably in recent years. In 1997, they were just 13 percent higher.  But that's not the case in Maryland, because the state's all-payer system means that every price is the same, regardless of whether the payer is public or private. This results in somewhat lower private payments—about 13 percent lower than the national average, according to Pope. But it also means that Medicare rates are much higher than is typical—on the order of 40 percent higher for inpatient services and 60 percent for outpatient.  When all rates are the same, in other words, the rates paid by the federal government go way up, resulting in much higher than usual total payments. Maryland's rate-setting system is designed to extract a windfall from the federal government.  And just because the rates are regulated doesn't mean hospitals don't find other ways to exploit the reimbursement system. For much of the system's life, the state's hospitals posted lower than average growth per admission but had significantly higher than average volume, which allowed them to extract additional money since total reimbursements weren't capped.  That changed somewhat over the last decade with the adoption of so-called "global budgets," a complex system designed to contain total payments to a hospital and prevent volume-based gaming. Early reviews of the state's global budgeting system found that savings didn't always materialize. There are other concerns, too: By capping spending, global budgets have the potential to punish hospitals that attract more patients by offering higher-quality care.  And even in a capped system, there are other ways around the state's rate regulations: As Pope notes, the state is home to more ambulatory surgery centers—which are not bound by all-payer prices—than any other state. There is some reason to suspect that privately insured patients who might pay higher rates are being pushed into those venues.  In addition, the rules themselves become a kind of labyrinth of formulas and adjustment mechanisms. As Pope writes, "decades of reform have seen layers of regulations piled up to deal with the unintended consequences of previous regulation—in turn, generating still additional challenges that must be addressed with still further regulation." Adjustments to the rates are governed by obscure formulas that few really understand.  All of this tracks with previous studies of rate-setting programs. A 1997 Health Affairs piece on the history of state-based rate setting found that "the statutes and regulations needed to sustain their rate-setting systems were complex and often incomprehensible." Even in their heyday, it was clear that rate-setting systems had limited usefulness. In 1985, a study in the Journal of Health Politics, Policy, and Law, for example, found that states implementing rate setting saw lower per-admission costs but found "no direct evidence that total health care costs" were contained. Although these systems perform well on some targeted metrics, the hoped-for savings have always been something of a mirage.  In part that's because confusion about these systems tends to benefit large incumbents who are better equipped to manage their quirks than lower-cost upstarts. So it is no surprise that Pope describes Maryland's rate-setting process as being "dominated by hospitals," and offers some historical evidence to suggest that the original rules were crafted in part by the state's hospitals themselves.  This is how health care payment schemes almost always are: inscrutable, convoluted, yet somehow designed almost perfectly to funnel as much money as possible to health care providers. As Charles Silver and David Hyman argued in their recent book, Overcharged: Why Americans Pay Too Much for Health Care, much of the U.S. health care system only makes sense if you imagine it as a tool for funneling as much money as possible to health care providers.  The limitations of Maryland's program offer a lesson not only for would-be technocrats touting the virtues of price controls on their own but also for those backing single-payer, which, in transferring control of virtually all of the nation's health care financing to the government, would require federal bureaucrats to set rates and budgets. There would be formulas and systems. They would necessarily be complex, because the delivery of health care is inherently complex. And eventually, if not immediately, they would probably be captured by the organizations—especially hospitals—that stand to benefit.


hitandrun--2019-04-02--Trump Says Republicans Are Working on a New Health Care Plan Somehow Mitt Romney Is Involved

Trump Says Republicans Are Working on a New Health Care Plan. Somehow, Mitt Romney Is Involved.

Although Republicans failed to repeal and replace the health care law in a months-long push in 2017, and have signaled in recent months that they were ready to move on—especially since Democrats ran successfully on maintaining Obamacare's pre-existing conditions rules in last year's midterm—President Donald Trump has put repeal back at the center of the GOP's domestic policy agenda.  In a tweetstorm last night, Trump announced that Republicans "are developing a really great HealthCare Plan," that will be voted on after the next election, once Republicans "win back the House."  Trump's tweets follow last week's decision by the administration not to defend any part of the health care law in court, and reports that the White House is working with several conservative think tanks to develop a new health care plan, and that Mitt Romney is also involved in "preliminary discussions."  You may now be thinking to yourself: Mitt Romney? That Mitt Romney? To which I can only answer: Yes, that Mitt Romney.  We all remember how Romney, who, as governor of Massachusetts, passed RomneyCare, a state-based health care system built around an individual mandate, a health insurance exchange, and subsidies for regulated health insurance. At the time, Romney said the plan should be a national model for health care reform. Then Democrats under the Obama administration used the Massachusetts system as a model for their own health care legislation, Mitt Romney ran for president and denied that he actually wanted it used as a model—and, well, here we are, about a decade later, with a national system of subsidies that can be used to purchase regulated insurance on an exchange, known as Obamacare, which Trump is pushing to repeal, with, apparently, Mitt Romney's help. If this were a serialized television show, people would complain that the plot is too complex, and the lore contradicts itself, the characters aren't consistent, and that despite tons of activity, the story never really goes anywhere...and they would be right.  Trump says Republicans are developing a plan to vote on right after the 2020 election. But, as with any of Trump's promises, some skepticism is in order.  The first problem is that Trump's plan doesn't exist. Not only has the White House never put forward a health care plan of their own, Trump has never offered anything other than the barest, briefest explanation of what he would like to see a health care plan do. In his tweets last night, Trump simply says that it will lower premiums and "support Pre-Existing Conditions," which, like "HealthCare" itself, have apparently risen to capital letter status in Trump's mind.  In many cases, it's reasonable for the White House to hang back from the legislative process, letting Congress take charge. But one of the reasons that the repeal effort failed in 2017 was that Trump was utterly clueless about the various plans and processes; without presidential leadership to guide them, Republicans couldn't rally around an idea or even begin to attempt to sell it to the public. But Trump couldn't be bothered to learn the most basic details about the health care legislation the GOP was attempting to pass, so, again, here we are.  That dynamic, and the perception amongst congressional Republicans (including and perhaps especially leadership) that the biggest factor contributing to the party's midterm losses was Democrats campaigning on pre-existing conditions, is one reason why there now appears to be a huge split between Republicans on Capitol Hill, who are wary of putting health care back into play in 2020, and the White House, which is gung-ho about doing so.  On the election merits, Hill Republicans are probably right: A 2020 election about whatever replacement plan the Trump White House dreams up will probably ensure that Republicans remain a minority in the House, rendering this whole exercise moot.  Which bring us to the second problem: The plan the Trump administration settles on, assuming it does, will most likely be a bad plan that pleases almost no one. According to Mitt Romney (yes, still, that one), the new idea that is currently being cooked up is not a new idea at all, but a modification of an old one: Romney told Buzzfeed the forthcoming GOP plan will likely be based on Graham-Cassidy, a last-ditch plan introduced in 2017 that was, itself, only sort of a plan. The short version is that it would eliminate Obamacare's mandatory coverage requirements and take the money that is currently being spent on subsidies and Medicaid under the law and split them up between the states. States could then use that money to fund something like Obamacare (most blue states, presumably) or something else that they come up with later (most red states, presumably).  Almost everyone will hate this plan, including, probably, some people who say they are fine with this plan.  Liberals and defenders of Obamacare will hate it because it dismantles some of the regulatory infrastructure of Obamacare. In particular, it eliminates the health law's essential health benefits—which include things like maternity care—and therefore undermines the law's pre-existing conditions regulations.  Republicans running for reelection in 2020 will hate it, though many will admit this only in secret, in anonymous quotes attributed to "leading Republicans" and terse refusals to discuss the plan at length on the record, because it puts pre-existing conditions back on the table (see above), and Republicans in tight races don't want to run re-election campaigns built around pre-existing conditions.  Republicans from states that expanded Medicaid under Obamacare will hate it because it will almost certainly penalize states that did so by taking that money and splitting it (more or less) equally among states, meaning states that chose not to expand Medicaid would get more, and states that did expand would get less. These Republicans may be coy about the precise reasons, but they will be there, looming in the background of the debate.  Or perhaps the foreground. Among the Republicans who represent an expansion state are Senate Majority Leader Mitch McConnell and Sen. Rand Paul of Kentucky. In 2017, the last time a Graham-Cassidy style block grant was proposed, Paul said he opposed the plan because "It just means you're keeping all the money we've been spending through Obamacare, most of it, re-shuffling it, taking the money from Democrat states and giving it to Republican states. I think what it sets up is a perpetual food fight over the formula."  He's not wrong. Which is why critics of Obamacare are also likely to grumble about this idea as well. A Graham-Cassidy style block grant would merely take the money that's already being spent and redistribute it a different way, to politically powerful states who would lobby not only for more money for themselves, but more money overall. It's not a plan to improve the quality of health care in America so much as a politically contrived policy dodge, allowing Republicans in Washington, who don't agree on much of anything about health care, to say they took down Obamacare while leaving current spending in place—and redirecting a bunch of it toward Republican states.  For all of these reasons, it's hard to imagine that something like this passes, even if Republicans do retake control of the House in 2020, and hold control of the Senate and the White House. In other words, there's no reason to think the underlying dynamic that kept a repeal bill from passing in 2017, when the GOP held all of Congress and the White House, would be different.  This is quite likely to go nowhere, anyway. As Trump ramped up the health care chatter last week, The Washington Post reported that administration insiders knew it was just for show: "White House aides acknowledge that there is no specific plan and that when Trump has said the Republicans need to be the party of health care, it is more of a branding exercise." A branding exercise! Why, it's almost like Trump is someone specializes in sticking his name on hacky, low-quality products he doesn't actually create himself.  But to recap: Trump promises a great new health care plan is on the way, but there's no plan yet, and when there is a plan, it will probably be a bad plan that can't pass. And somehow Mitt Romney is involved.


hitandrun--2019-04-30--House Democrats Back Bill That Would Result in 500000 People Losing Health Insurance

House Democrats Back Bill That Would Result in 500,000 People Losing Health Insurance

Democrats have spent years complaining that Republican health care legislation would result in fewer people with health insurance, often while pointing to Congressional Budget Office (CBO) estimates showing just how many would go without coverage. But now Democrats in the House are backing legislation that would result in 500,000 people losing coverage, according to a new report from the CBO.  The bill would prohibit the sale of renewable short-term health plans allowed by a Trump administration rule that went into effect last year. These plans, which can be extended for up to three years, tend to offer more limited coverage than the plans sold under Obamacare's rules, and they also tend to be significantly less expensive. If the bill were to go into effect, about 1.5 million fewer people would end up purchasing short term plans, CBO estimates. About half a million of those people would end up purchasing coverage through Obamacare's exchanges instead. Others would obtain coverage through their employers. And about 500,000 "would become uninsured." That is, half a million people who had coverage would lose it—and replace it with nothing.  The bill would also have a modest effect on the deficit, resulting in a decrease of about $8.9 billion over the next decade. For context, CBO projects the deficit will total about $900 billion in 2019.  Although the bill is unlikely to become law while Republicans hold the Senate and the White House, House Democrats in both the Energy and Commerce and Education and Labor committees have already voted to support it.  The bill's effects are smaller than those of the GOP repeal legislation introduced during 2017, and total coverage may not be the only or best metric by which to judge such legislative proposals. Nevertheless, the bill exposes one of the fundamental rifts in today's health policy debates—the division between those who believe health insurance plans should be required, by law, to offer a comprehensive suite of benefits, and those who believe in allowing for more customized and personally tailored options. Essentially, it is an argument about whether politicians and bureaucrats should design coverage, or whether it should be left to individuals to choose for themselves.  That divide was reflected in the structure of Obamacare, which required health insurance plans to offer a suite of "essential health benefits," from maternity care to mental health, and outlawed an array of existing plans that offered more limited coverage.  The benefits of such comprehensive plans are plain: They offer a broad spectrum of benefits. But so are the drawbacks: They tend to be substantially more expensive, which is one reason why the price of unsubsidized plans sold through Obamacare's exchanges has soared.  In a report on short-term plans last year, for example, The Washington Post noted the case of one Iowa man who purchased a short term plan for $90 a month; the Obamacare-approved alternative would have cost about $450. Individuals and families have struggled to afford the more heavily regulated plans offered under the law, and some have simply been priced out of the market.  Rather than allow those people to purchase less expensive plans, even as a fallback option, the Obama administration restricted their sale, with backers of the health law deriding them as "junk insurance." In this view, a second-best option is not worth allowing at all.  Yet as Michael Cannon, the Cato Institute's health policy director, has pointed out, those plans can fill gaps in Obamacare's coverage scheme. With some exceptions, the health law's exchanges only make new coverage available during a few weeks or months at the end of each year known as an open enrollment period. Someone who purchased a three-month plan under the Obama-era rules in, say, January, would not be able to extend it and could find themselves unexpectedly sick and unable to renew the coverage for months. Allowing short-term plans to last for a year, as the Trump rule does, offers them a better option.  But these sorts of options are apparently not what Democrats have in mind when they say they want to expand coverage. Instead, they appear willing to potentially allow hundreds of thousands of people to go without coverage entirely in order to prevent anyone from having coverage they deem insufficient.


hitandrun--2019-06-17--San Francisco Wants To Force CEOs To Pay for a Citywide Free Mental Health Care Program

San Francisco politicians want to offer tax-funded mental health care to all city residents, and they're expecting companies with well-paid CEOs to foot the bill.  On June 11, six of the 11 members of the Board of Supervisors introduced a motion to put a new tax on "disproportionate executive pay" before San Francisco voters in November. Companies that pay their chief executives 100 times the median compensation of their employees would pay an additional .1 percent tax on gross receipts, in addition to the .3 to 1.3 percent gross receipts taxes they currently pay. The tax will increase incrementally to an additional .2 percent for firms that pay their chief executives 200 times their company's median employee compensation. The new tax would cap out at .6 percent for companies with chief executives who earn 600 times the company's median employee compensation.  This tax would fund another program slated to appear on the ballot in November, called Mental Health SF, which "will create a 24 hour, 7-day-a week" mental health services system "that will offer immediate care to any San Franciscan who needs it," said Supervisor Hillary Ronen when she first floated the policy in late May.  "We have a crisis of people who are severely addicted to drugs and that have severe mental health illnesses that are wandering the street and that desperately need help," Ronen said in an interview with KQED.  To be placed on the ballot, both proposals need support from at least six of the board's 11 supervisors. Both measures have that support, and the Board of Supervisors is expected to vote to place them on the November 2019 ballot by the end of July. The CEO tax question would require two-thirds support from San Francisco voters to pass because it is for designated spending. The Mental Health SF question requires only a simple majority of voter approval to pass.  If the mental health initiative passes and the tax fails, the city would likely need to find another way to fund the program.  In an interview with the San Francisco Chronicle editorial board, Ronen and fellow Supervisor Matt Haney said they would try to get more money from the state if the CEO tax does not pay for the mental health funding.  They might need to do that anyway, as the revenue from the CEO tax would likely not cover the total cost of Mental Health SF.  The city's Public Health Department estimates that the Mental Health SF proposal will cost between $244 million and $1.1 billion annually, reports the San Francisco Chronicle. Those estimates, the Chronicle notes, don't include the $278 million required to build or establish a new mental health drop-in center that the program would require. Meanwhile, the CEO tax is estimated to only bring in $140 million, according to the city controller's office. San Francisco currently spends $370 million per year on mental health services, according to USA Today.  In addition to the funding problems, there's also the question of who would be eligible for publicly funded care. "Among the many questions that seemed to trip [Ronen and Haney] up during a Monday meeting with our editorial board: Who, exactly, would qualify for the free care? What would be the residency requirement?" the Chronicle editorial noted.  Lastly, the new CEO tax being put forward to fund this proposal could well see highly nimble corporations choose to leave the city or reduce their presence there, warns Jared Walczak of the Tax Foundation.  Corporations "might well reduce their footprint in the city of the tax burden grows too onerous," Walczak. "Many businesses clearly want to be in San Francisco but as the diffusion of tech clusters demonstrates, there are limits."  In the last couple of years, San Francisco has seen companies leave to open up headquarters in places like Salt Lake City and Austin—places that have much friendlier business taxes and lower costs of living.  What's more, San Francisco voters passed the largest tax increase in city history just last November. Raising taxes again could drive away businesses and shrink the tax base, thereby reducing revenue and making it difficult to pay for existing programs, much less new ones.


hitandrun--2019-08-28--Democrats Are Retreating on Single Payer Health Care

A decade ago, single payer health care—the government-run health care system that Sen. Bernie Sanders (I–Vt.) refers to as Medicare for All—was a fringe idea in the Democratic Party. President Obama positioned his health care law as an alternative to the notion of a fully government-run system, and the few Democrats in Congress who supported single payer tended to do so softly, believing that most Americans would reject the idea.  When former Sen. Max Baucus (D–Mont.) led negotiations over the legislation that would become the Affordable Care Act, he had one rule: All options would be up for discussion—except for single payer. As Baucus tells Robert Draper of The New York Times in a sharply reported feature on the rise of single payer as a force in Democratic politics, the senator was sympathetic to the idea, but didn't believe America was ready. Given how difficult it was to pass the comparatively less radical plan that became Obamacare, I'd say he was right.  Over the last decade, however, single payer has become a widely held policy preference on the left—what Draper describes as a "litmus test for progressives," with more than a hundred backers in the House, and multiple top-tier supporters in the race for the Democratic presidential nomination. Medicare for All, Draper writes, has gone mainstream.  Yet in recent weeks, there are also signs that the momentum has slowed, and that some Democrats are retreating—or at least proceeding with caution.  Most prominently, there is Sen. Kamala Harris (D–Calif.), one of the original co-sponsors of Sanders' Medicare for All bill in 2017. After months of backtracking and flip-flopping on whether she supports eliminating most private health insurance, as the Sanders plan calls for, she appears to have fully reversed course, expressing discomfort with the Sanders plan and releasing her own (confused) competing plan.  The party's old guard meanwhile, continues to think Medicare for All is a bad idea, with House Speaker Nancy Pelosi (D–Calif.) repeatedly questioning it, and former Senate Majority Leader Harry Reid (D–Nev.) saying last week that it would be a problem for Democrats to back it in the 2020 election because it couldn't pass. Former Vice President Joe Biden, who represents this wing of the Democratic Party and is the primary field's most prominent critic of Medicare for All, remains at the top of the polls.  Sanders himself, meanwhile, recently modified his plan in response to concerns from unions, suggesting that even Sanders is not completely unmoved by criticism of his plan, at least if it comes from the left.  Meanwhile, it appears that there's little enthusiasm for single payer legislation where it matters—among the Senate Democrats positioned to exert the most influence over any future legislation.  Ezra Klein of Vox recently spoke to a quartet of upper chamber Democrats about their health policy plans. He found that they had ambitious expansions of Obamacare in mind, and no plans to seek Republican votes, assuming that their opponents would oppose any plan Democrats put forward. So these Democrats are feeling ambitious and expansive about health policy and unburdened by the need to compromise with Republicans. Yet even now they remain wary of the sort of full-fledged single payer system called for in Sanders' plan, largely because it would abolish most private coverage:  Which isn't to say Senate Democrats are prepared to abolish private health insurance. As in Wyden's comment, the word "choices" came up a lot in my conversations. "As a practical matter, the way we move forward on health care has to be recognizing people's current insurance system and allowing people to make choices," says Stabenow. "If everyone chose the Medicare public option, then it would be very clear what the public wanted." "I understand the aspirational notions around Medicare-for-all, but if there's one thing that I think we still have to wrestle with, it's that Americans want to see more of their fellow citizens covered but they are very nervous about losing what they have," says Sen. Mark Warner (D-VA). "There's a huge risk aversion." Brown, who has long supported single-payer, agreed. "I think you want people to have choice still," he says. "You don't want to take people's insurance away. A lot of people don't want government insurance. I understand that."  Single payer supporters like to argue that the energy is on their side, that the public broadly supports their plans, and that incrementalism has proven disastrous as both politics and policy. And they can point to polls like the one released this morning reporting that about two-thirds of Democratic primary voters are more likely to back a candidate who supports Medicare for All versus one who wants to expand Obamacare.  But while there's certainly truth to the notion that Medicare for All has risen in prominence and popularity, especially among the left, it also seems clear that there are limits to its rise. A separate poll from Monmouth released this week finds that less than one-quarter of Democratic voters want a system that replaces private insurance with a government-run plan—which is exactly what Medicare for All as envisioned by Bernie Sanders would do. And remember: This poll result is limited to self-described Democrats, who are almost certainly more favorable to wiping out private insurance than others.  Even if Democrats somehow managed to win control of the White House and both chambers of Congress—which looks unlikely at this point—it would be a real struggle to pass the sort of radically disruptive plan that Sanders has called for. And it's not just obstructionist Republicans who won't stand for it; it's Democrats themselves. A decade after Obamacare, it seems that Baucus' intuition that most Americans aren't ready for single payer remains correct.  So yes, Medicare for All has gone mainstream, and yes, it will likely remain a prominent part of the Democratic Party's policy vernacular going forward, and worthy of discussion and criticism as a result. But for the foreseeable future, at least, it will probably remain out of reach.


hitandrun--2019-09-05--A Government-Run Health Insurance Plan Would Be Less Radical Than Medicare For All But It Still Wou

A Government-Run Health Insurance Plan Would Be Less Radical Than Medicare For All. But It Still Wouldn't Work.

The health care debate in the Democratic primary so far has, for the most part, revolved around a single question: Medicare for All—or something else?  Given the persistent political and policy challenges to passing and implementing a single-payer system along the lines envisioned by Sen. Bernie Sanders (I–Vt.) and other Medicare-for-All boosters, the answer is probably going to be "something else." So it's worth asking what that something might be.  The most likely answer is a "public plan" or "public option"—that is, a government-run health insurance plan that would exist alongside today's insurance options, supplementing employer coverage, Obamacare, Medicare, and Medicaid without fully displacing them. Indeed, should Democrats win both Congress and the White House, the proposal of a public option is, at this point, far more likely than a big push for Sanders-style Medicare for All.  The public option was a feature of several early drafts of Obamacare, but was dropped from the final bill, primarily due to opposition from then-Sen. Joe Lieberman of Connecticut. So it's no surprise that the presidential race's most prominent public option backer is former vice president and current Democratic frontrunner Joe Biden, whose health care proposal has been billed as both an update to Obamacare and a moderate alternative to Sanders' single-payer plan.  A public option would probably be less radical, less disruptive, and, on paper, less expensive for the government than Sanders' Medicare for All proposal. Yet it would still pose real challenges in terms of cost and political viability.  Although the final text of Obamacare didn't include a full-fledged public plan, it did include a substitute in the form of funding for nonprofit insurance co-ops. As the health care law was being drafted, members of the Obama administration, including President Barack Obama himself, made clear that they saw little difference between the two systems: "You could theoretically design a co-op plan that had the same attributes as a public plan," then–Health and Human Services Secretary Kathleen Sebelius told Bloomberg. "I think in theory you can imagine a co-operative meeting that definition," Obama told Time, referring to a public option.  Public plan proponents often pitch the idea as a way to increase insurance market competition. It wouldn't outlaw private insurers like a Sanders-style Medicare for All plan. Instead, they argue, it would force them to compete with government-run insurer that wouldn't need to make a profit and could therefore be more efficient. And, they add, if a public option pays rates comparable to Medicare's—which tend to be much lower than the rates—then cost estimates indicate the plan could actually save the federal government money, reducing the federal budget deficit by more than $100 billion over a decade.  This was the basic argument for Obamacare's co-ops as well. Yet by and large, they were failures. The health law called for $6 billion in federal funding to help start these nonprofits, a figure that was eventually whittled down to about $2.4 billion. More than 20 were launched. By 2016, 17 had collapsed, leaving hundreds of thousands of beneficiaries without coverage. In every case, the reason was simple fiscal math: The co-ops couldn't bring in enough premium revenue to cover medical expenses.  If you view the co-ops as test cases for a public option, there are lessons to be learned from these failures: Launching a new health insurance plan at reasonably competitive rates that also bring in enough money to pay the bills is difficult, even with billions in federal funding at your disposal. There's little reason to think that a federally backed public option would fare any better, especially since lawmakers would face considerable political pressure to keep premiums artificially low.  There's a crucial difference, of course, between a government-subsidized insurer run as a nonprofit and an entirely government-run health insurance plan. When Obamacare's co-ops ran out of money, they shut down. A national public plan might conceivably continue to operate at a loss forever, with taxpayers making up the difference. Medicare's long-looming insolvency—currently set for 2026—makes clear that long-term actuarial soundness is no requirement for a government health care program.  And a public option's costs could be greater than Medicare's, since it there would be considerable political pressure to pay higher rates.  That's what happened in Washington, the only state to implement a public option. As The New York Times reported in June, state legislators originally wanted to set up a state-run health insurance plan that would pay the same rates as Medicare. But that would have represented a steep reduction from the rates paid by private insurance; Obamacare plans, for example, paid about 174 percent of Medicare rates. Doctors and hospitals pushed back against the proposal, and lawmakers eventually gave in, passing a plan that paid 160 percent of Medicare rates.  As the bill's sponsor, state Sen. David Frockt (D–46th District), told the Times, that concession was the only way to get the bill over the finish line. "I don't think the bill would have passed at Medicare rates," he said. "I think having the Medicare-plus rates was crucial to getting the final few votes."  Biden isn't the only prominent Democrat to back a public option. Influential Senate Democrats—who would presumably end up crafting much of any actual legislation—have been touting the idea recently too, saying that they no longer worry about trying to appease their Republican opponents.  But the problems and complications with building a new government-run insurance plan aren't exclusively a matter of Republican obstructionism. Hospitals and doctors will lobby for higher rates under any circumstance, and designing insurance that is actuarially sound while offering competitive benefits and pricing will be a challenge no matter what. In other words, it would still come with plenty of potential pitfalls—and so far, Democrats appear to have few if any plans to deal with them.  Finally, there is the matter of the public option's place in the health care debate as the sensible, pragmatic fallback position for those who see Medicare for All as too much, too soon. Biden and others are pitching the idea as a moderate alternative to single-payer, but this is a relative comparison that works only because Medicare for All is even more radical. A public option might be less immediately disruptive than a full-stop single-payer overhaul, but it would still substantially increase the feds' role in financing health care. Over time, it would expand and extend the federal government's control over the system, giving both Congress and the executive branch another means with which to influence the delivery of health care. It wouldn't quite be a government takeover, but the government would certainly tighten its grip.


hitandrun--2019-12-13--Public Health Scholars Warn: 'Prohibitionist' E-Cigarette Policies Undermine a 'Tremendous' Harm Red

Public Health Scholars Warn: 'Prohibitionist' E-Cigarette Policies Undermine a 'Tremendous' Harm Reduction Opportunity

In a wake-up call for people who claim to be concerned about smoking-related disease and death, five prominent public health scholars warn that the "tremendous" harm-reducing potential of e-cigarettes could be nullified by panicky political responses to underage consumption and vaping-related lung injuries. "The evidence warns against prohibitionist measures," they write in a Science article published yesterday. "Restricting access and appeal among less harmful vaping products out of an abundance of caution while leaving deadly combustible products on the market does not protect public health. It threatens to derail a trend that could hasten the demise of cigarettes, poised to take a billion lives this century."  The authors—Amy Fairchild, dean of the Ohio State University's College of Public Health; Cheryl Healton, dean of New York University's College of Global Public Health; James Curran, dean of Emory University's Rollins School of Public Health; David Abrams, a professor of social and behavioral sciences at New York University; and Ronald Bayer, a professor of sociomedical sciences at Columbia—observe that discussions of vaping "often neglect distinctions between nicotine and THC; between adults and youth; and between products obtained through the retail and black markets." While black-market cannabis products containing the additive vitamin E acetate figure prominently in the recent lung disease outbreak, they note, "nicotine or flavored vaping liquids have not yet been implicated." And while adolescent vaping, which has surged in recent years, does involve legal nicotine products, the authors warn that misguided efforts to curtail it could deter smokers from switching to a much less hazardous source of nicotine.  Consider the prohibition of flavored e-liquids, which the Food and Drug Administration (FDA) is considering and which several jurisdictions, including Michigan, Massachusetts, and New York City, already have imposed. "Vaping flavors with or without nicotine may appeal to youth, but flavors also appeal to adult smokers and help them switch," Fairchild et al. write. "Evidence suggests that the vast majority of smokers who successfully switch completely from smoking combustible products to vaping do so—after weeks, months, or years of dual use—by transitioning from vaping tobacco or menthol flavored liquids to other flavors and often to lower nicotine concentrations or even to no nicotine in order to reduce the triggers that remind them of their prior smoking product."  San Francisco has gone further than flavor restrictions by banning e-cigarettes outright, a policy endorsed by the American Medical Association. That approach, the article argues, gives insufficient weight to the reductions in smoking-related mortality that could be achieved if e-cigarettes remain legal, accessible, and appealing as an alternative to the conventional, combustible kind.  "There is solid scientific evidence that vaping nicotine is much safer than smoking," the authors note, while "evidence from multiple strong observational studies and randomized trials suggests that vaping nicotine is more appealing and more effective than [nicotine replacement therapy, such as patches and gum,] at displacing smoking." Although the FDA does not like to talk about it, that displacement is not limited to adults. Fairchild and her co-authors point out that "population youth smoking rates dropped much faster in the years vaping surged the most (2013–2019) than in prior years, reaching record lows during that same period, which suggests that nicotine vape use may be replacing smoking more than promoting it."  E-cigarette prohibitionists may think they are acting "out of an abundance of caution," but the policies they advocate look downright reckless when you consider the ongoing death toll from cigarette smoking. "The most conservative estimates suggest that were vaping nicotine to replace most smoking over the next 10 years, 1.6 million premature deaths would be avoided and 20.8 million quality adjusted years of life would be saved in the United States alone," the authors write. "The greatest gains would be among younger cohorts. Across the globe, more than 8 million smokers will die prematurely from smoking cigarettes, not from nicotine itself, in 2019 alone. The potential benefit of appropriately regulated, innovative, noncombusted nicotine modes of delivery could have a tremendous impact globally."


lifesitenews--2019-11-12--Alberta passes bill to protect conscience rights of pro-life healthcare workers

EDMONTON, Alberta, November 11, 2019 (LifeSiteNews) — The Alberta United Conservative Party (UCP) passed a private member’s bill on first reading Thursday that protects the conscience rights of healthcare workers and religious organizations who refuse to participate in practices such as abortion or euthanasia.  While mainstream media is full of stories warning that Bill 207 will restrict access to abortion and euthanasia, Alex Schadenberg, executive director of the Euthanasia Prevention Society, lauded the bill as “fabulous.”  Introduced by UCP backbencher Dan Williams (Peace River), the Conscience Rights (Health Care Providers) Protection Act reasserts the Charter rights of healthcare professionals to refuse to advise, assist or perform any “medical procedures” — such as abortions, contraception and euthanasia — they object to for personal or religious beliefs, CBC reported.  The purpose of the bill is to “protect healthcare providers and religious health care organizations from being subject to a claim for damages based on the exercise of rights under section 2(a) of the Charter,” it reads.  It will safeguard physicians “from having to do an act or refer for an act that they consider to be morally wrong,” Schadenberg told LifeSiteNews.  A great benefit of the law is that it does not list specific procedures, which allows wide latitude for doctors to conscientiously object to a number of “procedures” based on their religious convictions, he pointed out.  Currently, Alberta has a “1-800” number for a health ministry service that will direct patients who are seeking such morally objectionable services as euthanasia or abortion, and that doctors are expected to give to their patients, he said.  The bill also extends conscience protection to religious organizations, which the Charter does not, Schadenberg said.  The bill passed 36-15 on first reading, with all UCP members present voting for it and all NDP members voting against it. Premier Jason Kenney was not present for the vote.  Williams tweeted Thursday about the bill’s first step:  However, among media naysayers were Global News talk-show host Charles Adler and Macleans Magazine reporter Jason Markusoff, who tweeted in response:  Calgary Herald columnist Don Braid pointed out the conscience rights’ bill “provides immunity from complaint or discipline to health providers that refuse to deal with patients whose needs offend their conscience.”  The bill “never uses the word abortion, which makes it potentially wide-reaching. Conscience rights could also be expanded to help for LGBTQ people and assisted death,” opined Braid.  Moreover, CBC ran a story Sunday warning the bill could affect access to hormone therapy or medical treatment for transgender individuals.  The NDP also claimed the bill is the UCP’s attempt to limit access to abortion, but Williams said last Wednesday that is “absolutely not” the case.  “Let me be clear, this bill not only protects freedom of conscience, but it also in no way limits access to healthcare services in the province,” Williams said.  The rookie MLA said his bill was a response to the “moral distress” of doctors who believe their conscience rights are under threat, particularly after the Appeal Court of Ontario ruling last May, the CBC reported.  The appeal court upheld the College of Physicians and Surgeons of Ontario’s policy mandating that doctors who conscientiously object to certain medical “procedures” must provide an “effective referral” — that is, for the purposes of the act — to their patients.  “There is a real concern. They feel as though within the province, particularly in health care, but in our country at large across all professions and in public, there is an attack on conscientious belief and a diversity of views,” Williams said, as quoted in the CBC.  “This legislation is intended only to protect the Charter rights that individuals have and access to all these (medical) services will continue afterwards as before — no changes,” he added.  The bill has now been referred to the Standing Committee on Private Bills and Private Members' Public Bills. There are 63 UCP MLAs in the Alberta legislature to the NDP’s 24.


motherjones--2019-08-05--Trump Blames Shootings on Mental Illness But Hes Spent the Past 2 Years Trying to Cut Access to He

Trump Blames Shootings on Mental Illness. But He’s Spent the Past 2 Years Trying to Cut Access to Health Coverage.

During an address to the nation on the Monday morning following a weekend in which two mass shootings in the United States left 31 people dead, President Donald Trump deflected the blame for the massacres away from firearm access, saying, “Mental illness and hatred pulls the trigger, not the gun.”  But despite voicing concerns about mental illness, Trump has taken repeated action during his presidency to restrict Americans’ access to health care, including mental health care.  Trump has been a long-time critic of the Affordable Care Act, most recently supporting a lawsuit that aims to strike down the ACA entirely. As Edwin Park, a research professor at the Georgetown University McCourt School of Public Policy, explains, the ACA requires insurers to cover mental health care and bars them from discriminating against individuals with pre-existing conditions, including mental illness.  “The research is very clear that the ACA significantly increased coverage, which in turn increased access to behavioral health treatment, mental health services, treatment for addition, that have all resulted in improved mental health for individuals who gained coverage,” Park said. “If you take that coverage away, certainly that would be a huge negative impact on mental health in the United States.”  Prior to the ACA, popularly known as Obamacare, insurance companies didn’t necessarily have to pay for mental health coverage, and, as a result, 18 percent of people enrolled in private plans didn’t have mental health benefits. The ACA included mental health as one of the 10 “essential benefits” that must be included in all insurance plans sold on the individual or small-group markets. But through the lawsuit and the bills that Republican lawmakers tried to pass in 2017, Trump has spent his presidency trying to erase those essential benefits.  “The Trump administration has worked to roll back the ACA and insurance regulation, moving in the direction of less coverage of mental health, not more,” Larry Levitt, the executive vice president for health policy at the Kaiser Family Foundation, said via email. “The administration is arguing in court that the entire ACA should be overturned, including the expansion of Medicaid and benefit requirements, including for mental health.”  The Trump administration has already diminished access to mental health care by expanding the duration of short-term health plans, so-called “junk insurance” plans that do not have to comply with the ACA and typically don’t include coverage for mental health. “People get stuck in these plans, and if they have a behavioral health issue, they’re gonna likely go without needed care,” Park said.  The connection between mental illness and mass shootings, it should be noted, is weak. Even though research has shown that gun control reduces firearm-related deaths, the United States—which has had more mass shootings than any other country—has failed to pass comprehensive gun control measures. Recent mass shootings have been motivated by racism, anti-Semitism, and anti-immigrant sentiments. But if we were to accept the specious notion that unchecked mental illness was solely responsible for the epidemic of mass shootings in the US, Trump’s efforts to restrict Americans’ access to mental health care would have done more to contribute to the problem than to solve it.  “His general approach is to make it harder for people to access health coverage,” Park said. “As a result, that would make it more difficult to access needed care for behavioral health issues.”


newsmax--2019-12-24--Critics: Buttigieg Health Plan Slams Consumers at Year's End

Pete Buttigieg's moderate alternative to Medicare for All has a catch: People who choose not to enroll could still face bills totaling thousands of dollars, in a plan that critics say expands the individual mandate, the least popular part of Obamacare.  "Mayor Buttigieg's retroactive enrollment is just a supercharged version of the unpopular individual mandate that he's trying to obscure with misleading rhetoric," said Matt Bruenig, head of the People's Policy Project, a left-wing think tank, reports The Washington Post. "Instead of paying a $695 fine at the end of the year for being uninsured, you are hit with a bill to pay an entire year of premiums that could be ten times that amount. This will be a political nightmare."  Buttigieg's plan, critics say, might leave Americans with bills at the end of the year of more than $7,000.  Under Buttigieg's proposal, people who do not have healthcare coverage will find themselves automatically enrolled in the government plan, and then billed at the end of the year for "retroactive coverage."  His campaign says the plan will him to fill his promise of universal health coverage while not tossing out private insurance altogether. A spokeswoman denied Buttigieg has misled voters and justified charging back payments because people being charged will have had coverage over the year.  The choice, according to a statement, will not involve whether or not to have insurance, but instead where to get it.  Sens. Bernie Sanders, I-Vt. and Elizabeth Warren, D-Mass., both back Medicare for All plans that would require Americans to switch to a new $30 trillion single-payer system, which has led to criticism from Buttigieg, the mayor of South Bend, Indiana.  He says his own $1.5 trillion plan is more centrist and less expensive, as it offers patients the choice between a government plan and a private one.  "You take a version of Medicare, a public plan," he said at a recent Davenport, Iowa, event. "You can stay on a [private] plan if you'd rather. Or you can come to the public plan if you want."  Buttigieg, along with former Vice President Joe Biden and Sen. Amy Klobuchar, D-Minn., have released policies that would create a public option, or new government insurance plan, that would provide competition with private health insurance.


npr--2019-01-09--Democrats Health Care Ambitions Meet The Reality Of Divided Government

Democrats' Health Care Ambitions Meet The Reality Of Divided Government

House Speaker Nancy Pelosi said in a speech Thursday to the new Congress that Democrats want "to lower health care costs and prescription drug prices and protect people with pre-existing medical conditions." **Carolyn Kaster/AP** ****hide caption****  ****toggle caption****  Carolyn Kaster/AP  House Speaker Nancy Pelosi said in a speech Thursday to the new Congress that Democrats want "to lower health care costs and prescription drug prices and protect people with pre-existing medical conditions."  Carolyn Kaster/AP  In her first speech as speaker of the House, Nancy Pelosi made it clear that she knows that health care is key to why voters sent Democrats to Congress.  "In the past two years the American people have spoken," [Pelosi ](https://www.speaker.gov/)told members of Congress and their families who were gathered Thursday in the House chamber for [the opening day](https://www.npr.org/2019/01/03/681727613/pelosi-poised-to-retake-gavel- as-house-speaker-with-new-session-of-congress) of the session.  "Tens of thousands of public events were held, hundreds of thousands of people turned out, millions of calls were made, countless families, even sick little children — [our little lobbyists,](https://www.npr.org/sections/health- shots/2017/07/19/537208601/her-own-medical-future-at-stake-a-child-stormed- capitol-hill) our little lobbyists — bravely came forward to tell their stories and they made a big difference," said Pelosi, a California Democrat.  What is the Democrats' mandate?  "To lower health care costs and prescription drug prices and protect people with pre-existing medical conditions," she said to applause.  In their campaigns last year,[ Democrats promised](https://www.npr.org/2018/10/25/660281890/2018-is-the-year-democrats- got-comfortable-talking-health-care-again) to protect the Affordable Care Act, and the access to coverage that it guarantees for many people. Many Democrats went further, running on the promise of "Medicare-for-all."  But now that Democrats control the House, their ambitions are meeting up with reality.  With the Senate in Republican hands and President Trump having promised to repeal the ACA, Democrats' ability to make sweeping health policy changes is limited.  Instead, they'll likely rely on hearings and turn to the courts to try to influence health policy and shore up the ACA.  Pelosi started on Day 1.  Just hours after her speech, House Democrats voted to [intervene in a lawsuit](https://www.npr.org/2019/01/04/682349986/house-democrats-hire-new- top-lawyer-to-defend-affordable-care-act) in an effort to protect the Affordable Care Act. The House will join several state attorneys general in appealing [the ruling of a federal district judge in Texas](https://www.npr.org/sections/health-shots/2018/12/14/677002085/texas- judge-rules-affordable-care-act-unconstitutional-but-supporters-vow-to-app) that the law is unconstitutional.  And [Rep. Frank Pallone](https://pallone.house.gov/), D-N.J., head of the [Energy and Commerce Committee](https://energycommerce.house.gov/), announced a hearing on the impact of the ruling. He said he intends to hold lots of hearings to review the Trump administration's actions around the ACA — actions he calls "sabotage."  "At a time when the Trump administration is doing all the sabotage of the ACA, I think the focus really has to be on trying to prevent the sabotage and making sure the ACA is strengthened," he said in an interview in his Capitol Hill office.  That "sabotage" includes Trump's decision to[ stop reimbursing insurance companies](https://www.npr.org/sections/health-shots/2017/10/13/557541856 /halt-in-subsidies-for-health-insurers-expected-to-drive-up-costs-for-middle- clas) for discounts they're required by law to give to their lowest-income clients, Pallone said.  He also cited a Department of Health and Human Services rule change that allows insurance policies that [don't carry the full benefits ](https://www.npr.org/sections/health-shots/2018/10/01/652141154/buyer-beware- new-cheaper-insurance-policies-may-have-big-coverage-gaps)required by the ACA to be renewed for up to three years. In the past, those plans were intended to serve as a bridge for someone between jobs and were limited to just a few months  Pallone said these and other changes may violate the law.  "I think if you do some good oversight and find out what the sabotage consists of, then you can say, 'Well this isn't allowed under the law,' " Pallone said. "And then you either take it to court or try to get legislation passed."  Oversight is a powerful tool, said [Chiquita Brooks- LaSure](https://www.manatt.com/Chiquita-Brooks-LaSure), a former HHS official who is now a managing director at Manatt Health Strategies, a lobbying firm.  "I don't think we should underestimate how important that is, when decisions that are being made are questioned and officials have to defend them," she said.  For the past two years, the focus in Washington has been on repealing or dismantling the Affordable Care Act. That's about to change, she said.  "That energy can now shift to examining what the administration is doing and putting forth other ideas and other proposals, some of which might generate bipartisan agreement," she said.  Pallone is hopeful that Republicans may support some measure to shore up the ACA. In the last Congress, Sen. Lamar Alexander, R-Tenn., [proposed bills ](https://www.npr.org/sections/health-shots/2017/08/01/540656651/trumps- tweets-threaten-to-destabilize-insurance-markets)that would restore those payments to insurers, and he backed a plan to create a reinsurance program that could help reduce premiums.  Pallone acknowledged Democrats' plans are much less ambitious than the "Medicare-for-all" proposals that many of his colleagues touted during their campaigns.  "I just think it's unlikely that we could ever pass it," he said. "So I don't want to prioritize that."