14 October 2016
Dear Interested Readers,
Inside This Week’s Letter
This last week has been quite eventful and cramming everything that I want to say to you into a letter of a reasonable length has been a challenge. I failed, as you will discover. There was so much that I wanted to share. The letter begins with a description of my experience last weekend as a campaign worker. I learned a lot going door to door with a new friend interviewing a list of people in my town who were registered as “independent”.
I have complained on several occasions about the lack of a real healthcare discussion in the election. Following the discussion of “locker room” humor, the “town hall” of Sunday night’s debate format did include questions that forced the candidates to discuss healthcare for a few minutes. This letter is quite long because it incorporates some of the transcript of the debate that has been annotated with “fact checking” into the discussion. You may enjoy and be informed by reading the document which comes from NPR.
Another new key resource discussing the potential impact of the election on healthcare that adds to the length of the letter are quotes that are excerpted from the publication last Thursday (October 6) of a group of three papers by the New England Journal of Medicine in its “Perspectives” section:
From Obamacare to Hillarycare — Democrats’ Health Care Reform Agenda by
Jonathan Oberlander, Ph.D.
What Would a Republican Win Mean for Health Policy?
Gail R. Wilensky, Ph.D.
and finally from David Blumenthal and James Morone, the authors of The Heart of Power: Health and Politics in the Oval Office
Past as Prologue — Presidential Politics and Health Policy
I would encourage you to do what I have done and read all three articles in reverse order. They are short articles and taken together are only about 4,000 words. Whether or not you have the time or interest to read them I do give you bits and pieces of all three woven within this letter.
It is important for you to realize that this letter is not an effort to convince you to cast your votes (now I am talking about the whole ticket) as I will vote. My objective is to help you consider what I consider to be a more important set of concerns. Why has the election evolved the way it has? What is likely to change after the election? What can any of us do individually or collectively to make a difference? I hope that when the election is over our elected officials will be able to share a common objective of bringing better healthcare to every person in this country for a cost that each individual can afford. That cost must fit into a budget that allows for other important priorities that must be financed within the resources that we collectively share. For emphasis I reprint the very succinct expression of this goal almost every week:
Care better than we’ve seen, health better than we’ve ever known, cost we can afford…for every person, every time.
I postulated last week that most of us in healthcare have agreed on the Triple Aim as the “what” of our objective. It is the “how” that confounds us as we are divided by positions that are expressions of our equally valid personal world views.
At the end of the letter you will not find my usual attempts to use the microcosm of sports to find a clue to the meaning of life. The Red Sox are done for the year. David Ortiz’s next stop in baseball is Cooperstown. As always, the letter closes with a celebration of the continuously changing beauty of all that is around me here in my own little corner of the world. I hope that the picture in today’s header is ample evidence of that reality.
I greatly appreciate the several comments that followed last week’s letter. Keep them coming. Your comments and ideas help shape my view of what is important and help me understand the variety of opinion that exists in healthcare. Through your comments I have a sense of being connected to a community. It has been said that information is one of the few things that we can give away and simultaneously keep. I hope that you feel that these notes and strategyhealthcare.com are something that you would like to give to a friend and colleague as you keep them for yourself.
Continuing Concerns About the Election and the Future of Healthcare
Perhaps I answered the phone rather than letting the call go to voicemail because I had just come in from enjoying another evening on the water in my kayak. The sunset had been glorious, and as is often true, I had caught several fish in the waning light. This has been the year of many “little fish”. In past years the fish have been larger. This year there have been only a few truly “photo worthy” fish. On this evening, as the sun slipped away, I had pulled in a good sized bass and was still quite energized by the experience.
On the phone I was met by a cheery “Hello!”. The young woman with a pleasant voice on the other end of the line identified herself as a campaign worker for the local Democratic Committee and asked whether or not she could recruit me to work as a volunteer on the phones or help with some door to door canvassing. Suddenly and unexpectedly I was faced with a test. Was I going to be a sideline player, all talk and no participation, or was I going to get involved? Did I care enough to give more than lip service and a few bucks? Would I have the courage to actually ask people to engage in considering the candidates that had captured my confidence?
I knew that sitting in a phone bank and talking on the phone to people that I did not know was not something that I wanted to do. I am annoyed to get such calls and in turn did not want to be the source of annoyance for someone I did not know. For some reason being the annoying knocker at the front door was more appealing. I agreed to show up on Saturday morning to do something I had never ever done before. My final quick statement to myself before saying yes to the voice on the phone was that if my team lost the election, and I had done nothing to help, I would feel derelict in my sense of my responsibility to my community. Is avoidance of a possible sense of guilt acceptable as a motivating objective? I amended that thought with the reassurance that the forecast for Saturday was that it would be a pretty nice day, and the worst outcome would still be the opportunity to enjoy being outside.
Saturday morning was beautiful and the experience was rewarding. Two of us showed up and the young woman who had recruited us gave us a quick “how to” lecture along with a computer print out of several dozen names and addresses. We drove to a diffuse neighborhood of homes that ranged from ranch houses out of the fifties to large antique farmhouses surrounded by glorious sugar maples that were probably over a hundred years old. These houses, along with some new and architecturally interesting homes, were interspersed with residual farmland bordered by beautiful stone walls. Because the land was open and had not been abandoned and allowed to return to forest, the visitas available from most of the homes on our list were spectacular. To the West the view was dominated by Mt. Sunapee. To the North I could see Croyden Peak and thought at times I could even faintly recognize Killington Peak more than forty miles away. Mount Kearsage was looking over our shoulders from the South. The only bummer was that because of the need to move quickly to see the entire list we drove from house to house rather than enjoying a good walk. In many ways it was like the exercise I would do when I was collecting on my paper route almost sixty years ago. Are they home? If so will they come to the door?
We were instructed to record everything we could. In many ways it was like a “roster review” in a population health exercise. The process was an exercise in inquiry. Are you planning to vote? What candidate in each race are you favoring now? Do you have questions about Hillary or any of the other Democrats down the ballot? Will you share with us for whom are you are planning to vote and why? Since you are not sure for whom you will vote may we offer you some literature about our candidates’ positions?
It was an amazing experience in part because my partner, a retired architect, had been a resident of the area for forty years and had designed some of the houses that we visited. He knew many of the people. Everyone that knew him seemed genuinely happy to see him, even though many of them were clear that although they were registered as an independent, they would be voting a straight Republican ticket this year, as they always did. One ninety year old WWII vet who was cleaning up his garden when we arrived cheerfully out did Donald Trump in his expressions of loathing about “dishonest Hillary and her philandering husband”, even as he updated my friend on the latest adventures of his son who once played soccer with my new friend and would be back in town in a few weeks. We asked his 89 year old wife who was getting into her car to go to town if she had seen the videos of Donald Trump and Billy Bush talking about women that had been released the day before. She quickly said yes, but thought there was no problem because that’s just the way men talk.
The issue of the remarks on the video came up in almost every conversation. For many the lewd conversation was the finally straw that forced them to let go of Trump and embrace Hillary as the better of the two candidates. They stated that both were flawed almost beyond acceptability. One retired school teacher announced that he was busy writing a letter that outlined all of Trump’s campaign atrocities and that he was going to send it to every newspaper in New Hampshire. A bright and energetic 85 year old man said the tapes exceeded everything he had ever seen in politics, and he had been active in local and state politics for decades. For the first time in memory he was going to vote a straight Democratic ballot. I was moved by a woman who looked frail and was probably around eighty who had seen the video on TV shortly before we arrived. She was still upset and could hardly maintain her composure.
At the end of the morning my sense was that the attitudes of the people on our list were representative of the published polls from our state. Hillary was slightly ahead among the “independents” we canvassed who would declare their voting plans. Several were “still thinking” and not so sure. One woman, whom my colleague knew well and whose two sons were throwing passes in the front yard, and a man in his mid forties a few doors away who was painting his basement, but stopped to talk to us, both seemed matter of fact about the flaws of both candidates and unsure about the real issues in the election. Neither had decided for whom they would vote. Issues other than the election seemed more important in their lives. They seemed to feel that they could not see how either outcome would make a difference to them.
The inability to decide who really deserved their vote that many people expressed was hard for me to understand. We offered them an alternative process to consider. Rather than examine what the candidates were selling as ideas and opinions, perhaps they should go through a list of issues and record their own opinions. We informed them of a website, https://www.isidewith.com, where they could respond with their own preferences to questions about the issues. The tool then matches up their answers with the candidates. I tried the questions and was not surprised that I was a 99% match with Clinton and only a 7% match with Trump. I was surprised that I was almost as high a match with Jill Stein as I was with Clinton. You might enjoy the exercise.
All in all, it was a great morning and early afternoon. I made a new friend and met my neighbors. I learned that there was a huge range of opinion within our little town among people who deserved my respect. They were not a “basket of deplorables”. I was eager to hear what I would learn from Sunday night’s debate and was also better informed because I had read the articles published that week in the New England Journal of Medicine.
The third article in the issue which was written by David Blumenthal and James Morone is a good launching point for a serious update of the history behind the healthcare issues in this election. They remind us of the long story that they beautifully outlined in their 2009 masterpiece.
...Since Harry Truman first advocated universal national health insurance during his 1948 campaign, Democratic presidential contestants have generally endorsed expanding coverage for the uninsured through governmental financing and regulation. This position has reflected the interests of their political base: lower-income, more heavily minority, and more likely to be uninsured.
Republican candidates have often opposed these coverage extensions. When pressed to set out alternatives, they’ve proposed more modest programs that rely on private-sector solutions. These positions have reflected the interests of Republicans’ political base: more affluent, less likely to be minorities, more likely to be insured, and mistrustful of government.
These dynamics are playing out once again. Hillary Clinton supports the Affordable Care Act (ACA) and proposes to augment its coverage provisions. According to a recent RAND Corporation analysis, her plans would increase the number of insured Americans by up to 9.6 million individuals. Donald Trump promises to repeal the ACA and replace it with programs that will, according to the RAND analysis, cover as many as 15.6 million fewer individuals and rely more heavily on market mechanisms.
The historical perspective that their book The Heart of Power: Health and Politics in the Oval Office provided us in 2009 is augmented when they say:
When Barack Obama supported expanded insurance during the 2008 election and his presidency, he and his allies sought to build political support by adopting a number of ideas first proposed or supported by Republicans.
They supported the employer mandate and the much-maligned individual mandate (requiring all Americans to obtain insurance coverage), which, correctly or not, they perceived as a Republican concept. They proposed subsidizing the purchase of private coverage by uninsured Americans from competing private insurers — an idea advanced by President George H.W. Bush in 1992 (though the details of the Bush and Obama plans differed significantly). Obama and his congressional allies also abandoned the cherished Democratic principle that whatever the methods used, health care reform should result in coverage for all Americans. The Congressional Budget Office projected in 2010 that the ACA, once fully implemented, would leave 21 million Americans uninsured.
As we look back on this history, a clear pattern emerges. Democrats propose. Republicans oppose and (frequently) counter. Political reality stalemates insurance expansion. When Democrats suffer a defeat, they pursue more modest objectives and try again, often adopting Republican ideas in the hope of building political consensus. The end result: Hillary Clinton now forcefully defends a law that leaves millions of people uninsured — something she passionately opposed in 1993.
This analysis really counters the argument, often presented by those who do not like the ACA, that the law was not the product of a bipartisan process. The ACA was the product of a bipartisan process that has gone on for more than fifty years. The core concepts of the ACA are Republican ideas that really can be traced as far back as Eisenhower’s administration. It is also easy to see that Bernie Sander’s position was a reversion to the entitlement proposal first articulated by Truman in the late forties, and that the core Democratic proposal shifted from Truman’s idea of entitlement to the Republican concept of a mandate as far back the first Clinton proposal in 1993. Since then and continuing on now, the core questions for most of the electorate that define the problem are:
- How do we cover more people?
- How do we pay for the program?
Healthcare professionals and the industry have more probing questions that also need consideration. A short and incomplete lists includes:
- How will we be paid and our institutions funded?
- How will quality be measured and maintained?
- How will care be organized?
- How will our sense of professionalism change?
- What voice will we have in the evolution and revision of the rules and policies?
Those are some of the questions that the debates should be covering. How well did the debate explore those questions? Let’s briefly look at the transcript.
The debate began at 9:02. At 9:10 Trump actually introduced healthcare in his first strange word salad:
...When I watch the deals being made, when I watch what's happening with some horrible things like Obamacare where your health insurance and health care is going up by numbers that are astronomical 68 percent, 59 percent, 71 percent, when I look at the Iran deal and how bad a deal it is for us, it's a one-sided transaction where we’re giving back one hundred fifty billion dollars to a terrorist state, really, the number one terrorist state, we've made them a strong country from really a very weak country just three years ago.
The fact checkers give us a little different picture of the costs the average family bears:
Health insurance premiums for families rose an average 3 percent last year, according to the Kaiser Family Foundation. Premiums have risen 20 percent from 2011-2016, according to the Kaiser report. However, costs to families have increased even more because families are facing higher deductibles and copayments. In the past five years the average cost of health care to families before their insurance kicks in has risen 67 percent.
The next comment about healthcare came as a question at 9:34. Here for you to read is the entire transcript along with comments by the NPR fact checkers. The conversation lasted less than ten minutes.
ANDERSON COOPER
9:34 PM
We have a question here from Ken Karpowitz. He has a question about healthcare. Ken?
DONALD TRUMP
9:34 PM
I'd like to know Anderson, why aren’t you bringing up the emails? I’d like to know. It hasn’t been finished at all.
ANDERSON COOPER
9:34 PM
Ken Karpowitz has a question.
DONALD TRUMP
9:34 PM
It's nice - it's one on three.
AUDIENCE MEMBER
9:34 PM
Affordable Care Act, known as Obama care. It is not affordable. Premiums have gone up. Deductibles have gone up. Co-pays have gone up. Prescriptions have gone up. And the coverage has gone down. What will you do to bring the costs down and make coverage better?
ANDERSON COOPER
9:34 PM
That first one goes to Secretary Clinton because you started up the last one to the audience.
HILLARY CLINTON
9:35 PM
He wants to start, he can start. No go-ahead, Donald.
DONALD TRUMP
9:35 PM
No, I’m a gentleman. Hillary, go ahead.
ANDERSON COOPER
9:35 PM
Secretary Clinton?
HILLARY CLINTON
9:35 PM
Well, I think Donald was about to say he's going to solve it by repealing it. And getting rid of the Affordable Care Act. And I'm going to fix it because I agree with you. Premiums have gotten too high, co-pays, deductibles, prescription drug costs. And I have laid out a series of actions that we can take to try and get those costs down. But here’s what I don't want people to forget when we’re talking about reigning in the costs, which has to be the highest priority of the next president. When the Affordable Care Act passed, it wasn't just that twenty million people got insurance that did not have it before. But that in and of itself was a good thing. I meet these people all the time and they tell me what a difference having the insurance meant to them and their families. But everybody else, the one hundred and seventy million of us, who get health insurance through our employers, got big benefits. Number one, insurance companies can’t deny you coverage because of a pre-existing condition. Number two, no lifetime limits, which is a big deal if you have serious health problems. Number three, women cannot be charged more than men for our health insurance, which is the way it used to be before the Affordable Care Act. Number four, if you are under 26 and your parents have a policy, you can be on that policy until the age of 26.
Alison Kodjak, NPR Health Policy Correspondent inserted a comment on the facts...
The Affordable Care Act mandates that health insurance cover a minimal set of health care services, including the ones listed here. And it also bans insurance companies from refusing insurance to people who have pre-existing conditions
The transcript continues with Clinton still speaking:
Something that didn’t happen before. So I want to very much to save what works and what is good about the Affordable Care act. But we have got to get costs down, we have to provide some additional help to small businesses so that they can afford to provide health insurance. But if we repeal it, as Donald has proposed, and start over again. All of those benefits I just mentioned are lost to everybody. Not just people who get their health insurance on the exchange, and then we would have to start all over again. Right now, we are at ninety percent health insurance coverage. That is the highest we have ever been in our country.
ANDERSON COOPER
9:37 PM
Secretary Clinton, your time is up.
HILLARY CLINTON
9:37 PM
So I want to ask to get to an hundred percent but get costs down and keep quality up.
ANDERSON COOPER
9:37 PM
Mr. Trump you have two minutes.
DONALD TRUMP
9:37 PM
It is such a great question, and it's maybe the question I get almost more than anything else. Outside of defense.Obamacare is a disaster. You know it, we all know it. It is going up at numbers that nobody has ever seen worldwide. Nobody has ever seen numbers like this for health care. It is only getting worse. In seventeen, it implodes by itself.
Scott Horsley, NPR White House Correspondent, inserted a fact explaining comment into the transcript:
Obamacare has pushed the uninsured rate to an all-time low of just over 9 percent while extending coverage to some 20 million people (including Medicaid expansion, exchanges and young adults on family plans). The uninsured rate would be lower still had the 19 holdout states expanded Medicaid.
Competition on the exchanges is shrinking. Fewer insurance companies are playing, and 19 percent of exchange enrollees will have just one company to choose from in 2017. (That’s up from 2 percent in 2016.) Sixty-two percent of enrollees will still have at least three choices. The problem tends to be worse in rural areas and in the South. Premiums in the exchanges are also increasing. McKinsey Center looked at 18 states and found an average increase of 11 percent for the benchmark plan next year. Some of that increase will be absorbed by the federal government as most exchange subscribers receive a subsidy. A study by the Urban Institute finds that even without the subsidy, exchange plans cost an average of 10 percent less than employer-provided coverage.
Trump’s answer continues:
Their method of fixing it is to go back and ask Congress for more money. More and more money. We have right now have almost twenty trillion dollars in debt. Obamacare will never work. It is very bad, very bad health insurance. Far too expensive, and not only expensive for the person that has it, unbelievably expensive for our country. It's going to be one of the biggest line items, very shortly.
Alison Kodjak, NPR Health Policy Correspondent, inserted a comment to provide some perspective here:
The subsidies to individuals who buy health insurance under the Affordable Care Act are estimated by the Congressional Budget Office to be about $500 million [did she mean billion?] over 10 years or about $50 million [?billion]a year, out of a total federal budget of $4 trillion. However, Obamacare also expanded Medicaid coverage in many states, putting about 10 million more people into health plans that are fully paid for by the federal government. Including that spending, and subsidies for employers who provide insurance to their workers, total federal subsidies for health care are about $660 billion, according to the CBO.
Trump’s answer continues:
We have to repeal it, and replace it with something absolutely much less expensive. And something that works. Where your plan can actually be tailored. We have to get rid of the lines around the state, artificial lines. Where we stop insurance companies from coming in and competing because they wanted President Obama and whoever was working on it. They want to leave those lines because that gives the insurance companies, essentially, monopolies.
Joe Neel, NPR Science Desk Editor and Correspondent, adds a fact:
Buying insurance across state lines is a perennial Republican favorite. It has gone nowhere in the decade-plus years it has been proposed. Opponents say it would reduce standards for insurance coverage to the lowest levels out there. For example, people living in a state with strong insurance protections — like New York or California — would lose those protections if they were buying a policy in a low-regulation state like Texas. People might save money on premiums this way, but they ultimately might suffer. The conservative Heritage Foundation maintains that individuals should be able to purchase the health plan that "best meets their needs regardless of the location of the issuer."
Trump continues his answer but inserts a false statement:
We want competition. You will have the finest health care plan there is. She wants to go to a single-payer plan, which would be a disaster. Somewhat similar to Canada. And if you haven't noticed the Canadians, when they need a big operation, they come into the United States, in many cases. Because their system is so slow, it is catastrophic in certain ways. But she wants to go to single-payer.
Joe Neel corrects the misstatement:
Clinton does not support single-payer. She supports expanding Medicare to people 55 and over but has not come out in support of a complete overhaul of the health system so that it would be more like Canada or many European health systems.
Trump finishes his analysis and answer:
Which means the government basically rules everything. Hillary Clinton has been after this for years. Obamacare was the first step. Obamacare is a total disaster. And not only are your rates going up by numbers that no one has ever believed, but your deductibles are going up. So that unless you get hit by a truck, you are never going to be able to use it. It is a disastrous plan and it has to be repealed and replaced.
Danielle Kurtzleben, NPR Politics Reporter, corrects the statement and adds a disturbing fact:
According to recent analyses from Rand and the Commonwealth Fund, Clinton’s plan could potentially cost much more than Trump’s — hers could cost up to $90 billion, compared with his $41 billion. However, the analyses found that Clinton’s “would increase the number of insured individuals by 400,000 to 9.6 million, and decrease consumers’ health spending relative to current law.” Trump’s plan “would increase the number of uninsured individuals by 16 million to 25 million relative to the ACA,” and those increases would “disproportionately affect low-income individuals and those in poor health.”
ANDERSON COOPER
9:40 PM
Secretary Clinton let me follow up with you. Your husband called Obamacare “the craziest thing in the world”, saying that small business owners are getting killed as premiums double, coverage is cut in half. Was he mistaken or was his mistake simply telling the truth?
HILLARY CLINTON
9:40 PM
No, I mean he clarified what he meant. And it's very clear. I mean look, we are in a situation in our country where if we were to start all over again, we might come up with a different system. But we have an employer-based system. That's where the vast majority of people get their healthcare. And the Affordable Care Act was meant to try to fill the gap between people who were too poor, and couldn't put together any resources to afford health care, namely people on Medicaid, obviously Medicare, which is a single-payer system, which takes care of our elderly and does a great great job doing it, by the way. And then all the people who were employed and people who were working but didn't have the money to afford insurance and didn't have anybody, an employer or anybody else, to help them. That was the slot that the Obamacare approach was to take.
And like I say, 20 million people now have health insurance.
Alison Kodjak, NPR Health Policy Correspondent, adds perspective to Hillary’s statement:
This is technically true. But about half of those 20 million are now covered because of the expansion of Medicaid, and the rest are covered through insurance policies purchased through the Obamacare exchanges.
Hillary’s answer continues:
So if we just rip it up and throw it away, what Donald is not telling you is, we just turn it back to the insurance companies the way it used to be. And that means the insurance companies get to do pretty much whatever they want, including saying, look, I’m sorry you got diabetes, you had cancer, your child has asthma, you may not be able to have insurance because you can’t afford it. So let's fix what is broken about it, but let's not throw it away. And give it all back to the insurance companies.
ANDERSON COOPER
9:41 PM
But let me follow up with you on this, Mr. Trump.
DONALD TRUMP
9:41 PM
Just one thing. First of all Hillary, everything is broken about it. Everything. Number two, Bernie Sanders said that Hillary Clinton has very bad judgment. This is a perfect example of it. Trying to save Obamacare which is -
ANDERSON COOPER
9:42 PM
Mr. Trump you have said you want to end Obamacare. You have also said that you and make coverage accessible for people with pre-existing conditions. How do you force insurance companies to do that if you are no longer mandating that everybody has insurance? What does that mean?
DONALD TRUMP
9:42 PM
Well, I'll tell you what it means. You’re going to have plans that are so good. Because we are going to have so much competition in the insurance industry, once we break out the lines and allow the competition to come.
ANDERSON COOPER
9:42 PM
Are going to have a mandate that Americans have to have health insurance?
DONALD TRUMP
9:42 PM
Anderson, excuse me. President Obama, by keeping those lines, the boundary lines around each state, and it was almost gone until just very toward the end of the passage of Obamacare, which by the way was a fraud. You know that. Because Jonathan Gruber, the architect of Obamacare has said, he said it was a great lie was a big lie. President Obama said you keep your doctor, you keep your plan. The whole thing was a fraud. And it doesn't work.
Danielle Kurtzleben, NPR Politics Reporter, again inserts the facts:
Jonathan Gruber wasn’t “the architect” of Obamacare, as CNN wrote in 2014. However, it is true that he helped craft the Obamacare system. The comments Trump is talking about are likely controversial comments Gruber made in 2013, which surfaced in 2014. He said, "This bill was written in a tortured way to make sure CBO did not score the mandate as taxes,” the Washington Post wrote in 2014. "Lack of transparency is a huge political advantage. And basically, call it the 'stupidity of the American voter' or whatever, but basically that was really, really critical to getting the thing to pass.”
Gruber later apologized for the comments, saying that he was talking about the political environment in which the law passed, as the Post wrote, and that he wanted a system more like there is in Massachusetts. CNN’s explainer further elaborated that Gruber was trying to talk about the fact that politicians knew taxes wouldn’t be popular.
Trump’s response continues
But when we get rid of those lines you will have competition.
Again Joe Neel, NPR Science Desk Editor and Correspondent, inserts a comment into the transcript:
It is not at all clear that the insurance companies would embrace this and create the competition that Trump and other Republicans have proposed. A study from October 2012, from Georgetown University, looked at states that have laws permitting out-of-state insurance sales and found that no insurers had taken the states up on this. A New York Times article from last year laid it out in detail.
Trump continues to explain his vision:
And we will be able to keep pre-existing. We’ll also be able to help people who can't get, don't have money. Because we are going to have people protected. And Republicans feel this way, believe it or not, and strongly this way. We are going to block grant into the state. We are going to block grant into Medicaid.
ANDERSON COOPER
9:43 PM
Thank you, Mr. Trump.
DONALD TRUMP
9:43 PM
Into the states so that will be able to take care of people without the necessary funds to take care of themselves.
That was it. In nine minutes we have the script that verifies the presentations in the NEJM. In What Would a Republican Win Mean for Health Policy? Gail Wilensky, the well respected Republican health economist who was the Administrator of CMS from 1990 to 1992 under President George HW Bush, reviewed most of the ideas that Mr. Trump presented in the debate. In her article she begins by saying that the President alone, despite the power of executive orders, can’t do away with the ACA. She goes on to say:
As a candidate, Donald Trump has supported several policy changes commonly proposed by Republicans. These include repealing the Affordable Care Act (ACA), though with little indication of what would replace it; expanding the availability of health savings accounts (HSAs, nontaxable money that can be used to cover medical expenses not covered by insurance and that can be rolled over from one year to the next, unlike flexible spending accounts); permitting insurance to be sold across state lines; turning Medicaid into a block-grant program; protecting people from large increases in insurance premiums or exclusions because of preexisting conditions, as long as they maintain continuous coverage; and allowing people without employer-sponsored insurance to deduct their premiums from their taxes. Unlike other Republicans, Trump has also proposed allowing drug importation and permitting Medicare to negotiate drug prices (though he hasn’t provided any details about what that would mean). The Republican platform committee adopted policies that reflect some of the positions advocated by House Speaker Paul Ryan (R-WI) and the House Republicans, which are more expansive in some ways than Trump’s proposals. The platform’s wording more clearly recognizes the limits of presidential power, stating that the president should use “legitimate waiver authority . . . to halt [the advance of the ACA but] then, with unanimous support of Congressional Republicans, [should] sign its repeal” — a distinction that congressional Republicans have not always made.
Wilensky is reassured by the fact that the most likely outcome of the election is that neither party will control both houses of congress and the presidency which may create an environment for bipartisan change:
Any changes will have to be reached with bipartisan support — because Republicans and Democrats are each likely to control one house of Congress and there’s unlikely to be a supermajority in the Senate.
Republicans may be willing to provide support for strategies to help stabilize the ACA insurance exchanges — such as continued use of risk corridors (which limit the amounts that insurers can gain or lose through risk sharing) after 2016, perhaps with some increased funding from existing appropriations in exchange for increased flexibility using innovation waivers (1332 waivers), such as allowing budget neutrality to be measured over 3 years rather than 1 and allowing states to pool savings from Medicaid with those from exchanges.
There are technical arguments in her paper that are worth your scrutiny. Overall I like her analysis because it reveals that the future will be about searching for consensus.
In From Obamacare to Hillarycare — Democrats’ Health Care Reform Agenda Jonathan Oberlander, Ph.D asks a question and then sees a possibility:
What happens to Obamacare after its namesake leaves the White House? The Affordable Care Act (ACA) has faced fierce opposition from congressional Republicans and many GOP-led state If Hillary Clinton wins the presidency, however, Democrats can advance the ACA. For decades, reformers sought to enact universal health insurance. Now that they’ve taken a major step toward that goal, what happens next? Victory in the 2016 elections could allow Democrats to shift their focus from preserving the reforms to strengthening and improving them. The ACA’s record reflects both substantial accomplishments and significant shortcomings. One priority should be to make health plans more affordable and thereby achieve further gains in coverage.
He is realistic about the millions who are uninsured and concerned about costs:
Many Americans are paying more out of pocket for medical care, especially for deductibles. This trend, which began before the ACA was passed, extends beyond the exchanges. For workers with employer-sponsored insurance, the average annual deductible increased from $303 in 2006 to $646 in 2010 and $1,077 in 2015.4 Clinton has proposed a refundable tax credit (up to $2,500 for an individual and $5,000 for a family) for Americans with high out-of-pocket costs. She’s also outlined a plan to cap out-of-pocket prescription-drug costs for persons with serious or chronic health conditions. Yet if major gains are to be made in marketplace enrollment, ACA plans may have to be made more attractive, with larger premium subsidies and better cost-sharing protections...A related priority is stabilizing the marketplaces...Three major insurers — UnitedHealthcare, Humana, and Aetna — have decided to curtail participation in the exchanges, citing financial losses and risk pools of people who are sicker and more expensive than anticipated ...Other insurers are doing well financially with their marketplace plans, and in some states insurance competition remains strong. But in a growing number of geographic areas, consumers shopping for insurance on the exchanges have little choice, since one insurer has a monopoly...Ironically, private insurers’ withdrawals could revive interest in a reform they intensely oppose: creation of a Medicare-like government insurance plan that would compete alongside private plans in the marketplaces. Clinton has endorsed such a public option.
He also adds information that Hillary Clinton did not emphasize in her debate answers:
Clinton has proposed extending provision of 100% federal funding for the first 3 years to any state expanding Medicaid. Making that funding level permanent — it’s scheduled to phase down to 90% by 2020 — could further entice states. There are also about 9 million uninsured Americans who are eligible for but not enrolled in Medicaid or the Children’s Health Insurance Program. Vigorous outreach and enrollment efforts are needed to reach these people and those eligible for subsidized marketplace coverage — together, they account for nearly half the remaining uninsured population.
He adds:
Growth in health care spending has been remarkably moderate since 2008, and the ACA has cost much less than initially forecast. Obamacare has produced considerable Medicare savings, though its precise contribution to the spending slowdown outside that program is unclear... The biggest obstacle to building on the ACA’s achievements and addressing its flaws is hyper-partisanship. Lawmakers are deeply polarized, and public attitudes about health care reform are divided. Even modest changes can become existential struggles in this environment. If Clinton is elected, her chances of strengthening the ACA will depend on whether Democrats have congressional majorities — and on her ability to advance reform in this extraordinarily polarized time.
Against all this background the questions that Blumenthal and Morone ask are important to consider:
- Why have today’s Republicans, despite their strong influence on the ACA, continued to campaign so strongly for its repeal?
- Why has Trump been so nonspecific in his proposals to replace it?
They answer their own questions:
- Republicans resent what they perceive as the partisan manner in which the law was passed — without a single Republican vote.
- Conservative Republicans deeply oppose the new federal spending and regulation in the program.
- Strong opposition to health care reform long ago became a pillar of Republican politics.
- A replacement would most likely alienate some Republican voters, since the replacement would require some additional government spending that they would find objectionable.
They conclude their analysis by saying:
Trump’s supporters include many downwardly mobile Americans who may be losing insurance as well as good jobs as economies lag in some communities. Indeed, during the primaries, the Trump campaign broke with established party doctrine on numerous issues, including a pledge not to change Medicare...Fascinating as it is, presidential campaign policy should not be confused with presidential health care governance. Once elected, presidents — regardless of party — must confront health care issues of deep consequence and complexity because they profoundly affect the welfare of Americans and the fiscal health of the republic. Intricate details that were easily evaded or ignored on the campaign trail regularly land on the Oval Office desk. As we’ve seen, the two major U.S. political parties have drawn closer over time in some of their approaches to major healthcare issues. The next president will almost certainly try to take advantage of this convergence in seeking common ground and practical solutions to the nation’s health care problems. Whether he or she will be able to overcome the partisan rancor that has so deeply affected U.S. health policy and politics in recent years will have profound importance for the future health of Americans.
That analysis is surely good news. I hope they are right! Perhaps we will learn more with the next debate.
Highs and Lows of the Past Week
The picture in today’s header was taken last Friday morning after last week’s letter was completed. After having breakfast with a friend in Warner, the town just south of Mount Kearsage, I decided that it was such a beautiful day that I should get the view from the top. This picture was taken looking South from the parking lot that is a half mile from the summit. It is a pretty easy climb up from there. It was so beautiful and so easy that I convinced my wife to return with me at the end of the day to see all the colors in the late afternoon sun. This week I plan to take a house guest up to the top. The entrance to the trail is less than 85 miles from downtown Boston. Perhaps I might see some refugees from the Eastern Mass traffic up there this weekend since we are not going to need to watch the Red Sox play the Blue Jays. Cleveland is taking care of that chore.
The trout fishing season in the rivers and brooks ends on Saturday. Where did the time go? It is hard to believe that in the midst all this beauty it is time to begin to put the toys of summer away for the winter. I plan to tape the Patriots game and watch it after the sun sets. It would be a crime to waste a day indoors.
I hope that this weekend you will be outside enjoying the sunshine and color. |
