Is There a Resistance Movement or Resistance Moment?

Bristol   I definitely don’t want to be standing at the station when the whistle blows that the train is moving out. I have to admit that I have my ears perked up at every sound to try to hear whether it’s the thundering feet of a movement or just the sharp cry of a moment.

I’m too jaded in this work to see Congressional town halls as the birthplace of the next revolution, but I don’t want to be blind to history either, and a snippet of the news like the one that follows makes me sit up straight and stand at total attention:

In fact, some of the most formidable and well-established organizing groups on the left have found themselves scrambling to track all of the local groups sprouting up through social media channels like Facebook and Slack, or in local “huddles” that grew out of the women’s marches across the country the day after the inauguration.

When the people are moving and established organizations and institutions are having to work overtime to catch up with them, that’s a very, very interesting sign. In a time of movement, it may be difficult for this kind of activity and anger to be channeled in the way that these same organizations and institutions are hoping to move the stream. It’s good news though for the 30 million lower income families taking advantage of the Affordable Care Act that there are many of the flags being waved as elected representatives slink home from the Congressional chaos are focusing on saving health care.

There are other signs too. When seasoned organizers report that they expected 200 at a meeting, and 1000 showed up, as my generation said, “you don’t need a weatherman to see which way the wind is blowing.” The Times also reported on other barometers that people were in motion:

Anti-abortion demonstrations in some cities this month were met with much larger crowds of abortion rights supporters. At a widely viewed town-hall-style meeting held by Representative Gus Bilirakis in Florida, a local Republican Party chairman who declared that the health care act set up “death panels” was shouted down by supporters of the law.

And, perhaps more interestingly, an organizer for Planned Parenthood posed the question plainly as she tries to ride this wave of momentum:

“It doesn’t work for organizations to bigfoot strategy; it’s not the way organizing happens now,” said Kelley Robinson, the deputy national organizing director for Planned Parenthood, which is fighting the defunding of its health clinics. “There are bigger ideas coming out of the grass roots than the traditional organizations.”

If she’s right, that’s a call to arms for all of us to get ready to move, because grassroots activity needs formation, planning, resources, and direction in order to win. That’s not bigfoot, that’s soft touch, listening, and work on the ground that takes a moment and helps make a movement and births new organizations and great social change.

When that whistle blows, we have to all be on the train.

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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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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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Obamacare is Delivering Some of the Goods in Poor States

Screen Shot 2016-08-14 at 10.37.59 AMNew Orleans   There are now some thirty states that have expanded eligibility for Medicaid under the Affordable Care Act. There are twenty states – and a lot of the Republican Congress — that are still dragging their wagons through the dirt, and, if researchers are right, putting their people under the ground as well.

Researchers connected with Harvard’s Public Health School conducted an important experiment. They surveyed people in Kentucky and Arkansas before Medicaid expansion in 2013, again after the first full year in 2014, and finally at the end of 2015 with another year under peoples’ belts. They used Texas as the so-called control state for comparison, since Texas refused to budge on the Obamacare Medicaid expansion for lower-income, working families. Bottom line: 5% more people in Arkansas and Kentucky, too very different states with different approaches on the expansion, felt that they were in “excellent” health compared to do-nothing-much Texas.

Reading about the researchers work on the Harvard Public Health website and its lead author, Dr. Benjamin Sommers, an assistant professor there, offered a good summary that goes deeper than 5%:

Sommers and colleagues surveyed approximately 9,000 low-income adults in Arkansas, Kentucky, and Texas from late 2013 to the end of 2015. The results showed that, between 2013 and 2015, the uninsured rate dropped from 42% to 14% in Arkansas and from 40% to 9% in Kentucky, compared with a much smaller change in Texas (39% to 32%). Expansion also was associated with significantly increased access to primary care, improved affordability of medications, reduced out-of-pocket spending, reduced likelihood of emergency department visits, and increased outpatient visits. Screening for diabetes, glucose testing among people with diabetes, and regular care for chronic conditions all increased significantly after expansion. Quality of care ratings improved significantly, as did the number of adults reporting excellent health.

Debate over? Of course not. Many will wonder, and wait, until larger studies, including the government’s own, provide more data on whether or not people really are healthier or just feel healthier.

Regardless, how people feel may not answer the medical questions fully, but could start to provide answers for the political questions. As we find every day, particularly in the Age of Trump, people vote on how they feel, not based on the facts of the matter. If everything were equal, politicians would see that the trend line of how people feel about their own health and Medicaid expansion is now improving annually. If it continues along these lines, politicians will start playing “duck and cover” which might mean more expansion in the twenty holdout states.

There’s a big “if” though. These same politicians would actually have to care about the poor families that are the beneficiaries of Medicaid expansion, and believe, regardless of the evidence, that they vote, and that some of these poor are their voters.

It might be easier to deliver better healthcare than to convince elected officials of the value of the poor and their votes.

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Dutch Fight to Take Health Care Away from Private Insurers

Holland-plus-medicalBrussels   What is the old saying? Something like, I’ve seen the future and it is in the Netherlands at least when we are talking about the inevitable fight to come someday in the United States to seize control of our national health care programs from big health care insurers. On the way between Germany and Belgium, I had the opportunity to meet with several organizers and campaigners who have built a powerful effort in Holland on this issue and are finding the response amazing with the potential to dominate the campaigns in the country’s elections in the spring of 2017.

If you were paying close attention during the health care debates in recent years over the Affordable Care Act or Obamacare, as it is known popularly, you often heard about the health care insurance scheme in the Netherlands which was better in its broad coverage of the population but, unlike many other countries, was provided by private, rather than public, insurers. Meeting with the organizers, I came to understand the situation a bit better. Everyone pays the equivalent of about one-hundred euros or $112 per month to private companies for insurance. I was fuzzy on exactly how this part works but the fact that they mentioned that much of the Dutch public’s opposition was rooted in disgust at the millions and millions spent by the insurers in advertising and promotion leads me to believe that a family chooses an insurer for their coverage.

There’s also a hammer to the head in this program along the lines of the deductibles that come under Obamacare. Everyone has coverage and everyone pays, but when they actually use the insurance, they have to come up with another 385 euros or $429. For some reason it is called an “own risk” payment, since if you don’t need to buy medicine or go to the doctor, your monthly payments are more like a healthcare tax or donation, so that when you do utilize the system, this is more like an admissions fee. Similar to the US experience with high deductibles blocking utilization under Obamacare, estimates are that 20% of the Dutch people are avoiding accessing the healthcare system, even when they need it, because they cannot afford the additional payment.

So the campaign is seeking to get rid of that payment of course, but also to move to a national healthcare fund more along the lines of the national healthcare program enjoyed by other countries. The support for their campaign has surpassed all expectations, and that’s part of what brought us together in this exciting conversation. In less than two months about 60,000 people have signed up to support the campaign either online or directly, and, amazingly, almost half of them are taking the additional step of asking for an “action” package on steps they can take in their communities to build the campaign.

With elections happening in mid-March of next year, this campaign couldn’t have been timed any better, so if it continues to build momentum in the summer, this could be the issue that dominates progressive debate at every level during the election. Meanwhile, regional meetings throughout the country are also pulling in crowds double, triple, and quadruple of organizers’ expectations, more are set coming off the summer with big demonstrations and other actions planned in the fall. They are riding the whirlwind here, and while they are doing so, as I said earlier, they are running the pilot program that organizers in the United States and elsewhere will need to be studying and copying in order to deal with many of the same issues involving national – and better – healthcare in our countries.

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Is Their Hope for Obamacare?

77639392New Orleans     A federal court somewhere gave new hope to the haters that the subsidies the Affordable Care Act to lower income families might be blocked.  The Administration says they will win on appeal.  But, this is only one cloud of many in the building thunderstorm.

            Insurance companies and those that follow them are almost universally saying that there will be significant price hikes in 2017.  Others are dropping by the wayside, largely because of their own bad pricing and marketing decisions, but nothing keeps them from finger pointing as they leave.  In many ways this was predictable.  As the signature legacy of President Obama, they are smart enough to wait until his long goodbye transitions into whatever and both he and Congress are lame ducks caught in a quacking stalemate, and roll up heavy on Clinton or Trump with the fait accompli

            Clinton has flirted towards the left with a vague proposal to potentially allow people 50 or 55 years of age to “buy into” Medicare, which would expand the coverage to millions more, if they have the money.  What it would still not do is solve any of the problems that continue to weigh heavily on Obamacare.

            Drug prices have continued to rise for example.  In fact, drug profiteering still seems a winning business plan despite the problems with Valeant and profiteers. 

            Charity requirements for nonprofits are still largely more pretense than policy.  Modern Healthcare reported 7 of the 10 most profitable hospitals of the top one-hundred in the country, according to a researcher at John Hopkins, were tax exempt nonprofits.  The three most profitable for profits were all part of the HCA chain and all three were in states like Texas and Florida that have not extended coverage under Obamacare.  Nonprofits were very well represented in the top 100, including Herman Memorial which has been the target of campaigns by Local 100 United Labor Unions and community allies in Houston and Ochsner, headquartered in New Orleans, which has also been called out for its miserly charity record.

            Emergency room doctors are reporting that half or more of the patients they are seeing are coming in late and with insurance, but had delayed seeking care because of the astronomical level of their deductibles, equivalent to having no insurance at all.   Employers of lower waged workers continue to develop such minimal coverage programs with impunity.  The coming year will see an even higher level of penalties appropriated against lower income workers who are running from the cost, deductibles, and copays, but will be caught by the mandated penalties.

            The bottom line is that, like any major piece of new potentially groundbreaking, safety net legislation there are problems.  There are pieces that beg to be fixed.  Meanwhile the deadlock in Congress simply lets the sores fester and pain endure without stepping up and fixing what is broken.  Health care continues to be a political football, as politicians maintain the fiction that this is all part of the game, rather than coming to terms with the fact that for many low and moderate income families, it’s life and death.

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