A Good Checklist for Grading an Obamacare Replacement

Greenville   In the chaotic back and forth over what may be about to happen to the Affordable Care Act, it is becoming almost impossible to follow the real issues as the bull passes our knees and rises towards our chin on all sides of the debate. We know something bad is about to happen, but we need a good checklist to measure the extent of the disaster even as we know the pain is likely to be terrible.

Harold Pollack from the University of Chicago and Timothy Jost from Washington and Lee University School of Law did all of us a favor in an op-ed in the Times by listing what they called “seven important questions that Congress must answer before repealing the Affordable Care Act.” Many of their questions are also clearly benchmarks for measuring the minimum standards for equity and justice that should be demanded by all Americans for any so-called replacement coming from Congress.

Here’s their list in brief:

1. How many millions of Americans will lose coverage? They also make the point often lost in the debate that tax credits and deductions are “nearly worthless” to lower income filers who would likely be priced out without direct subsidies.
2. Will people over 55 pay higher health premiums for the same coverage? This is a critical equity and cost issue for senior citizens with fixed incomes. The current Act limits the premium for older Americans to no more than three times that for younger citizens. Speaker Ryan has proposed going five times, which would be a budget buster for seniors.
3. Will the new plan let insurers charge women higher premiums than men while offering them less coverage? Obamacare in a critical reform banned this practice? Will the Republicans attack and penalize women for being women?
4. What other services are likely to be cut? Before Obamacare a third of the market policies did not cover addiction treatment and “nearly 20 percent lacked mental health coverage.” Will Republicans embrace the tragedy and roll this back along with other benefits?
5. Will the new plan let insurers reinstate annual or lifetime limits on coverage? Will Republicans allow a life-threatening illness to bankrupt victims and families while giving insurers a free-ride? We have to ask what insurance is for if there’s no coverage?
6. What will happen to the more than 130 million Americans with pre-existing conditions? This is huge and Congress needs to have the right answer because this was a critical reform of Obamacare and one that was popular enough that Trump even echoed its promise during the campaign.
7. How much more will those with costly illnesses or injuries have to pay in out-of-pocket costs? Costs are now capped at $7150 for individuals and $14,300 for families, and that’s way too much. Current Republican proposals thus far offer no cap to either deductibles, which are already leaving lower income workers outside of coverage in healthcare and service jobs, or cost sharing. You could drive a truck over people unless this loophole is closed.

This list of questions is really only the starting point, but any replacement at the least needs to answer these questions correctly to even pretend to be called a national healthcare protection plan. Keep them handy to grade the outcome in the common debate.

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Here Come the 50s Again, Complete with a Cold War

Ad from 1950s

Puerto Aventuras   Reading the news online doesn’t count as a pleasure these days, if it ever did. The upshot in the domestic and international news seems to be that we are going into 2017 and ending a presidency of the 21st century by dialing the clock back to inaugurate a presidency of the mid-20th century.

The incoming administration and many of its cabinet positions and a frightening number of state houses are hopeful that women have forgotten what it was like to be standing up, leaning in, and having some modicum of control over their bodies and selves. A major conservative war party is coming after Planned Parenthood to not only deny them federal funding, but kneecap the Health and Human Services Department which has been the bulwark blocking states from also cutting them loose. We get to read credible reports that when Minority Leader Nancy Pelosi raises women’s issues to President-elect Trump, he literally hands the phone over to his daughter, Ivanka, to handle the call. Doesn’t that just take your breath away! Even after this campaign in which almost everything Trump did or said about women was called into question, he can’t even pretend to be interested enough in women’s issues to manage it through a phone call. We’re going to have a First Lady, who doesn’t even live in the White House it also seems. We’re going back to the 50s, so get ready for reruns of “Father Knows Best.”

On health care, it looks like they may want to take us back to the pre-Roosevelt 30’s rather than the 50’s. Dump the Affordable Car Act covering 30 million Americans, maybe with block grants to the states so that no one living in red states will live past 65, while blue state folks hang on to their 80s. Oh, but they are also going to try and privatize the Veterans Administration in order to take a slap at the sacrifices made by soldiers and cut back on Medicare for seniors as well, those freeloaders, so maybe no one will make it that far. It goes on and on.

Equality of the races and religions: forget about it! The efforts to move voting rights back to the 50s has been going on for years now, but expect it to go wild now. Respect for other religions? So far the attitude seems to be, why bother? Those Palestinians are Muslims, right?

Heck, it looks like we’re even going to dust off the Cold War again. We already knew it was coming when so many retired and often cashiered former generals were taken out of mothballs and the Fox News circuit to head up one agency and position after another. Now that President Obama has finally given a hand slap to the Russians for the hacking and interference in the recent elections and they have replied in kind by throwing 35 of our folks out to match the 35 eviction notices Obama served, it all seems so déjà vu. Castro may have died, but they want to bring back the Cold War with Cuba, too, it seems. And, let’s not forget about China.

For those of us who don’t remember the 50s being so swell, the next couple of years could be a bit of hell.

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Doctors Can’t Be Trusted About Healthcare

Cancun   Of all of the bad nominations coming our way, the notion of Georgia Congressman Tom Price running the Health and Human Services has the most impact on millions of people because of the impact of his virulent opposition to the Affordable Care Act and the jeopardy it places not only on 30 million beneficiaries there, but also on millions more because of additional threats to Medicare for the elderly and cutbacks in Medicaid for the poor generally. Some hold out a sliver of hope because Price keeps saying that he’s a doctor, and he wants that to mean something along the lines that he cares about peoples’ health. He’s taken the Hippocratic Oath, so he’ll “do no harm.”

James Surowiecki points out in the current New Yorker, that in fact the record of doctors and the American Medical Association has been to oppose virtually every governmental medical program providing health security for Americans for a century now. Doctors organized to oppose universal health care when it came to the ballot in California in 1917 during the First World War, claiming it was a “dangerous device imported from Germany.” The AMA in the 30’s opposed pre-paid medical groups where customers paid a flat fee in exchange for care and was fined for anti-trust violations. The AMA campaigned against the creation of Medicare, and hired Ronald Reagan to go on the air and warn us about so-called “socialized medicine.” The AMA was in the thick of the fight to oppose the Clinton health plan during his first term and only supported Obamacare after the so-called “public option” was off the table.

Ten thousand doctors have already organized in opposition to Price and his plan to scuttle the Affordable Care Act, and though the AMA has endorsed his nomination as a former member of their delegate board and a long-time friend in Congress, there is a schism mounting within the AMA over its stand as harmful to patients. Most hospital associations have been silent over Price’s nomination, but have come out strongly in opposition to the plans to end Obamacare as catastrophic in terms of patient care, hospital closings, job loss, and economic ruin within the healthcare industry. Nurses’ unions have been pretty unanimous in opposing the end of Obamacare.

Price is likely to hide behind the public’s assumption that as a doctor he’s an expert on healthcare. Reading Michael Lewis’ new book, The Undoing Project: A Friendship That Changed Our Minds, might take away any notion that doctors should be seen as our modern day priests. Experiments conducted under the influence of work by Daniel Kahneman and Amos Tversky found that fairly simply algorithms outperformed doctors in making diagnoses of many medical conditions, largely because of the unchecked biases of doctors for the way they are used to seeing and working. That’s scary, but true.

And, as Surowiecki points out repeatedly, the AMA is little more than a very effective special interest group, a closed shop union for doctors, if you will, and their own reports indicate repeatedly that their primary purpose is protecting the income security of doctors. Putting money in doctors’ pockets should never be confused with providing basic healthcare for Americans. We don’t need an algorithm to know the facts about that.

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Healthcare Pricing is More Proof that Transparency Isn’t Enough

New Orleans   It is amazing that big companies and governments continually believe, despite the outrageous costs involved, that simply creating apps and information packed websites will change the public’s ability to make choices and decisions. Criminals and scammers fully know the tricks of the predatory trade are such that information is unable to immunize the public, and for some companies this is a business model as well. Payday lenders and tax preparers in negotiations with ACORN were always more than willing to be totally transparent about excessive interest rates and charges, because they knew full well the customer sitting across the desk from them is desperate for the money, and is more than willing to pay whatever it takes to get it. Healthcare is usually the same.

Healthcare policy makers, providers, and insurers in this critical, multi-zillion dollar industry are now expressing surprise as they find out that all of assumptions about the value of their apps, website data dumps, and comparisons of pricing on drugs and quality of healthcare services are not lowering costs or modifying consumer behavior. Once again, similar to payday lending and other predatory schemes, the providers and the industry are trying to ignore the desperation and powerlessness of the consumer by pretending she is a free agent of some sort, rather than a victim. They are also ignoring increasingly well settled economic understanding that people are not rational economic agents, especially when it comes to change and their reliance on trusted intermediaries, like their usual doctors and hospitals. Looking at this mess, we almost want to say, if you are so rich, why aren’t you smarter?

The New York Times reported on the failure of many of these tools. Of course the rule continues to be, despite the actions of many states, that hospitals and healthcare professionals are hiding information about the comparative value of their services and the pricing in the market. But, even where efforts by some companies and insurers to offer price and value comparisons, people aren’t using them. Researchers compared the decisions of 300,000 workers who didn’t have access to a website cost calculator with 150,000 that did and found that only 10% used the site the first year and 20% the second year, and that it didn’t reduce outpatient spending. Aetna offers a price transparency tool but only 3.5% of its commercial market participants use it. A similar price tool in New Hampshire is used by only 1% of residents. Robert Wood Johnson did a 10-year study and found that doctor quality comparisons had only a “modest effect on the awareness and use of the information.” Duh.

Let’s skip the digital divide and the millions of lower income families without access to any of this information, and get right to the point of how difficult it is to either find this information most places or understand it. Why isn’t there a recognition that we need ubiquitous healthcare advocates, navigators, sherpas, assistants, or whatever we might want to call them? During the Affordable Care enrollment in Texas for example families who had never had insurance were asked to choose between more than 35 plans, each with multiple permutations, without our navigators, who were forbidden to offer any advice to these novice healthcare customers. Who would be surprised if decisions defaulted to nothing or self-interested agents and professionals?

Of course some of the industry believes that education can only be administered by the blunt instrument of punitively making people pay the cost of decisions they were unable to make well without assistance by adding consumer pain to their delusion. Others advocate outreach, and, eureka, finally someone gets it. People need help with all of this to offset the predation, whether it’s door-to-door or through ubiquitous health care centers and advisory facilities so that they can get the information in a user-friendly way with full explanations from someone committed to their best interests. Furthermore, the cost for funding such outreach and facilitation would be minuscule compared to the daily explosion of health related costs that are based simply on the principle of the buyer beware and keeping suckers born and nurtured by the system every minute.

If we really want to make change and lower costs, people need to help people, not websites, applications, and fancy tools.

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USA Election: A Movement Can Always Beat A Machine

socmvmtcollage1New Orleans   The election was over early, just not the way many had expected. I had always argued that regardless of the polls and pundits the election was going to be close, but I had also argued that I thought Clinton would win. Now, I will have to substitute the word “thought” for “hoped.” I had always argued that I hoped Trump would be the Republican nominee because he might be the only candidate Clinton could beat. I now may have to rethink that and revise my analysis, because Trump and his unique campaign may have been the only candidate that Clinton could NOT beat.

The bottom line is pretty clear: a real movement can always beat a machine. When you have almost vastly unpopular candidates in the contest, making everything relatively equal in that regard, a genuine movement can always beat even the best financed and well-oiled machine.

As progressives, we have to understand the simple facts. With courage, this could have been us. In fact given the closeness of the contest between Bernie Sanders and Hillary Clinton for the Democratic nomination, it almost was us.

As organizers, we have to give Trump credit for his willingness to unabashedly embrace a movement and his place in it. He argued a case for the abandoned and left behind by the economy. He railed against the adverse impacts of trade and globalization. He argued for jobs for the jobless. He made a better case against Wall Street and the Washington establishment. These are all our issues. A populist is someone who puts the people first, and as unlikely as Trump was as the bearer of that message, this was our message.

The contest in coming months on the right and throughout the establishment will be to see who can best capture Trump’s heart and soul to make him fit the usual mold better. We actually need to push him on the claims he has made to deliver change to our constituency, if we want to reclaim it. We need to push the demands of huge blocks of those who will feel suddenly disenfranchised by this counterattack by the white and rural and too much of the working class: women, Latinos, and African-Americans. These are also our constituencies and Trump is vulnerable to all of them in trying to convert his movement to governance.

We know these problems and their fragility, because we have faced it repeatedly. We saw how rapidly the movement behind Obama dissipated. Trump may be a horse less easily broken to the bit, and in that space the effort is being made to corral him, we have huge opportunities, if we are able to seize them. Make no mistake this new world order in America will hurt millions if allowed to settle and concretize or be usurped by the far right, so we really don’t have much choice. This is ride-or-die time.

Disruption forces realignments. Chaos provides opportunities, but only to those moving hard and fast to take them and create change out of the turmoil. We have to engage the struggle where we find it, and Trump has now created the new conditions for engagement, and we now have to adapt quickly and organize the alternative paths for new movements to take hold and win, before the door closes and the opportunities are once again lost.

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Sorting out Obamacare Problems Now

obamacare-premium-mapAmersfoort   To the degree that the final version of the Affordable Care Act was neither fish nor fowl and represented a compromise between those that hated the entire concept and those that were trying to make the best of whatever slices of the original loaf were left, we all knew that problems were inevitable. Over the last five years we have been treated to regular and confusing reports from the battlefront, but nothing that ever fixes any problems, some of which are normal and predictable in a huge, new program. Without progress many fall out of love with Obamacare, even as more than ten million have enrolled with huge positive health impacts. Now consensus is building that any new president will have to fix the plan in the coming year, though no one seems sure about the fix or how to come to agreement on a cure.

What to do?

Some notions are almost simple-minded. One I saw said the quick fix was essentially a minor tune-up. Raise the amount of the subsidies for lower income families so that they can absorb the higher premium costs, and raise the level of the penalties to force more of the young and able into the program.

I’m all for raising the level of subsidies, if there can be agreement on that from whoever emerges as the new Congress, but raising the level of penalties is not a real solution to anything. The quick fix folks think that the fact that 260 million Americans or covered by healthcare on their jobs means no problems there, but that’s wrong too. Or, at least it isn’t the whole story.

Many penalty payers are not necessarily just the young and healthy, but also lower waged workers caught in so-called company coverage that ostensibly is offered, but because of the combination of premium cost and exorbitant, almost no-limit deductible charges, means that almost whatever the penalty level might be, it will still be cheaper than paying a premium of 9% of your pay and then having to pay many thousands of dollars in deductibles before you get any real benefit from the so-called insurance. This is really not medical insurance but catastrophe insurance, meaning if you know you need a major operation, maybe you pay. If not, you take your chances and pay the piper. Luckily, it’s taken out of your IRS tax refund, so you can pretend it hurts you less.

A lower waged worker caught in the service industry by these kinds of premium plus high deductible policies would need to be making more than $20 per hour for full-time 40-hour per week work to make it worth taking the insurance rather than paying the penalty. In some healthcare companies where we have contracts, like the service contractor giant ResCare for example, there are literally no takers out of more than 400 workers. I know people who are literally saving up for a CT scan because they don’t have insurance and are paying the penalty, making their health care “cash-on-the-barrel.” The quick, simple fix does nothing for any of these people and pretends that the United States is not dominated now by the service economy and its workforce.

The argument for a public option, a government-funded insurance of last resort, for these workers and others that can offer real competition and leverage to the private insurers makes sense, as Jacob Hacker, the political scientist and health care experts has argued. That’s still not single-payer or any kind of a system that takes private insurers out of the market, but the last years have already established that there’s no free enterprise in this marketplace. There are private insurances still waiting for subsides — $2 billion from the government – and there are regular folks getting subsidies and more that need them who are caught in the bind. Either the government needs to let workers and families caught by corporate insurance gimmicks that technically qualify under the Act, but are worthless in reality, come into the marketplace and get subsidies if qualified, or set up a public option that offers real coverage for this huge segment of the population.

The justice of raising penalties to catch the scofflaws doesn’t work when we still need a lot more mercy or stiff requirements on corporations to provide real insurance coverage.

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