Browsing the archives for the Health Care category.


Stuff to Read, TrumpCare Edition

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Health Care, Trump Maladministration

I’m short on time today and can only provide some links to keep you busy —

Charles Pierce, Paul Ryan Doesn’t Know How Insurance Works

LA Times, The GOP isn’t replacing all of Obamacare — just the parts that work

Jonathan Chait, Watch Paul Ryan’s Adam’s Apple When He’s Asked Why His Health Plan Cuts Taxes for the Rich

Greg Sargent, Trump has a secret backup plan to kill Obamacare. It’s actually brilliant.

Gail Collins, Getting Freedom from Health

Josh Marshall, Why Repeal and Replace Are Going So Badly

If you run into any more good ones, please add them to the comments.

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Don’t Read This Without a Helmet

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Health Care, Trump Maladministration

Helmet on? Okay, this happened today:

President Donald Trump told a bipartisan group of governors at a White House reception Monday morning that GOP tax reform would have to wait for lawmakers to move on repealing Obamacare, cautioning that, “Nobody knew that health care could be so complicated.”

“I have to tell you, it’s an unbelievably complex subject,” Trump said.

I’ll pause to let you pound your head on the desk for a while.

I take it somebody attempted to explain to Trump why Republicans just couldn’t kill the mandate but leave the pre-existing condition coverage.

This also tells me he is just now finding out what the issues are with health care. I’m sure he assumed anybody could write a health care bill that gave everybody what they wanted. What was the big deal?

Right now, the Republicans seem to be dividing between the kill-Obamacare-and-let-the-chips-fall crowd and those who suspect that suddenly depriving millions of people of health care might hurt their re-election chances.

And it has to be said that Trump pre-screwed the pooch for them by promising that no one currently covered would lose coverage. Republicans can come up with all kinds of great plans as long as people don’t actually have to be covered. The coverage thing, though, is an impossible hurdle. Jonathan Chait wrote,

Health-care reform is extremely complicated even under the best of circumstances. But when you combine the inherent complexities of the subject with the ideological rigidities of the conservative movement, the problem goes from hard to prohibitively impossible. Providing access to medical care to the tens of millions of Americans who can’t afford it on their own, because they’re too poor or too sick, is arithmetically futile if you’re bound by a dogma that opposes redistribution from the rich and healthy to the poor and sick.

But we know what’s really important, don’t we?

House Republicans have decided to resolve the contradiction between party dogma and the promise not to harm the public in favor of the former. A study prepared by the National Governors Association, and which leaked to the media Saturday evening, finds that the House Republicans leadership’s formative plan to replace Obamacare will deprive millions of people of their insurance.

Repealing Obamacare is more important to these people than finding ways to deliver health care to the American people. Many would prefer to repeal the law and blow up the health care system than to dedicate even one tax dollar to helping a poor person see a doctor. They have principles, you know.

But Trump promised better and less expensive coverage. Back when he was still pretending to be developing a plan himself, he promised this. This is from January 15:

President-elect Donald Trump said in a weekend interview that he is nearing completion of a plan to replace President Obama’s signature health-care law with the goal of “insurance for everybody,” while also vowing to force drug companies to negotiate directly with the government on prices in Medicare and Medicaid. …

…Trump’s declaration that his replacement plan is ready comes after many Republicans — moderates and conservatives — expressed anxiety last week about the party’s lack of a formal proposal as they held votes on repealing the law. Once his plan is made public, Trump said, he is confident that it could get enough votes to pass in both chambers. He declined to discuss how he would court wary Democrats….

…As he has developed a replacement package, Trump said he has paid attention to critics who say that repealing Obamacare would put coverage at risk for more than 20 million Americans covered under the law’s insurance exchanges and Medicaid expansion.

“We’re going to have insurance for everybody,” Trump said. “There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.” People covered under the law “can expect to have great health care. It will be in a much simplified form. Much less expensive and much better.”

Republican leaders have said that they will not strand people who gained insurance under the ACA without coverage. But it remains unclear from either Trump’s comments in the interview or recent remarks by GOP leaders on Capitol Hill how they intend to accomplish that.

For conservative Republicans dubious about his pledge to ensure coverage for millions, Trump pointed to several interviews he gave during the campaign in which he promised to “not have people dying on the street.”

“It’s not going to be their plan,” he said of people covered under the current law. “It’ll be another plan. But they’ll be beautifully covered. I don’t want single-payer. What I do want is to be able to take care of people,” he said Saturday.

Here’s a television news story from about the same time. So we’ve got him both in print and in video.


ABC Breaking News | Latest News Videos

Very smart people who have been wrestling with the health care issue for a long time understand that cost-effective, universal coverage can’t be done without going to a taxpayer-funded national health care system that includes price controls of all sorts. Short of that, there’s Obamacare or something like it, mandate and all.

But Trump promised everybody rainbows and ponies. People could get terrific, affordable coverage, and Republicans could nix the mandate and cut taxes. Everybody wins. Back to Jonathan Chait:

Trump held together the contradiction by simply pretending the solution would reveal itself over time and would be extremely easy. Quite likely Trump believed this himself — as a committed nonreader, and a narcissistic devotee of his own negotiating prowess, he surely believed that he could broker a deal that would satisfy both the moral objective of universal coverage and the specific ideological hang-ups that had prevented his party from ever supporting a plan that would accomplish it in the past.

The only thing that held Trump’s position together was a refusal to engage with the substance of the issue, and a magical belief that it could all be waved away. At best, he will keep either his promise to the Republican elite or his promise to the electorate. At worst he will keep neither. His offhand comment that the issue is hard is a window into the mind of a man who realizes the jig is almost up.

Maybe. Maybe he thinks that if he throws bigger tantrums someone will come up with the solution for him. I predict that eventually he will cave on his promise to voters and will blame them for it.

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Trump: Everybody Gets a Pony! But Maybe Not Health Insurance

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Bad Hair, Health Care, Medicare, Republican Party

By now you’ve probably heard that Trump is putting the finishing touches on a health care plan that will provide health insurance for everybody.

President-elect Donald Trump said in a weekend interview that he is nearing completion of a plan to replace President Obama’s signature health-care law with the goal of “insurance for everybody,” while also vowing to force drug companies to negotiate directly with the government on prices in Medicare and Medicaid. …

… Trump said his plan for replacing most aspects of Obama’s health-care law is all but finished. Although he was coy about its details — “lower numbers, much lower deductibles” — he said he is ready to unveil it alongside Ryan and Senate Majority Leader Mitch McConnell (R-Ky.).

“It’s very much formulated down to the final strokes. We haven’t put it in quite yet but we’re going to be doing it soon,” Trump said. He noted that he is waiting for his nominee for secretary of health and human services, Rep. Tom Price (R-Ga.), to be confirmed. That decision rests with the Senate Finance Committee, which hasn’t scheduled a hearing.

Since he mentioned Tom Price here, one suspects that if there is an actual Trump plan, it’s Tom Price’s. So let’s look at that. Here is what Price has proposed:

1. Get rid of the insurance exchanges and their subsidies. Instead, offer fixed tax credits to help people buy insurance on the private market.

Those tax credits would be fairly modest, ranging from $1,200 a year for people 18 to 35 years of age to $3,000 for those 51 and older. In many regions of the country, that would hardly begin to cover the premiums and out-of-pocket costs for a relatively comprehensive health insurance plan.

2. Insurance companies cannot deny insurance to people with pre-existing conditions provided they been insured continuously for the previous 18 months. If you lose coverage because you can’t make a payment, too bad. No insurance for you.

3. “Expanded” health savings accounts. HSAs are great for young, healthy people who need tax shelters; not so much for anybody else.

4. There would be taxpayer funded high-risk pools for sick people who can’t get insurance. These have been tried in the past and have proved to be bottomless money pits. I’m sure the insurance companies like this idea, though, because it lets them off the hook for insuring really sick people.

Price appears to be seriously low-balling the scope of the problem by proposing to invest a mere $3 billion into state risk pools over a three-year period. Ryan’s “Better Way” plan, for instance, would provide $25 billion over the coming decade, and even that might prove to be woefully inadequate.

5. Price wants to limit the employer tax exclusion for providing health insurance to $8,000 a year for individual policies and $20,000 for families. I suspect people would see their employee benefit health insurance taking bigger bites out of their paychecks.

6. Able-bodied single people would no longer be eligible for Medicaid, no matter how poor they are.

7. Price wants to allow insurance companies to sell insurance across state lines. Republicans are in love with this idea because they think that the competition would force insurance premiums to go down. Nobody who understands the health insurance industry thinks this would work.  See also articles in The Fiscal Times, Forbes, and the New York Times explaining why this is a dumb idea.

What Trump probably will propose is a system that would in theory allow anybody to get insurance, but in practice probably would leave out most or all of the people who gained insurance under the ACA, and more beside. Paul Ryan and other Republicans like to make speeches about giving people “universal access” to health insurance, instead of universal insurance coverage, which I interpret to mean “you can buy all the insurance you want, as long as you can pay for it.” Which, of course, is the catch.

But Trump specifically said,

“We’re going to have insurance for everybody,” Trump told the Washington Post. “There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.”

He’s either lying or he doesn’t know what he’s talking about. Of course, both might be true. You either stick with some version of the ACA, or go with a single payer/national health care plan, or throw people into the private insurance market to sink or swim. There really aren’t any other options. Tom Price’s ideas won’t work to make health insurance affordable or  reduce health care costs. Health care costs are the real cause of high premiums, and health care costs are high in the U.S. because we have a for-profit system that allows for rampant price gouging.

The part about allowing Medicare to negotiate drug prices is something Republicans have fought tooth and nail since Part D was established in 2003. (Medicaid already allows for some negotiation.) President Obama tried to tweak the Medicare system a bit to allow for some negotiation, but Republicans balked at that, too. Part D is a cash cow for the pharmaceutical industry, and those lobbyists aren’t going down without a fight. Trump will be in for a fight from his own party on that one.

(I have to crab about Democrats, too, however. Recently Bernie Sanders introduced an amendment that would have allowed importation of cheaper drugs from other countries. This had enough Republican votes it would have passed, except that a gang of Democrats voted against it.)

 

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Are Wheels Coming Off the ACA Repeal Bus?

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Bad Hair, Health Care

There are signs congressional Republicans are beginning to get a clue that repealing Obamacare without a good plug and play replacement already in hand might come back to bite them. Jonathan Chait writes,

Something big is happening in the Senate right now: The Republican plan, affirmed again today by Senate Majority Leader Mitch McConnell, is facing dire peril from Republican defections. Republicans need a House majority, 50 Senate votes, and soon-to-be President Trump to pass repeal and delay.

If Republicans lose three Senate votes, that drops them to 49, and repeal and delay cannot pass. At least three Republican senators (in addition to all the Democrats) now oppose repeal and delay. Rand Paul, of all people, has demanded that Congress repeal Obamacare at the same time it passes a plan to replace it. Paul has announced that he spoke with Trump and secured his agreement on this. Trump has not said so himself, confining his comments to date to a vague assurance, “That’s all gonna work out.”

Trump, of course, tends to change his mind frequently and agree with whomever he spoke with last. But other Republicans senators are taking the initiative. Fellow Republican Lamar Alexander says the same thing as Paul: “We have to take each part of it and consider what it would take to create a new and better alternative and then begin to create that alternative and once it’s available to the American people, then we can finally repeal Obamacare.” Senator Tom Cotton of Arkansas said on MSNBC, “It would not be the right path for us to repeal Obamacare without laying out a path forward.” And Senator Bob Corker is walking right up to the edge of the same position, asking Trump to tweet out confirmation of what Paul claims he promised. “If it is his view, it would be really good if he would consider tweeting it out very clearly. There’s more and more concerns about not doing it simultaneously,” Corker says.

Over in the House, Paul Ryan is pushing a bill that would use budget reconciliation to kill significant parts of the ACA. But on top of the three senators who oppose “repeal and delay,” four more Republican senators — Portman, Collins, Cassidy, and Murkowski — joined Corker in sponsoring a bill that would delay Ryan’s Obamacare repeal for a month. They say they just want to be sure everyone is clear about what comes next before they go forward with repeal.

(And since when do we ask presidents to “tweet out” what their intentions are?)

Conservatives hate Obamacare because it redistributes too much money from the rich and healthy to the poor and sick. But they don’t publicly attack the law on that basis. Instead they attack it for high premiums, high deductibles, and narrow choice of doctors and hospitals — all flaws that any Republican plan would have in much higher doses. Republicans have yet to unify around a single, concrete, scorable plan because it is conceptually impossible to design a health-care plan that meets conservative ideological goals and is also acceptable to the broader public.

Ryan is talking about making repeal and replace “concurrent” —

“It is our goal to bring it all together concurrently,” said Ryan. “We already show people what we believe in, what we believe Obamacare should be replaced with. so we’re going to use every tool at our disposal — through legislation, through regulation — to bring replace concurrent along with repeal so we can save people from this mess.”

Hmm. Well, what they believe in is that people without money should just die already. But we really haven’t seen what they think Obamacare should be replaced with. They make noises about various things — high-risk pools, tort “reform,” selling policies across state lines — that don’t add up to a comprehensive whole. There is no way they’re going to fund high-risk pools enough to make them work. That’s a symbolic fix only. Their other ideas barely rise to the level of “tweaks.”

But then there’s this:

On Monday night at Tortilla Coast, a Mexican restaurant on the Hill, the House Freedom Caucus – a group of fiscal conservatives with a reputation for rabble rousing–came to a consensus that they wanted more insight into what the GOP’s replacement is before they vote on a budget resolution slated to be taken up Friday in the House.

 If the House Freedom Caucus is getting nervous about repeal, this is serious. I would have expected them to push for repeal, period, and don’t worry about the replace. But I guess some of them want to be re-elected.

A reconciliation bill requites only a simple majority to pass the Senate, but you can do only so much with a reconciliation bill — change taxes and spending, and that’s about it. Actually changing the system requires a regular bill, which would require some Democratic votes.

The idea behind “repeal and delay” was that by setting a deadline for a replacement, Democrats might be pressured into writing the bill. Republicans, as you know, are congenitally incapable of crafting legislation without help from ALEC. But if there’s no delay, there’s no pressure.

And then there’s the Trump factor. Greg Sargent wrote this morning,

When Trump holds his news conference tomorrow, he will likely be asked whether he still thinks that Republicans should repeal and replace the Affordable Care Act “simultaneously,” as he said in a post-election interview. If he answers in the affirmative, it could throw the current GOP strategy — repeal on a delayed schedule with no guarantee of any replacement later — into further doubt.

 So, we’ll see.

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Hey, Republicans: Put Up or Shut Up

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Bad Hair, Health Care, Republican Party

Martin Longman sums it up:

The Republicans have had tremendous success with what they know best, which is being a very good minority party. They can counter-message and use procedural tools in obnoxiously innovative ways to obstruct. They can simply refuse to even hold hearings for presidential nominees or insist that those positions don’t even need to be filled. They excel at this stuff, but they do not excel at legislating or doing oversight of the federal government and its agencies.

Their plan here is the plan of a minority party. They want to force the Democrats to do something rather than figuring out a way to do it themselves. They have no idea how to replace Obamacare without blowing up the private insurance industry, costing hundreds of thousands of people their health insurance, and taking all the political blame. So, they’ll just try brinksmanship and maybe those clever law-writing Democrats will rescue them at the end of the day out of some bleeding heart do-gooder sense of decency.

So far, the Democrats appear to be happy to let the the Republicans twist in the wind.

Schumer is taking a hard line when it comes to Republican plans to repeal the law, and whether or not Democrats would work across the aisle on a replacement if Republicans are successful in rolling it back. “And if they think we’re going to come in and save their butts when they screw it up? No.”

Schumer also proposed “Make America Sick Again” as a new Republican motto.

The Trumpster issued a new tweetstorm in the wee hours in which, among other things, he called Chuckie Schumer the “head clown.” This was followed by a call for Republicans and Democrats “to get together and come up with a healthcare plan that really works – much less expensive & FAR BETTER!” Yeah, that’ll work.

Schumer fired back today.

“Now, we understand that President-elect Trump is in a difficult spot, that Republicans are in a difficult spot. They want to repeal ACA, and have no idea how to replace it,” he said. “But instead of calling names, [the] President-elect should roll up his sleeves and show us a replacement plan that will cover the 20 million Americans who gained coverage, that will cover students or post-college students, 21 to 26, who want to stay on their parents’ plan, that will show how we cover people with pre-existing conditions.”

“So I’d say to the President-elect and the Republicans that this is not a time for calling names. It’s time for them to step up to the plate if they want to repeal, and show us what they’d replace it with,” Schumer added.

Also, too, yesterday dear Bernie Sanders brought an oversized print of one of the Donald’s old tweets and put it on display in Congress.


Sanders said Trump should either admit he was lying or say he will veto any forthcoming cuts.

“Millions of people voted for him on the belief that he would keep his word,” he said. “If he was sincere, then I would hope that tomorrow or maybe today he could send out a tweet and tell his Republican colleagues to stop wasting their time and all of our time. And for Mr. Trump to tell the American people that he will veto any proposal that cuts Medicare, that cuts Medicaid or that cuts Social Security.”

And when Trump made those promises on the campaign trail, I suspect his followers assumed he knew how he would make it happen. But it’s obvious he doesn’t have a clue.

See this article by Drew Altman in today’s New York Times — “The Health Care Plan Trump Voters Really Want.”

Surveys show that most enrollees in the Affordable Care Act marketplaces are happy with their plans. The Trump voters in our focus groups were representative of people who had not fared as well. Several described their frustration with being forced to change plans annually to keep premiums down, losing their doctors in the process. But asked about policies found in several Republican plans to replace the Affordable Care Act — including a tax credit to help defray the cost of premiums, a tax-preferred savings account and a large deductible typical of catastrophic coverage — several of these Trump voters recoiled, calling such proposals “not insurance at all.”

And it isn’t insurance at all.

One of those plans has been proposed by Representative Tom Price, Mr. Trump’s nominee to be secretary of Health and Human Services. These voters said they did not understand health savings accounts and displayed skepticism about the concept.

When told Mr. Trump might embrace a plan that included these elements, and particularly very high deductibles, they expressed disbelief. They were also worried about what they called “chaos” if there was a gap between repealing and replacing Obamacare. But most did not think that, as one participant put it, “a smart businessman like Trump would let that happen.”

However, they also said this:

They were unmoved by the principle of risk-sharing, and trusted that Mr. Trump would find a way to protect people with pre-existing medical conditions without a mandate, which most viewed as “un-American.”

I don’t find the need for the mandate that hard to grasp, and I’m not exactly brilliant when it comes to number things.

But it does seem to me that if these people get their insurance ripped out from under them, with nothing to replace it but some blah blah health savings account blah, even they may notice they’ve been had.

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Republicans Scramble for a Plan. And a Clue.

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Bad Hair, Health Care, Obama Administration, Republican Party

The original plan to kill Obamacare was “repeal and delay,” meaning Congress would pass a repeal bill that wouldn’t go into effect for at least a couple of years, thereby putting pressure on Democrats to help come up with a replacement. But that appears to be abandoned.

According to this article by Peter Sullivan at The Hill, the new plan is to go ahead and repeal Obamacare — there will be a repeal bill on Trump’s desk by February 20, they say — and then Trump will magically make all the rough transitional thingies go away by executive orders.

Seriously, that’s the plan.

The Feb. 20 target was put forward by incoming House Budget Committee Chairman Diane Black (R-Tenn.), said Rep. Markwayne Mullin (R-Okla.), leaving a meeting with House Republicans and Vice President-elect Mike Pence on Wednesday.

Pence said Trump plans to take executive actions to start unwinding ObamaCare on day one, but did not get into specifics.

“It will be an orderly transition to something better … using executive authority to ensure it’s an orderly transition,” Pence told reporters. “We’re working now on a series of executive orders that will enable that orderly transition to take place even as Congress appropriately debates alternatives to and replacements for ObamaCare.”

Rep. Chris Collins (R-N.Y.), an early Trump supporter, added that, “The president in his first day in office is going to do some level of executive orders related to ObamaCare.”

But Collins said there were “no details whatsoever” on the orders discussed in the meeting.

They have no idea what they’re going to do. They’re about to hit the Put Up or Shut Up Wall, and they’re flailing.

Rep. Chris Collins (R-N.Y.) tweeted this right after that same meeting.

They don’t have a plan. How many years have they been hollering about replacing Obamacare? I’m not good with big numbers.

The February 20 deadline is not completely impossible. Dylan Matthews at Vox explains how congressional Republicans have already paved the way for doing away with most of the ACA through reconciliation, which will allow them to pass the repeal with a simple majority vote in the Senate. For budget reasons they would have to retain the ACA’s cuts to Medicare providers, but everything else could go immediately. See also Sarah Kliff.

Lauren Fox at Talking Points Memo has a different take. I’m not sure if she’s talking about the same meeting, but it seems not everyone is on board.

In a closed-door meeting in the House basement Wednesday with the whip team, a Republican rank-and-file member rose to convey his deep fear that Republicans were making a big mistake by repealing the Affordable Care Act without any concrete plan to replace it with.

According to one source in the room, the member rose and got the room’s attention.

“You lose all leverage once you repeal this thing. There will be people on the left who will never help you replace it and there will be people on the right who aren’t going to help you either,” the member said. “We will own this thing and there will be consequences.”

(Consequences? What is this thing, consequences? We Republicans do not know this word.)

The House isn’t the only place where members are sounding the alarm. Sen. Rand Paul (R-KY), whose own state expanded Medicaid under the Affordable Care Act, said earlier this week that Republicans will be making a mistake if they repeal the Affordable Care Act without replacing it at the same time.

The concern is that by moving rapidly to repeal President Obama’s signature accomplishment, Democrats may never work with Republicans on a replacement. That could leave Republicans with two options, either they could change Senate rules and jam through their replacement or they will never get one.

If they go the delay route, there are still those alien consequences things to deal with. Josh Marshall wrote,

The AMA, which has been rather comically pro-Trump to date, came out today and told Republicans that they shouldn’t repeal Obamacare without a clear replacement. Notably, even two of the most conservative health care economists at AEI, came out yesterday and said that ‘repeal and delay’ would be a disaster. The truth is that “repeal and delay” is the policy equivalent of taking off from JFK to Heathrow with 2,000 miles worth of gas and saying you’re going to figure it out en route. No one who knows anything about health care economics, even people who are staunch free marketeers and hate Obamacare, think that makes any sense.

Note that recent polls say only 26 percent of Americans want the ACA repealed.

This morning President-Elect Trump is out with an ambiguous and possibly meaningless (it’s sort of like Being There) series of tweets warning Republicans to “be careful” and make sure that Democrats “own” the “ObamaCare disaster.” …

… They simply have no idea what to do and now they’re being taunted by Trump not to blow and he doesn’t have any idea either. It would be funny if millions of people’s lives and well being weren’t on the line.

For the Democrats, the plan seems to be to let the Republicans hang themselves. CNN:

President Barack Obama delivered a mandate to Democrats on Wednesday: “Don’t rescue” Republicans on Obamacare.

Less than three weeks out from leaving the White House, Obama visited Democratic lawmakers on Capitol Hill with a mission to save his signature healthcare reform law as Republicans are moving quickly to unroll the Affordable Care Act.

In the closed-door meeting, the President urged fellow Democrats to not “rescue” Republicans by helping them pass replacement measures, according to sources in the room.

He also floated this idea: Start referring to the GOP’s new plan as “Trumpcare.”

The suggestion was a clear indication of the Democratic Party’s goal of turning the tables on Republicans, who are already facing pressure to quickly craft a replacement bill.

Regrettably, that may be the best plan.

Update: Apparently Trump (via the Mouth of Sauron, a.k.a. Kellyanne Conway) he can fix things so that everybody who has insurance will still have insurance, and that people with pre-existing conditions will still be covered. Heh.

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Can Obamacare Be Saved?

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Health Care

The Republican plan, as I understand it, is to pass a law repealing Obamacare as soon as the next Congress is called into session. However, sniveling weasels that Republicans are, the law won’t go into immediate effect. They’ll put the end date sometime after the 2018 midterms, of course.

The latest is that Republicans will repeal Obamacare right away in January using a process called budget reconciliation, which lets them repeal budgetary items with just 51 votes in the Senate. Then, Republicans will enact a self-imposed deadline roughly three years from now before they have to pass a replacement plan. How much of the existing Obamacare elements will limp along until then remains unclear, and whether you can repeal some but not all of Obamacare without causing it to collapse is a big open question.

But such a scenario also creates a self-imposed crisis that Republicans hope will pressure Democrats into coming to the negotiating table down the road. This is where clarity is crucial. Three years from now, it’s not the Democrats’ crisis. It’s a Republican one. There is no health care cliff, Obamacare doomsday, congressional-health-care-death-spiral apocalypse unless Republicans create one by repealing Obamacare without a replacement plan.

And they’ve never been able to come up with a replacement plan. Time and time again they claim to have done so, but that plan always falls apart under scrutiny, forcing them to come up with another replacement plan.

The biggest bite to any Republican so-called plan always is that they can’t cover people with pre-existing conditions without either a mandate for everyone to buy insurance (which, of course, in their minds is Evil) or without putting uninsurable people into high-risk pools, which have been tried in several states and just plain don’t work.

And if they eliminate the mandate but keep the pre-existing condition requirement, the costs of policies would more than skyrocket. It would set the health insurance industry into chaos. See “Why Keeping Only the Popular Parts of Obamacare Won’t Work.”

But the real bite is that the guy Trump wants to head Health and Human Services is a five-alarm whackjob. In his perfect world, only young, healthy people (and the very rich) would have insurance and the rest of us would just be required to suffer and die.

Rep. Tom Price (R-GA), President-elect Donald Trump’s pick for health and human services secretary, already has a plan for how to abolish Obamacare. …

…Price will arrive at HHS with a clear blueprint for what comes next. He is the author of the Empowering Patients First Act, one of the most thorough and detailed proposals to repeal and replace Obamacare. …

… It would replace the law with a plan that does more to benefit the young, healthy, and rich — and disadvantages the sick, old, and poor. Price’s plan provides significantly less help to those with preexisting conditions than other Republican proposals, particularly the replacement plan offered by House Speaker Paul Ryan (R-WI).

The biggest cut to the poor in Price’s plan is the full repeal of the Medicaid expansion, a program that currently covers millions of low-income Americans, which Price replaces with, well, nothing.

I caught a few seconds of Paul Ryan’s interview on 60 Minutes yesterday, before I was able to change the channel. Ryan assured America that Obamacare would be replaced by “Patient-centered healthcare that gets everybody access to affordable healthcare coverage, so that they can buy whatever they want to buy.” And I want a pony, too.

But now the Republicans will have to put up or shut up, and they can’t do it. Whatever they do is going to hurt a lot of people.

So they’ll make a big show out of repealing Obamacare, except most likely it will still be in effect — mandate and all — for the next three years or so. But it’s possible enough of the whackjobs — like Tom Price — will insist on taking it apart sooner, which will cause widespread disaster and lots of suffering.

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Stuck With the Bill

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Health Care

Seems to me the Epipen scandal pretty much exemplifies most of what’s wrong with America. Consider:

The Epipen is epinephrine inside  a fancy delivery system.  According to Raw Story, the delivery system was developed by the military on the taxpayers’ dime.  If this is true, one wonders how the pharmaceutical corporation Mylan got an exclusive patent on the thing. If taxpayers developed it, why isn’t it in public domain?

For that matter, EpiPen has been on the market since 1977. Why hasn’t anyone else come up with a competitive product? The only alternative, as I understand it, is to get a vial of epinephrine and a syringe and inject it the old-fashioned way. That might not be practical for some people with extreme allergies that might strike at any time, especially for children.

Epipen’s list price soared to $608 per pack, from about $100 in 2007. Of that, the corporate vampire squid Mylan makes $274. The rest goes to wholesalers, insurance companies, retailers and “pharmacy benefit managers,” whoever they are. Sounds like a whole lot o’ gouging going on.

Note that Mylan has made no significant changes to the Epipen for years. They raised prices, mostly over the past three years, because they expected a generic competitor to come on the market next year, but in fact the FDA did not approve the competitor. So Mylan still has a monopoly.

And there’s this: “For years, Mylan Pharmaceuticals has been selling the devices to schools at a discounted price, giving them a break from rising costs. But the program also prohibited schools from buying competitors’ devices — a provision that experts say may have violated antitrust law.”

And there’s this: “While Mylan was jacking up the price of the pens over the last nine years, making them nearly unaffordable for many patients, the company’s CEO, Heather Bresch, saw her total compensation package go from around $2.5 million when she was the company president to just shy of $19 million in 2015. ”

To add insult to injury, a couple of years ago Mylan re-incorporated in the Netherlands to save itself from paying U.S. taxes, but it’s still mostly located in the U.S.

In most civilized countries this sort of thing doesn’t happen because governments exercise price controls on medicines and medical technology. Companies can make a profit, but only so much profit.  People have been buying Epipen packs for about $100 in Canada, I understand.  Here, as you probably know, Medicare is prohibited by federal law from negotiating lower prices with pharmaceutical companies. Because it’s all about the profits.

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More Lives That Matter

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Health Care, Women's Issues

The United States has among the highest rates of infant and maternal mortality in the developed world. Worse, according to official statistics, the rate of maternal mortality in the U.S. has shot up in recent years, even as the rate is going down just about everywhere else

(Maternal mortality rate refers to the number of women who die as a result of pregnancy and childbirth per 100,000 pregnancies/births. Infant mortality rate refers to the number of infants per 1,000 births who die between birth and their first birthday.)

Maternal mortality has jumped from 7.2 in 1987 to 18.5 in 2013; I understand the U.S. is roughly tied with Iran and Hungary in the maternal mortality department. And keep in mind that those numbers are averages; some states are not that bad, and some are worse.

However, a recent article in Scientific American argues that the maternal mortality rate really isn’t going up; it’s always been that bad, and we just didn’t know it.

Until relatively recently most states relied on a death certificate form that was created in 1989. A newer version of the form, released in 2003, added a dedicated question asking whether the person who died was currently or recently pregnant—effectively creating a flag for capturing maternal mortality. Specifically, this recently introduced question asks if the woman was pregnant within the past year, at the time of death or within 42 days of death.

The addition of this question means that the apparent increase in maternal mortality in the U.S. “is almost certainly not a real increase. It’s better detection from the new certificates,” says Robert Anderson, chief of the Mortality Statistics Branch with the CDC’s National Center for Health Statistics. “The numbers are going up but it’s most likely not because women are more likely to die,” he contends.

In other words, maybe the problem isn’t getting worse; it’s just that the way we used to collect data camouflaged how bad things were before. That’s so … not a relief. However, other researchers quoted in the same article think there is an increase that can’t be entirely accounted for by the change in data collection.

Also:

One aspect of maternal mortality that has not changed over the years is the extent to which it varies by race. The risk of maternal mortality has remained about three to four times higher among black women than white women during the past six decades. Since 1999 maternal mortality has climbed among both black and white women—potentially due to those changes in death certificates and also how deaths are now coded in the U.S. using the ICD-10. Yet even with the cross-race increases in deaths related to pregnancy, in 2007 the maternal mortality rate for black women was still nearly three times higher than the rate for white women.

Researchers have shown that black women are not inherently more likely to have underlying pregnancy complications. Indeed, one national study that looked at five major common causes of maternal death and injury that collectively account for more than a quarter of all pregnancy-related deaths found that black women did not have a significantly higher prevalence than white women of those conditions—preeclampsia, eclampsia, obstetric hemorrhage, placental abruption and placenta previa. Yet black women were two to three times more likely to die than white women with the same complication.

Increased poverty and stress are an obvious reason why black mothers are at increased risk, IMO, but the medical science guys who look at this stuff aren’t persuaded that’s the entire story.

Whatever the cause, the data tell us that a lot of women die in the U.S. who would have lived had they gone through pregnancy and childbirth in any of about 50 other countries, including Estonia and Qatar. And a disproportionate number of those women are African American, and nobody knows why.

There are huge differences from state to state, for that matter. Maine has a maternal mortality rate of 1.2, according to data aggregated from the Center for Disease Control. Michigan has a rate of 21.0. The District of Columbia is even worse — 38.2. We’re in Third World territory with that number.

Similarly, the United States lags behind most of the developed world in infant mortality, and a disproportionate number of those infants also are African American. Conservatives for years have dismissed the data with claims that these are mere reporting anomalies. If an extremely premature infant dies immediately after birth, for example, it’s usually counted in the infant mortality data in the U.S. but would not be counted as such in some other countries.

An article in the Washington Post from September, 2014 blows that argument out of the water

Despite healthcare spending levels that are significantly higher than any other country in the world, a baby born in the U.S. is less likely to see his first birthday than one born in Hungary, Poland or Slovakia. Or in Belarus. Or in Cuba, for that matter. …

… One factor, according to the paper: “Extremely preterm births recorded in some places may be considered a miscarriage or still birth in other countries. Since survival before 22 weeks or under 500 grams is very rare, categorizing these births as live births will inflate reported infant mortality rates (which are reported as a share of live births).”

Oster and her colleagues found that this reporting difference accounts for up to 40 percent of the U.S. infant mortality disadvantage relative to Austria and Finland. This is somewhat heartening.

But what about that other 60 percent?

“Most striking,” they write, “the US has similar neonatal mortality but a substantial disadvantage in postneonatal mortality” compared to Austria and Finland. In other words, mortality rates among infants in their first days and weeks of life are similar across all three countries. But as infants get older, a mortality gap opens between the U.S. and the other countries, and widens considerably.

See the chart in the article. We’re not losing newborns as much as we are losing infants from one to 12 months old, and the gap widens as the infants get older. It appears many babies are dying in the U.S. who would have lived if they’d been born in Finland. And the biggest factor seems to be income; in the U.S., babies born into poor families die a lot more often than babies born into wealthy families. There also are big discrepancies from one state to another.

The U.S. rate of 6.1 infant deaths per 1,000 live births masks considerable state-level variation. If Alabama were a country, its rate of 8.7 infant deaths per 1,000 would place it slightly behind Lebanon in the world rankings. Mississippi, with its 9.6 deaths, would be somewhere between Botswana and Bahrain.

Needless to say, a disproportionate number of those poor families are African American. I couldn’t find raw numbers, so I don’t know how many African American women and babies die what must be preventable deaths in the U.S. every year. Maybe someone else can find that number. I don’t know how many White, Native American, Asian American and Latina women and their babies die, either. In 2013 about 800 women of all races died of complications of pregnancy and childbirth in the U.S., and if you have the data and can do math better than I can perhaps you can figure it out. I found no raw numbers of babies who die before their first birthday, just the rates.

The bottom line, though, is that access to health care, including reproductive health care, is a life and death issue for American women. And our lack of attention to this problem is a national disgrace. Yet instead of addressing it we’ve been manipulated into a phony controversy about Planned Parenthood. Really disgusting.

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SCOTUS Saves Obamacare!

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Health Care, Supreme Court

Vote was 6-3, Scalia, Thomas and Alito dissenting.

 Update: Roberts wrote the majority opinion. Apparently Scalia had a hissy fit and more or less accused the other justices of bowing to pressure. “We should start calling this law SCOTUScare,” he said.

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