Repeal and replace. Simple enough on the campaign trail. We heard this promise in 2010, when voters gave the House to Republicans. We heard it again in 2012, when voters gave them the Senate. Despite controlling Congress, Obamacare remained the law of the land. Candidate Donald Trump, along with most Republican members of Congress, promised repeal and replace last year.
Republicans now have their largest electoral majority in nearly a century, and repeal and replace is spinning its wheels, like an old Pontiac stuck in the snow.
Some think a grand bill is still possible, particularly Senate majority leader Mitch McConnell. Others are skeptical. Senators Rand Paul and Mike Lee favor a two-pronged approach: repeal first then repeal later. Herein lies the problem. Republicans can’t agree on anything.
Democrats had no such problem in 2010 when they passed Obamacare. The Bernie coalition didn’t get a single-payer plan as they wanted. Some wanted higher Medicaid reimbursement for their states, as in the “Cornhusker Kickback.” But they came together and passed Obamacare, each Democrat getting most but not all of what he wanted.
The toxic polarization of Washington politics might lead even the most stubborn optimist to abandon any hope for bipartisanship on healthcare. Despite endemic pessimism, the flagging efforts to forge a Republican consensus on “repeal and replace” might set the stage for overdue efforts at compromise. Congress will be tempted to move on to more promising areas such as tax reform and infrastructure funding. That temptation should be resisted. The threat to the nation posed by the current state of American healthcare calls for Congress to resurrect the long lost spirit of bold bipartisanship.
Before considering opportunities for compromise, the obstacles confronting the GOP reform efforts are worth considering. Republicans face the same stubborn reality that confronted the framers of the Affordable Care Act (ACA): Expensive services cannot be covered by cheap insurance. The cost of U.S. healthcare has simply priced low income and even middle income individuals out of health insurance. Without subsides, they get left behind. The Congressional Budget Office’s estimated that the Ryan plan would result in 24 million losing coverage underscored the political divide: Confronted with unmanageable healthcare costs, most Republicans would opt to reduce public expense whereas Democrats plus a handful of Republican moderates prefer more extensive coverage. The effort of the GOP leadership to split the difference by preserving some residual subsidies and the structures supporting them—“Obamacare light”—remains unacceptable to many on the right. No clear middle ground has yet emerged.
Congratulations! You have listened to the AMA and practicing physicians and made it a little easier to comply (at first) with the Medicare Quality Payment Program, part of the massive MACRA “pay for value” law.
But CMS’ announcements in The Federal Register and “fact sheet” are incomprehensible gobbledygook that will be understood by neither doctors, patients, nor the rest of society. The language personifies the complexity, unwieldiness and confused thinking in this huge national policy.
MACRA is a $15 billion boondoggle that the best research shows will neither improve quality nor control costs. Paying doctors for quality (e.g., doing a blood pressure exam) or efficiency may make sense theoretically, but it doesn’t work. Rather than making a dent in the continuing upward spiral of healthcare costs in America, it can even result in some doctors avoiding sicker patients because it affects their quality scores and income.
Early, poorly designed research suggested that paying for health or cost savings was effective, but these research designs did not account for already occurring improvements in medical practice that the policymakers took credit for. Decades of stronger, well-controlled research debunked these early findings and conclusively showed no effects of these economic policies.
So why does the Congress and administration continue to press ahead with this same tired and impotent policy?
… There is a far more fundamental issue affecting the overall success of our healthcare system. Doctors and patients need more transparency when it comes to health care costs.
Healthcare is becoming more expensive by the year. In 1960, healthcare costs accounted for 5% of the gross domestic product. In 2015, they made up 17.8 percent. Although the rates of spending growth actually decreased since 2010 when the Affordable Care Act was enacted, a recent study demonstrated that for employees under 65 with employer sponsored health insurance, the proportion of income consumed by health insurance premiums has increased from 6.5% in 2006 to 10.1% in 2015.
Why does this matter? Health care costs, often from an unexpected medical emergency are the #1 cause of personal bankruptcy in the US. There are 1.7 million Americans live in households that declared bankruptcy due to unpaid medical bills. Also, while more subtle, the rising incremental costs of routine medical care are wearing on the financial stability of many families leaving less funds for essentials such as housing and food, let alone other needs and hobbies.
Fake news has replaced responsible journalism. It’s hard to know what to believe. It wasn’t long ago that supermarket tabloids like National Enquirer were considered fake news. Now it seems the Enquirer and TMZ may be more reliable sources of accurate news than the New York Times or Washington Post.
Government agencies aren’t immune from the fake news trend either. The Congressional Budget Office describes itself as, “Strictly nonpartisan; conducts objective, impartial analysis; and hires its employees solely on the basis of professional competence without regard to political affiliation.”
I’ll bet most newspapers and television news networks say the same about their own objectivity.
The CBO analyzed the American Health Care Act of 2017, a lame effort by Republicans to repeal and replace Obamacare. Passed by the House, it’s now on to “the greatest deliberative body in the world.”
Is health insurance a plan to help healthy people mitigate against an unexpected illness, or an income subsidy to help the sick pay for medical care?
Conservatives ought to have a clear answer to that question. Not long ago Congressman Morris Brooks from Alabama did not and found himself on the receiving end of liberal ridicule.
By suggesting that those who take better care of themselves should pay lower health insurance premiums, Brooks implied that health insurance is indeed a type of insurance arrangement. After all, the risk adjustment of premiums is a practice proper to all other kinds of insurance services. A prudent driver pays less for auto insurance than one with a negative driving record. A homeowner pays more for home insurance if the property is on muddy terrain rather than on sturdy ground. A smoker pays more for life insurance than a non-smoker, as does anyone whose risk of dying prematurely is high, even if that predisposition is inherited genetically.
Brooks’s conception of health insurance, however, intuitive as it may be, is wrong. Health insurance is not insurance even if, on the surface, health insurance policies meet the dictionary definition of insurance as contractual arrangements “in which one party agrees to indemnify or reimburse another for loss that occurs under the terms of the contract.”
In late May the science and health news site STAT ran a provocative article titled: “Trump wasn’t always so linguistically challenged. What could explain the change?”
Not surprisingly, the piece went viral. After all, aren’t most of us wondering whether something is up with the President’s—how shall I say it—state of mind, psychological status, character, personality, and yes, mental health?
For over a year, there’s been speculation about this. Most of the talk is loose and politically inflected. But substantive reflections by mental health professionals and serious commentators are on the rise.
At first, media outlets were very careful. They didn’t want to say the president was “lying” let alone possibly crazy. Their caution was grounded mostly in journalistic ethics and policies. But that caution was also attributable to a thing called the “Goldwater Rule,” which warrants explaining because it infuses this whole issue.
When I first read about neurosyphilis in medical school, I became convinced that Mrs. Thatcher, who I detested intensely because it was fashionable detesting her, had General Paralysis of the Insane. The condition, marked by episodic bouts of temporary insanity, which indicated that the spirochetes were feasting on expensive real estate in the brain, seemed a plausible explanation why she had introduced the retarded Poll Tax.
A little bit of medical knowledge can lead to tomfoolery by the juvenile. I began diagnosing the powerful with medical conditions. I thought the former leader of the Labour Party, Neil Kinnock, who had an odd affect, was both hyperthyroid and hypothyroid – when he spoke he looked myxedematous and when was silent he looked like he had Grave’s Disease. The tacit, but not silent enough, Prince Charles spoke in a tone that seemed a cry for help for acutely thrombosed piles. I also realized that the Prince of Wales – who is the most compelling evidence for the magical kingdom of elves – wasn’t reducible to a single diagnostic code. Diagnosing Hillary was relatively straightforward. After reading a third of her memoirs, which permanently cured my insomnia, I felt someone had inadvertently given her dextrose without thiamine.
Climate change, or changes in weather extremes, are having an increasingly harmful effect on human health. Last year, the 20th consecutive year in which the US experienced above average annual temperatures, saw increasing instances of heat related ailments and deaths and increases in related exacerbations of chronic, including cardiovascular, cerebrovascular, respiratory and mental health, conditions as well as the spread of climate change-related food pathogens and vector borne diseases, most recently Zika.
One study estimated that absent any adaptation to climate change or disruption we will see an increase of 2,000 to 10,000 deaths annually in over 200 US cities. Worldwide, the WHO estimates 800,000 die prematurely each year from urban air pollution stemming from burning coal, oil and gasoline. Not surprisingly, those disproportionately paying the climate penalty are children, pregnant women, the elderly, the disabled, minorities and the poor. Half of those killed by Hurricane Katrina (responsible for almost half of hurricane related deaths over the past 50 years) were over 75 and black adult mortality was upwards of four times higher than for whites. Half of Hurricane Sandy deaths were of those over 65.
When President Trump announced the US would withdraw from the 2015 Paris climate accord, signed by 195 nations, the news was met with widespread criticism. The president’s own Secretary of State, and former Exxon CEO, Rex Tillerson, opposed the decision.
Many countries in the world have dysfunctional governments. Some have corrupt and devious ones, or even deadly ones. We’ve lived with serious dysfunction in Washington for two decades. Now we join the ranks of countries with a corrupt and devious government, one without a moral compass.
And I’m not just talking about Trump.
The news and blogosphere is replete with this sentiment surrounding the White House, of course, a la the “Russia thing” and Comey’s firing and all the rest.
But the cynicism and political bankruptcy that suffuses our elected leaders’ failure to assure that the cost-sharing subsidies for people buying health insurance through the exchanges will be secured for 2017 and 2018 is a new low in the wretched ongoing saga of Obamacare vs. Trumpcare.
This is playing out right now and could affect 12 million people come this fall and in 2018.