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Red States seek to gut the Affordable Care Act and make Blue States more like them.

Red States seek to gut the Affordable Care Act and make Blue States more like them.

In this timely piece from the LA Times we learn about two working mothers, one in California and one in Texas, and their very different health care experiences thanks to the Affordable Care Act’s expansion of Medicaid to low-income adults, or lack thereof, in their states. The California mum (Jenny) whose state enthusiastically embraced the ACA, has health coverage which kicked in last year when she was hospitalized from a severe infection. Texas on the other hand opted out of the Medicaid expansion and the Texan mum’s (Courtney) experience reflects that fact; without health coverage she’s not able to afford asthma inhalers nor dental treatment for a broken molar she received in a domestic dispute. Courtney’s been living on Orajel, she says.

In fact recent research has concluded that the Red States who refused Medicaid expansion suffered a higher mortality rate among near elderly low-income adults compared to states that expanded the program. The result is that the states who opted out likely sustained almost 16,000 avoidable deaths during the period studied. 

The fate of the ACA now rests in the hands of an ideologically extreme right-wing Supreme Court (SCOTUS) in California v Texas stemming from an effort by Texas and 17 other Red States joined now by the Trump administration to overturn the ACA. (The result will not be known until next year). It’s difficult not to see this as anything other than a continuation of an expanding war on Blue States who typically provide their citizens with more and better services. It’s bad enough that Texas and the others demonstrate such a studied unconcern for the health and well-being of their own residents, but it’s truly reprehensible that they’re driven to seriously damage that of low-income people in the rest of America. Apparently, Texas politicians will not rest until Jenny’s experience in California mirrors that of Courtney. Misery really does love company it seems.

And if Republicans win the November election, we can be assured that any chance of a meaningful replacement for the ACA in the event that SCOTUS throws it out will be just as dead as those 16,000 people who died prematurely. Nor should we forget that if the law falls, all who enjoy private health insurance will once again be subject to caps on their coverage, prohibitions on pre-existing conditions and the other means of victimization in the tool bags of the insurance companies. 

All of which is a strong reminder that the sooner we crush the GOP at the ballot box, the better it will be for our collective welfare.

Democrats’ Aim Should Be Universal Coverage – Improving the ACA is the Right Vehicle

Democrats’ Aim Should Be Universal Coverage – Improving the ACA is the Right Vehicle

I get why the liberal wing of the Democratic Party is obsessed with enacting Medicare-for-All as the vehicle to universal coverage. I do. There’s no question that if we got it right, it would be both far more equitable and cost-effective than the present chaotic patchwork of a “system” that we’re currently lumbered with. I was raised in England and I know what a blessing the National Health Service has been, warts and all, in providing first class health care to everyone and without driving any of anybody into bankruptcy.

I also understand only too well the frustration of forever being told that it simply can’t be done, that the odds are stacked against it. How do we know unless we try, right?

Nevertheless, reality must intrude. First, as we have already seen with the few states that have tried to add a public option to their ACA markets that the health care industry will wage total war on any suggestion of even a modest expansion of of a public health care option. And when I say the health industry, we’re talking the insurance companies, the hospital industry, the pharmaceutical industry and much of the medical profession, particularly specialists, surgeons and the hospitals each of whom gain the most from the present lack of price controls on any but Medicare patients, and who will fight tooth and nail to keep it that way. Added to the health industry’s implacable opposition will be the Republican Party and the entire right-wing universe complete with relentless fear mongering and lies. And they will have a powerful issue that lends itself to demagoguery. Socialized medicine! Egads!! The fact that they’ve called the ACA, modest insurance reform at best, the same thing will of course be lost in the din.

Second, a total reform of the entire US health care system, one that dwarfs the enactment of the ACA, will require the support of most Americans, 180 million of whom currently have employer-provided health insurance which most of them believe is just fine, thank you very much. And Democrats would be asking them to give that up and see their taxes increase to boot – a hard sell even though insurance premiums will go away. All of this on the promise that expanding Medicare to include everybody, entirely rationale but something we’ve never tried before, would be better. And then there’s the seniors who are currently well satisfied with their Medicare and will be scared into believing (by you know who – see above) that somehow they will lose much of what they have if their health care is folded into a national scheme for the whole population.

In short it will not merely be an uphill struggle to enact Medicare-for-all but the policy equivalent of free climbing Half Dome in Yosemite National Park and to believe otherwise is delusional.

But there are other ways to universal coverage. In fact there are many models among developed countries that have achieved and did so with a system that incorporates private insurance albeit heavily regulated. Switzerland is one, for example. Check this link to the non-partisan Commonwealth Fund for a thumbnail sketch of the Swiss system and that of other developed nations from whose systems we can draw lessons .

Which brings us to the Affordable Care Act. Like all compromises on huge and complex pieces of legislation, the ACA is manifestly imperfect and in need of substntial improvement, for example by vastly reducing out-of-pocket expenses and greatly expanding the income cut off to receive premium subsidies. Yet the law has significantly increased the number of people with health insurance whilst proving unexpectedly resilient in surviving GOP efforts to repeal it and the Trump administration’s attempts to weaken it. If Democrats win the White House and Congress in 2020, they have an opportunity to undo all the damage of the Trump era and to make the ACA a far bigger success in providing affordable health coverage to a vulnerable population.

As well, Democrats have other costly priorities to address such as climate change and relieving our kids of the huge debt burden of college loans, to name but two. A full throated battle for a single payer health system will suck all the political oxygen out of the air and leave us with little energy to seriously tackle those issues. And that would be a tragedy.

US healthcare system ranks last again. Obamacare will raise its future rankings.

US healthcare system ranks last again. Obamacare will raise its future rankings.

A recent study by the Commonwealth Fund ranking healthcare systems in eleven advanced countries found the United States in last place. And while we languished at the bottom the study, which ranked healthcare delivery on such metrics as quality of care, access, efficiency and healthy outcomes, rated the United Kingdom at number one (take that, Fox News know-nothings). Just to add insult to injury, the UK spends $3,405 per capita on health (second lowest behind New Zealand) while we spend a whopping $8,508, the most of any in the study by a country mile.

Unsurprisingly, we fared poorest in categories associated with access and equity thanks to our lack of universal insurance coverage, and in efficiency where we are burdened with such deficiencies as excessive insurance company administrative overhead, medical duplication and overuse of emergency room treatment.

We also performed the worst in healthy outcomes as measured by infant mortality, healthy life expectancy, and mortality amenable to medical care (i.e. unnecessary or avoidable deaths).

As if this study wasn’t bad enough, we also have the International Federation of Health Plans 2013 Comparative Price Report which annually measures the cost of medical procedures and drugs among selected countries. Guess who regularly emerges as the most expensive? Even Switzerland (where a hamburger meal can cost $50) is way cheaper. As Ezra Klein noted about the iFHP 2012 price report in the Washington Post:

This is the fundamental fact of American health care: We pay much, much more than other countries do for the exact same things. For a detailed explanation of why, see this article. But this post isn’t about the why. It’s about the prices, and the graphs.

One note: Prices in the United States are expressed as a range. There’s a reason for that. In other countries, prices are set centrally and most everyone, no matter their region or insurance arrangement, pays pretty close to the same amount. In the United States, each insurer negotiates its own prices, and different insurers end up paying wildly different amounts.

So the US healthcare system is definitely ailing. But relief may be at hand. In noting the results of the Commonwealth Fund report, a New York Times  editorial states:

The poor results for the United States reflect the high cost of its medical care and the absence of  universal health insurance, a situation being addressed by the Affordable Care Act. The federal law is already increasing the number of Americans with health coverage and will substantially cut the number of uninsured in coming years. Other advanced nations are far ahead in the game because they have long had universal health coverage and promoted strong ties between patients and doctors.

Already the ACA’s beneficial effects on the rate of uninsured are being felt, particularly in states that embraced it wholeheartedly, as this piece about Minnesota from Jonathan Cohn in the New Republic shows.

So, despite the best efforts of Republicans to keep us mired in a rotten system that is inefficient, inequitable, prohibitively expensive, and too often lacking in overall effectiveness, there is hope that the future will be significantly brighter for American healthcare, thanks to Obamacare.

The case for Obamacare just keeps getting stronger.

The case for Obamacare just keeps getting stronger.

Two recent news items lend strong support to the notion that the Affordable Care Act will be a very significant benefit to the country going forward.

First, Sarah Kliff at Vox reports on recent evidence that the percentage of uninsured Americans is at its lowest rate since before the economic meltdown in 2008. The decrease in the uninsured is particularly strong among lower income Americans who were a particular focus of the law:

The gains of insurance coverage have been especially large among lower-income Americans – the people who qualify for Medicaid or insurance subsidies under the Affordable Care Act. There’s been a 5.2 percentage-point drop in the uninsured rate, for Americans who have a household income lower than $36,000 since the end of 2013.

Second, Jonathan Cohn in The New Republic has a piece on a newly published study in the Annals of Internal Medicine by highly regarded researchers showing that the overall mortality rate in Massachusetts fell significantly following the introduction of the state’s health care law (“Romneycare”), the one on which Obamacare is largely based.

This last is important for several reasons, not least because conservative opponents of the ACA have gleefully cited a different study, of Oregon Medicaid recipients, which seemed to show that having medical insurance did not equate to better health outcomes.

Cohn explains that for the Massachusetts study, the researchers

….obtained figures on mortality and, better still, they were able to isolate causes of mortality “amenable to health care.” In other words, they were able to get data on cancers, various cardiac problems, and other conditions that, with better medical care, people should be more likely to survive. Then they compared how the people in Massachusetts fared relative to groups of people from around New England, who were similar in almost every meaningful way—age, income, and so on—except that they lived in states where similar expansions of health insurance were not underway.

The results were clear. In those other places, outside of Massachusetts, the death rate from “amenable” causes went down by only a little bit and the overall death rate actually increased a tad. But in Massachusetts, deaths overall and deaths from “amenable” causes both went down—significantly. The authors calculated that, for every 830 people who got insurance in Massachusetts, about one person avoided a premature death.

The Massachusetts study covered a broader population than did the Oregon Medicaid research and a longer period. And the greatest improvement came, unsurprisingly, in counties where there were more low-income and uninsured adults. The researchers also examined whether factors other than expanded insurance could conceivably account for the decrease in mortality but concluded they could not.

Some caution is necessary. Certainly this is only one study in one state. But as Cohn puts it

The findings from a Massachusetts are consistent with a long line of similar, previous work. In the 1990s, for example, economists Janet Currie and Jonathan Gruber found that expanded eligibility for Medicaid led to lower infant mortality and fewer low birthweight babies.  “More work is clearly needed,” says Gruber, an MIT professor who was an architect of both the Massachusetts and federal health reforms, “but we should basically be back to our presumption that health insurance improves health.”

Conservatives continue to be in denial about Obamacare and to insist on dire predictions of the ill that will befall us if we do not repeal it. The decreasing percentage of uninsured in America and the Massachusetts study showing the benefits of health insurance, however, seriously undermine that narrative.

Obamacare’s overdue reform of a lousy private health insurance market.

Obamacare’s overdue reform of a lousy private health insurance market.

We’re hearing an awful lot from and about those in the private health insurance market who are receiving policy cancellation letters with lots of heat but little light being shed on what is a serious issue. Much of the focus has been on President Obama’s repeated and misleading assertions that everyone would be able to keep their existing insurance plan and doctor. Perhaps mindful of the fact that, more often than not in America, nuance falls on deaf ears, he foolishly neglected to make a distinction between employer-provided insurance plans, which will be unchanged, and those purchased on the individual market which constitute about 6% of the insured overall.

Republicans who have been and continue to be unmoved by the plight of the uninsured are apoplectic in behalf of the people in this small segment of the insurance market who are losing their current insurance plans. This selective outrage is driven, of course, by their desperate desire to seize on anything that can help them destroy the Affordable Care Act.

The Washington Post’s Ezra Klein is one who has successfully put the issue in some perspective and his detailed analysis is a must read.

The individuals and families affected and whose plans fail to meet the requirements of the ACA, broadly fall into two categories. The first group has lousy insurance plans with features such as high deductibles, limited coverage and low caps on total expenditures by the insurance company, that ensure crushing out-of-pocket expenses in the event of a chronic or acute illness requiring serious and expensive treatment. The cancellation of these policies is an unequivocally good thing since such bare bones plans offer little security to the policy holders and cause higher costs to health providers and ultimately to the rest of us. The ACA will almost certainly provide much better, affordable plans once subsidies for those who qualify are factored. These people have little to complain about.

The second group, however, has a genuine beef. They are generally healthy, middle aged or older folks who have a decent insurance plan which, nevertheless, does not meet the ACA. Some of them, as highlighted in Klein’s story, have received cancellation letters and been unable to find a plan as good as the one they are losing at a comparable price either in the exchanges (assuming they’ve been able to check the federal website if they reside in a state without its own exchange) or from their current carriers. If they have a decent income they don’t qualify for subsidies.

Regrettable as their situation may be, it has to be kept in perspective. As Klein points out, these people have benefitted enormously from the ability of insurance companies to exclude others from coverage that had pre-existing conditions. By excluding these poor risks, insurance companies were able to offer more favorable plans to those who are now vexed by seeing them cancelled. A further consequence is that some of those who previously benefitted from the dysfunctional and rather pitiless individual health insurance market will likely pay more for less under the ACA, as appears to be the case for the individual mentioned at the beginning of Klein’s piece.

It is likely scant comfort for this group to know that many more people will gain health coverage previously denied them under the reformed private insurance market, and that others will get better, more comprehensive plans than they had before. Nevertheless, for the country as a whole and the cause of social justice, it’s a very worthwhile tradeoff.

America may be Exceptional but not always in a Good Way

America may be Exceptional but not always in a Good Way

Being a naturalized United States citizen, I don’t pretend to understand everything about the Americans. That said, I’ve never really thought of Americans as being particularly inscrutable except when it came to two issues: universal healthcare coverage and the unfettered availability to any Tom, Dick or Harry of guns, about which I confess I have been completely stumped for some 33 years.

When I left the United Kingdom I left behind what many ignorant Americans on the right refer to pejoratively as socialized medicine. In fact, that system provides universal health coverage to all residents; primary and emergency care is first-rate, and while there may be waiting times for non-emergency surgeries these have decreased in the last several years with extra funding. No Brit pays out-of-pocket expenses for medical care (dentistry is a different matter) and statistically health outcomes compare favourably with this country. And all of this is achieved with an expenditure of a bit less than 9% of GDP compared to more than 16% in the US. And among industrialized countries, the UK represents the rule not the exception.

By way of contrast, at any given moment between 40 and 50 million residents of the US are without health care insurance. Thousands die every year of treatable conditions for which they did not seek timely treatment because they lacked insurance. Out-of-pocket medical expenses are the leading cause of personal bankruptcy in America. Under the current system insurance companies can refuse to cover people with pre-existing conditions; many are so underinsured that limits on coverage can be reached quickly in the event of expensive and long-term treatments for conditions such as cancer.

A delightful illustration of why Americans should be ashamed of this state of affairs comes with the news that some of the wounded victims of the Aurora movie theatre shooting lack insurance and will have to depend on the charity of friends and relatives, and perhaps a national whip-round to pay their hospital and rehabilitation bills.

Yet, inexplicably, a plurality of Americans appears to prefer this awful status quo to the first meaningful reform effort to be signed into law: the Patient Care and Affordable Care Act or “Obamacare” as the preferred pejorative label this time from the ignoramuses on the right. While far from perfect (a public option would have been nice) the ACA promises to bring real and substantive benefits to both the insured and uninsured to address the flaws in the current system; but to most Americans it’s the policy equivalent of being forced to take castor oil.

And on the subject of guns, America again has taken a different path from other advanced nations. Unless one is to believe (which I do not) that Americans are inherently more violent than Europeans or Canadians, it is virtually impossible to escape the conclusion that America’s weak gun laws account for its murderously high homicide rate. And I’ve never understood why Americans on the one hand express shock and outrage at events such as the Aurora movie theater shooting-spree when, on the other, they have made such incidents inevitable by their refusal to vote for stronger controls and restrictions on the sale and possession of firearms.

The result, as with the lack of universal healthcare reform, is that thousands more Americans die or suffer grievously every year than would otherwise be the case if ordinary Americans and their political leaders made a different choice.

So is it Americans’ ignorance of the rest of the world which feeds their delusions that no matter their own travails they are better off than everyone else? Or are Americans simply a nation of masochists who suffer to be free or simply want to be free to suffer?

For me it continues to be a mystery and more than a little sad.

Mitt Romney Praises Israel’s Single Payor, Government Controlled Healthcare System

Mitt Romney Praises Israel’s Single Payor, Government Controlled Healthcare System

While speaking at a fund-raising party in Jerusalem that raised a million dollars for his presidential campaign, Mitt Romney praised Israel’s universal, cost-effective, single-payor, government-controlled healthcare system:

When our health care costs are completely out of control. Do you realize what health care spending is as a percentage of the GDP in Israel? 8 percent. You spend 8 percent of GDP on health care. And you’re a pretty healthy nation. We spend 18 percent of our GDP on health care. 10 percentage points more. That gap, that 10 percent cost, let me compare that with the size of our military. Our military budget is 4 percent. Our gap with Israel is 10 points of GDP. We have to find ways, not just to provide health care to more people, but to find ways to finally manage our health care costs.

Right on Mitt, you nailed it!

In order for us to provide insurance for everyone, lower our nation’s cost of medical care, and improve the overall health of our nation, we need to do what Israel does:

  • Take the profit out of basic health insurance.
  • Provide universal coverage.
  • Implement a tax-based, single payor plan.
  • Negotiate with healthcare providers to control costs.
  • Allow citizens to purchase supplemental insurance for items outside of the basic government controlled plan.

It works for Israel, so why wouldn’t it work for us?

The only obstacle preventing the U.S. from adopting Israel’s exceptional system is the Republican Party and the uninformed, stubborn people that vote for them.

I can’t wait to hear you explain your love Israel’s government-run health insurance plan to the Tea Partiers at your next rally.

When it comes to Obamacare, are Americans able to tell Fact from Fiction anymore?

When it comes to Obamacare, are Americans able to tell Fact from Fiction anymore?

Polling suggests that two thirds of Americans want to see all or part of the Affordable Care Act thrown out by the Supreme Court, the most unpopular provision being the individual mandate.

Many of these are, of course, Republicans whose opposition is mostly mindless: They’re against it on principle because, well, it was pushed by President Obama and a Democratic Congress and that’s enough in itself. The rest are among the 31% of Americans who even after two years still seem to have no clue what’s in the bill according to the Pew Research Center. And this includes many who would benefit the most from the law, as highlighted by the New York Times.

It is simply mind-boggling to have that much ignorance in the country on a major piece of legislation that will benefit all of us in one way or another two years after it was enacted.

Particularly troubling is the extent of opposition to the individual mandate even as other polling shows strong support from many of the same people for keeping popular provisions such as barring insurance companies from excluding people with pre-existing conditions. Which begs the question: Do these Americans actually understand how insurance works?

For example, would we compel an automobile insurance company to take on an uninsured motorist who’s just had a prang and then expect them to pay for the damage? Of course not; so how can we require a medical insurance firm to do likewise for a willfully uninsured individual who has just discovered he’s ill. And if we did, what the heck would happen to our insurance premiums? Yes, they’d skyrocket and, furthermore, such a mandate would drive most insurance companies entirely out of the individual market quicker than you can say “pre-existing condition”. And this isn’t guesswork either. We have empirical evidence from states who tried it, including my own state of Washington.

The Affordable Care Act is our last chance to reform the private medical insurance market to make it work for all of us, not just for the industry. And the individual mandate is the pillar which supports the rest of it. Don’t be fooled by the plethora of articles from those who suggest that much of the law’s provisions will survive without it – they won’t.

If two thirds of Americans truly oppose the individual mandate, then two thirds of Americans are idiots, although as Greg Sargent explains in The Washington Post most of them will never know what they missed.