tag:theconversation.com,2011:/au/topics/us-health-care-reform-40185/articlesUS health care reform – The Conversation2024-03-13T12:45:24Ztag:theconversation.com,2011:article/2222472024-03-13T12:45:24Z2024-03-13T12:45:24ZBuyouts can bring relief from medical debt, but they’re far from a cure<figure><img src="https://images.theconversation.com/files/577693/original/file-20240223-20-aiwmsy.jpg?ixlib=rb-1.1.0&rect=0%2C15%2C5145%2C3462&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Medical debt can have devastating consequences.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/stethscope-on-pile-of-us-banknotes-royalty-free-image/153349316">PhotoAlto/Odilon Dimier via Getty Images</a></span></figcaption></figure><p><a href="https://www.kff.org/health-costs/press-release/1-in-10-adults-owe-medical-debt-with-millions-owing-more-than-10000/#:%7E:text=Americans%20Likely%20Owe%20Hundreds%20of,who%20owe%20more%20than%20%2410%2C000.">One in 10 Americans</a> carry medical debt, while <a href="https://www.commonwealthfund.org/publications/issue-briefs/2022/sep/state-us-health-insurance-2022-biennial-survey">2 in 5</a> are underinsured and at risk of not being able to pay their medical bills.</p>
<p><a href="https://doi.org/10.1001/jamanetworkopen.2022.31898">This burden</a> <a href="https://www.commonwealthfund.org/publications/podcast/2023/oct/how-medical-debt-makes-people-sicker-what-we-can-do-about-it">crushes millions</a> <a href="https://doi.org/10.1377/hlthaff.2023.00604">of families</a> under mounting bills and contributes to the <a href="http://doi.org/10.1001/jamanetworkopen.2022.31898">widening gap</a> between rich and poor. </p>
<p>Some relief has come with a wave of debt buyouts by <a href="https://fortune.com/2023/03/10/local-communities-are-buying-medical-debt-for-pennies-on-the-dollar-and-freeing-american-families-from-the-threat-of-bankruptcy/">county and city governments</a>, <a href="https://apnews.com/article/business-georgia-nonprofits-2a5c3afc4a646d489242bd99eb6652fc">charities</a> and even <a href="https://www.wmdt.com/2024/01/chick-fil-a-pays-medical-debt-on-delmarva/">fast-food restaurants</a> that pay pennies on the dollar to clear enormous balances. But as a <a href="https://scholar.google.com/citations?user=cGZVMkoAAAAJ&hl=en">health policy and economics researcher</a> who studies out-of-pocket medical expenses, I think these buyouts are only a partial solution.</p>
<h2>A quick fix that works</h2>
<p>Over the past 10 years, the nonprofit <a href="https://ripmedicaldebt.org/">RIP Medical Debt</a> has emerged as the leader in making buyouts happen, using <a href="https://www.cnn.com/2020/03/01/us/medical-debt-campaigns-give-back-trnd/index.html">crowdfunding campaigns</a>, <a href="https://www.theguardian.com/us-news/2016/jun/06/john-oliver-medical-debt-forgiveness-last-week-tonight">celebrity engagement</a>, and partnerships in the private and public sectors. It connects charitable buyers with hospitals and debt collection companies to arrange the sale and erasure of large bundles of debt. </p>
<p>The buyouts focus on low-income households and those with extreme debt burdens. You can’t sign up to have debt wiped away; you just get notified if you’re one of the lucky ones included in a bundle that’s bought off. In 2020, the U.S. Department of Health and Human Services <a href="https://revcycleintelligence.com/news/hospitals-can-sell-patient-bad-debt-to-charitable-orgs-oig-says">reviewed this strategy</a> and determined it didn’t violate anti-kickback statutes, which reassured hospitals and collectors that they wouldn’t get in legal trouble partnering with RIP Medical Debt. </p>
<p>Buying a bundle of debt saddling low-income families can be a bargain. Hospitals and collection agencies are typically <a href="https://www.wbur.org/onpoint/2023/09/21/buy-and-sell-medical-debt-health-care">willing to sell</a> the debt for <a href="https://www.theatlantic.com/health/archive/2019/08/medical-bill-debt-collection/596914/">steep discounts</a>, even <a href="https://fortune.com/2023/03/10/local-communities-are-buying-medical-debt-for-pennies-on-the-dollar-and-freeing-american-families-from-the-threat-of-bankruptcy/">pennies on the dollar</a>. That’s a great return on investment for philanthropists looking to make a big social impact.</p>
<p>And it’s not just charities pitching in. <a href="https://www.npr.org/sections/health-shots/2024/01/23/1225014618/nyc-joins-a-growing-wave-of-local-governments-erasing-residents-medical-debt">Local governments</a> across the country, from <a href="https://arpa.cookcountyil.gov/medical-debt-relief-initiative">Cook County, Illinois</a>, to <a href="https://www.axios.com/local/new-orleans/2023/05/23/new-orleans-medical-debt-forgiveness">New Orleans</a>, have been directing <a href="https://apnews.com/article/health-care-costs-boston-toledo-e423c64c1322bc8e4254b7a70b1da50c">sizable public funds</a> toward this cause. <a href="https://www.nytimes.com/2024/01/22/nyregion/medical-debt-forgiveness.html">New York City</a> recently announced plans to buy off the medical debt for half a million residents, at a cost of US$18 million. That would be the largest public buyout on record, although Los Angeles County may trump New York if it <a href="https://www.latimes.com/california/story/2023-10-04/la-county-buy-forgive-medical-debt-how-work">carries out its proposal</a> <a href="https://www.cbsnews.com/losangeles/news/la-county-considering-plan-to-erase-medical-debt-for-residents/">to spend</a> $24 million to help 810,000 residents erase their debt.</p>
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<figcaption><span class="caption">HBO’s John Oliver has collaborated with RIP Medical Debt.</span></figcaption>
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<p>Nationally, RIP Medical Debt has helped clear more than <a href="https://ripmedicaldebt.org/about/">$10 billion</a> in debt over the past decade. That’s a huge number, but a small fraction of the estimated <a href="https://www.kff.org/health-costs/issue-brief/the-burden-of-medical-debt-in-the-united-states/">$220 billion</a> in medical debt out there. Ultimately, prevention would be better than cure.</p>
<h2>Preventing medical debt is trickier</h2>
<p>Medical debt has been a persistent <a href="https://files.consumerfinance.gov/f/documents/cfpb_medical-debt-burden-in-the-united-states_report_2022-03.pdf">problem over the past decade</a> even after the reforms of the 2010 Affordable Care Act <a href="http://doi.org/10.1056/NEJMsr1406753">increased</a> <a href="http://doi.org/doi:10.1001/jama.307.9.913">insurance</a> <a href="http://doi.org/doi:10.1001/jama.2015.8421">coverage</a> and <a href="https://doi.org/10.1353/hpu.2020.0031">made a dent</a> in debt, especially in states that <a href="http://doi.org/10.3386/w22170">expanded</a> <a href="http://doi.org/10.1001/jama.2021.8694/">Medicaid</a>. A recent <a href="https://www.commonwealthfund.org/publications/issue-briefs/2022/sep/state-us-health-insurance-2022-biennial-survey">national survey by the Commonwealth Fund</a> found that 43% of Americans lacked adequate insurance in 2022, which puts them at risk of taking on medical debt. </p>
<p>Unfortunately, it’s incredibly difficult to close coverage gaps in the patchwork American insurance system, which ties eligibility to employment, income, age, family size and location – all things that can change over time. But even in the absence of a total overhaul, there are several policy proposals that could keep the medical debt problem from getting worse.</p>
<p><a href="https://www.urban.org/sites/default/files/2022-06/Which%20County%20Characteristics%20Predict%20Medical%20Debt.pdf">Medicaid expansion</a> has been shown to reduce uninsurance, underinsurance and medical debt. Unfortunately, insurance gaps are likely to get worse in the coming year, as states <a href="https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-the-unwinding-of-the-medicaid-continuous-enrollment-provision/">unwind their pandemic-era Medicaid rules</a>, leaving millions without coverage. Bolstering Medicaid access in the <a href="https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/">10 states</a> that haven’t yet expanded the program could go a long way.</p>
<p>Once patients have a medical bill in hand that they can’t afford, it can be tricky to navigate financial aid and payment options. Some states, like <a href="https://medicaldebtpolicyscorecard.org/state/MD">Maryland</a> and <a href="https://medicaldebtpolicyscorecard.org/state/CA">California</a>, are <a href="https://doi.org/10.1001/jama.2021.23061">ahead of the curve</a> <a href="https://medicaldebtpolicyscorecard.org/">with policies</a> that make it easier for patients to access aid and that rein in the use of liens, lawsuits and other aggressive collections tactics. More states could follow suit.</p>
<p>Another major factor driving underinsurance is <a href="https://www.npr.org/sections/health-shots/2022/06/16/1104679219/medical-bills-debt-investigation#:%7E:text=For%20many%20Americans%2C%20the%20combination,slightly%20lower%20than%20the%20uninsured.">rising out-of-pocket costs</a> – like high deductibles – for those with private insurance. This is especially a concern for <a href="https://www.chiamass.gov/assets/docs/r/pubs/2020/High-Deductable-Health-Plans-CHIA-Research-Brief.pdf">low-wage</a> <a href="https://www.ajmc.com/view/financial-burden-of-healthcare-utilization-in-consumer-directed-health-plans">workers</a> who live paycheck to paycheck. More than half of large employers believe their employees <a href="https://www.kff.org/report-section/ehbs-2023-summary-of-findings/#:%7E:text=As%20noted%20above%2C%2025%25%20of,a%20moderate%20level%20of%20concern">have concerns</a> about their ability to afford medical care.</p>
<p>Lowering deductibles and out-of-pocket maximums could protect patients from accumulating debt, since it would lower the total amount they could incur in a given time period. But if the current system otherwise stayed the same, then premiums would have to rise to offset the reduction in out-of-pocket payments. Higher premiums would transfer costs across everyone in the insurance pool and make enrolling in insurance unreachable for some – which doesn’t solve the underinsurance problem.</p>
<p>Reducing out-of-pocket liability without inflating premiums would only be possible if the overall cost of health care drops. Fortunately, there’s room to reduce waste. Americans <a href="https://www.pgpf.org/blog/2023/07/why-are-americans-paying-more-for-healthcare">spend more on health care</a> than people in other wealthy countries do, and arguably get less for their money. <a href="http://doi.org/doi:10.1001/jama.2019.13978">More than a quarter</a> of health spending is on <a href="https://www.brookings.edu/articles/reducing-administrative-costs-in-u-s-health-care/#:%7E:text=Cutler%20proposes%20several%20reforms%20to,in%20the%20health%2Dcare%20system.">administrative</a> <a href="http://doi.org/10.1111/1475-6773.13649">costs</a>, and the <a href="https://doi.org/10.1377/hlthaff.2018.05144">high prices</a> Americans pay don’t necessarily translate into <a href="https://www.doi.org/10.1001/jama.2019.13978">high-value care</a>. That’s why some states like <a href="https://www.milbank.org/publications/the-massachusetts-health-care-cost-growth-benchmark-and-accountability-mechanisms-stakeholder-perspectives/">Massachusetts</a> and <a href="https://hcai.ca.gov/get-the-facts-about-the-office-of-health-care-affordability/">California</a> are experimenting with <a href="https://www.chcf.org/wp-content/uploads/2022/04/HealthCareCostCommissionstatesAddressCostGrowth.pdf">cost growth limits</a>.</p>
<h2>Momentum toward policy change</h2>
<p>The growing number of city and county governments buying off medical debt signals that local leaders view medical debt as a problem worth solving. Congress has passed substantial <a href="https://www.cms.gov/priorities/key-initiatives/hospital-price-transparency">price transparency laws</a> and prohibited <a href="https://www.cms.gov/nosurprises">surprise medical billing</a> in recent years. The Consumer Financial Protection Bureau is <a href="https://www.consumerfinance.gov/about-us/newsroom/cfpb-kicks-off-rulemaking-to-remove-medical-bills-from-credit-reports/">exploring rule changes</a> for medical debt collections and reporting, and national credit bureaus have <a href="https://www.urban.org/urban-wire/medical-debt-was-erased-credit-records-most-consumers-potentially-improving-many">voluntarily removed</a> some medical debt from credit reports to limit its impact on people’s approval for loans, leases and jobs. </p>
<p>These recent actions show that leaders at all levels of government want to end medical debt. I think that’s a good sign. After all, recognizing a problem is the first step toward meaningful change.</p><img src="https://counter.theconversation.com/content/222247/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Erin Duffy receives funding from Arnold Ventures. </span></em></p>Local governments are increasingly buying – and forgiving – their residents’ medical debt.Erin Duffy, Research Scientist, University of Southern CaliforniaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1542132021-02-08T18:24:07Z2021-02-08T18:24:07ZFact check US: Can progressive and centrist Democrats finally agree on health care reform?<p>The Democrats are back in the driving seat. Some are demanding a complete overhaul of the health care system, specifically from progressive Senator Sanders. Sanders has just been named to the strategic position of Senate Budget Committee Chairman. Does this mean that the left and center of the Democratic Party will finally agree on a more comprehensive health insurance system?</p>
<p>Senator <a href="https://www.politico.com/news/2021/01/12/bernie-sanders-big-budget-plans-458461">Bernie Sanders</a> is already promoting his campaign for a universal, public health insurance model with a vengeance: </p>
<blockquote>
<p>“I am a very strong advocate of Medicare for All. I introduced legislation in the Senate. I think, at the end of the day, the American people understand that our current health care system is so dysfunctional, so cruel, so wasteful, so expensive that we need to do what every other major country on Earth does, and get health care to all people. What we will be doing is working within the context of what Biden wants.” </p>
</blockquote>
<p>Sanders’ statement comes as no surprise. As a senator from the progressive state of Vermont, he has been fighting for years to implement a public health care system in the United States similar to models in Europe. This has long been a core aim of <a href="http://www.pressesdesciencespo.fr/fr/book/?gcoi=27246100830610">progressives in Wisconsin</a>, from the days of Roosevelt’s New Deal to the debate around Bill Clinton’s proposed health care reform in 1993. That was when progressive Democrats started to advocate for single-payer health care – that all essential health care be covered by a single public system, rather than private insurers.</p>
<h2>Seeking a fairer health care system while the pandemic rages</h2>
<p>For many in the United States, the debate remains the same – it’s still a case of choosing between a “grand illusion” of universal care and a <a href="https://ajph.aphapublications.org/doi/10.2105/AJPH.2019.305315">“feasible solution”</a>. However, the Covid-19 pandemic, which has caused nearly 450,000 deaths so far, has pushed supporters of public health care to speak out more forcefully, right when the Biden administration is taking over. </p>
<p>So what can we expect from the new president? As part of the moderate wing of the Democratic Party, Joe Biden was not supportive of Medicare for All during the primaries. He stated that he was in favor of improving the Affordable Care Act (ACA), Barack Obama’s health care reform, which gave coverage to <a href="https://www.cbpp.org/research/health/chart-book-accomplishments-of-affordable-care-act">20 million Americans</a> who previously had none. Under the act, popularly known as Obamacare, Americans are encouraged to get private health insurance, with public assistance for those who could not afford to do so. Two longstanding public programs with narrow criteria complete the system: Medicare (for those over 65 years old) and Medicaid (for minors and single women).</p>
<p>Biden was in favor of increasing public funding so that all citizens could afford insurance, essentially an Affordable Care Act 2.0. The high public cost of Medicare for All as well as the number of Americans who are relatively satisfied with the current employer-based system meant that the Delaware senator considered larger reform out of the question.</p>
<p>However, with Kamala Harris as his running mate and now vice-president, and an eye on getting progressive Democrats on board, Biden has shifted to the left. One such move was proposing a more substantial reform of Obamacare, introducing a “public option”. Harris had earlier come out in favor of an “open” version of Medicare for All, with the option to take out supplementary private health insurance. The two compromised on a solution with both private and public insurance. However, this kind of reform requires budget legislation that cannot be passed by a simple majority (which the Democrats have in the Senate). They would need a supermajority of 60 votes to get it through, and avoid Republican obstruction (a.k.a., the <a href="https://theconversation.com/fact-check-us-lobstruction-parlementaire-lun-des-obstacles-majeurs-a-venir-pour-joe-biden-153902">filibuster</a>).</p>
<p>What’s more, with the absolute priority currently given to the fight against the Covid-19 pandemic, it’s unclear whether Biden will take an extra step toward the far-reaching reform sought by progressive Democrats. Looking at the make-up of Biden’s new administration, one cannot precisely assess the importance that this issue could have on the upcoming political agenda. Out of the <a href="https://www.washingtonpost.com/politics/interactive/2020/biden-appointee-tracker/">19 executive positions</a> in the Department of Health awaiting appointments, and approval by the Senate, only one has been confirmed – Dr. Francis Collins, the new director of the National Institute of Health. Nominations of Xavier Becerra as the secretary, as well as the deputy and assistant secretary candidates, are awaiting confirmation. </p>
<p>By comparison, the 2008–09 Obama administration was set up as a sort of task force, with a number of veterans from the Clinton administration. These advisers, many of whom held positions in the White House and Department of Health, backed the consensus-based health-insurance reform bill. There is nothing of the sort in the current administration.</p>
<h2>A bare majority for Democrats in Congress</h2>
<p>President Biden’s main priority is to fight the Covid-19 pandemic, hence his promise for <a href="https://www.forbes.com/sites/roberthart/2021/12/29/biden-promises-100-million-covid-19-vaccinations-in-first-100-days-warning-that-trumps-approach-would-take-years/?sh=6efbc5892a97">“100 days, 100 million vaccinations”</a>. This is also his reasoning behind the recruiting of his chief of staff, Ron Klain, who as part of the Obama administration was responsible for managing the US response to the Ebola epidemic. </p>
<p>Responding to Covid-19 also allows for the triumphant return of experts to the White House, who were both badly treated and side-lined by the Trump administration. Biden’s choice of the ten members of his task force shows a change in tack. And the nomination of Jeff Zients, an economist and a former Obama advisor, to coordinate the federal vaccination program reaffirms this choice. Zients was the one who fixed the rollout of the ACA’s federal health insurance marketplace website.</p>
<p>Assessing the Biden administration’s opportunities for substantial US health care reform requires a careful reading of the recent election results. Despite Trump’s baseless claims, Biden comfortably won, but there wasn’t a “blue wave” in Congress. The Democrats actually lost seats in the House of Representatives and have only the barest majority in the Senate, with Harris as the tiebreaker vote. Any major Medicare for All–type reform bill will inevitably be subject to criticism from the Republicans who warn against so-called “socialized medicine” while dismissing the benefits of universal care. The Biden administration has also committed $1.9 billion to fight the impacts of Covid-19, with more planned.</p>
<p>All this means that it is likely that Biden will choose to improve the ACA, introducing measures by passing budget legislation or budget balancing, which would only require a relative majority in the Senate (50 votes).</p>
<p>As vice-president, Harris will likely will leave her health care reform agenda for a later date. Committing to such a reform without having 60 Democratic votes in the Senate would be a major political risk for the 2022 midterm elections. And there are certainly other issues to tackle, such as securing minority rights or providing a stable situation for the 11 million undocumented immigrants or the 700,000 “dreamers” (children of migrants born in the United States). These political battles are just as deeply felt as Medicare for All and certainly much less risky for Harris, who no doubt hopes to embody the future of the Democratic Party in the post-Biden era.</p>
<hr>
<p><em>The Fact check US section received support from <a href="https://craignewmarkphilanthropies.org/">Craig Newmark Philanthropies</a>, an American foundation fighting against disinformation.</em></p>
<p><em>Translated from the French by Rosie Marsland for <a href="http://www.fastforword.fr/en">Fast ForWord</a>.</em></p><img src="https://counter.theconversation.com/content/154213/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Les auteurs ne travaillent pas, ne conseillent pas, ne possèdent pas de parts, ne reçoivent pas de fonds d'une organisation qui pourrait tirer profit de cet article, et n'ont déclaré aucune autre affiliation que leur organisme de recherche.</span></em></p>From Vice-President Kamala Harris to Senator Bernie Sanders, voices were raised during the campaign for a more accessible US health care system. What can we expect from the Biden administration?William Genieys, Directeur de recherche CNRS au CEE, Sciences Po Larry Brown, Professeur invité au Laboratoire interdisciplinaire d'évaluation des politiques publiques (LIEPP), Sciences Po, Columbia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1489632020-11-03T13:26:59Z2020-11-03T13:26:59ZPoor US pandemic response will reverberate in health care politics for years, health scholars warn<figure><img src="https://images.theconversation.com/files/367112/original/file-20201102-23-1tywzd2.jpg?ixlib=rb-1.1.0&rect=0%2C137%2C5383%2C3419&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A COVID-19 test in Utah. The country's pandemic response has been politicized, making comprehensive changes to public health more difficult. </span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/VirusOutbreakUtah/83ec3c8c78fd46b39752cfeaa6241a66/photo?Query=COVID-19%20surge&mediaType=photo&sortBy=arrivaldatetime:desc&dateRange=Anytime&totalCount=1467&currentItemNo=36">AP Photo/Rick Bowmer</a></span></figcaption></figure><p>Much has been written about the <a href="https://theconversation.com/experts-agree-that-trumps-coronavirus-response-was-poor-but-the-us-was-ill-prepared-in-the-first-place-133674">U.S. coronavirus response</a>. Media accounts frequently turn to experts for their insights – commonly, epidemiologists or physicians. <a href="https://www.kff.org/coronavirus-covid-19/report/kff-health-tracking-poll-july-2020/">Countless surveys</a> have also queried Americans and individuals <a href="https://www.ipsos.com/en/public-opinion-covid-19-outbreak">from around the world</a> about how the pandemic has affected them and their attitudes and opinions. </p>
<p>Yet little is known about the views of a group of people particularly well qualified to render judgment on the U.S.’s response and offer policy solutions: academic health policy and politics researchers. These researchers, like the <a href="https://scholar.google.com/citations?user=QY68LSIAAAAJ&hl=en">two</a> of <a href="https://scholar.google.com/citations?user=UEH-XXoAAAAJ&hl=en">us</a>, come from a diverse set of disciplines, including public health and public policy. Their research focuses on the intricate linkages between politics, the U.S. health system and health policy. They are trained to combine applied and academic knowledge, take broader views and be fluent across multiple disciplines.</p>
<p>To explore this scholarly community’s opinions and perceptions, <a href="https://doi.org/10.1002/wmh3.371">we surveyed hundreds of U.S.-based researchers</a>, first in April 2020 and then again in September. Specifically, we asked them about the U.S. COVID-19 response, the upcoming elections and the long-term implications of the pandemic and response for the future of U.S. health policy and the broader political system.</p>
<p>Overall, the results of our survey – with 400 responses, which have been published in full in <a href="https://doi.org/10.1002/wmh3.371">our recent academic article</a> – paint a picture of a damaged reputation to government institutions. Surveyed scholars also believe the <a href="https://www.theatlantic.com/magazine/archive/2020/09/coronavirus-american-failure/614191/">poor government response</a> will shift the politics of health care. At the same time, our findings don’t show strong belief in major policy changes on health. </p>
<h2>Parceling out the blame</h2>
<p><a href="https://doi.org/10.1002/wmh3.371">We first asked</a> respondents how much responsibility various actors bear for the lack of preparedness in the U.S. Here scholars overwhelming assign blame to one source: 93% of respondents blamed President Trump for the overall lack of preparedness “a lot” or “a great deal.” Moreover, 94% in April and 98% in September saw political motivations as the main drivers of the president’s actions.</p>
<p>The <a href="https://www.cdc.gov/">Centers for Disease Control and Prevention</a> and the <a href="https://www.fda.gov/home">Food and Drug Administration</a>, as well as Congress, also deserve a significant amount of blame, survey respondents said. At the other end of the spectrum, scholars were relatively content with the response by local and state governments as well as that of the World Health Organization.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/367030/original/file-20201102-13-1l1jox.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="coronavirus testing site in Los Angeles with cars." src="https://images.theconversation.com/files/367030/original/file-20201102-13-1l1jox.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/367030/original/file-20201102-13-1l1jox.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/367030/original/file-20201102-13-1l1jox.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/367030/original/file-20201102-13-1l1jox.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/367030/original/file-20201102-13-1l1jox.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/367030/original/file-20201102-13-1l1jox.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/367030/original/file-20201102-13-1l1jox.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Insufficient testing was one of the first major problems the U.S. confronted in the pandemic.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/VirusOutbreak/d9637980cbfb4c73ad42c09633e9acbb/photo?Query=coronavirus%20testing%20United%20states&mediaType=photo&sortBy=arrivaldatetime:desc&dateRange=Anytime&totalCount=857&currentItemNo=21">AP Photo/Mark J. Terrill</a></span>
</figcaption>
</figure>
<p>Notably, perceptions grew significantly more negative for all entities between April and September. This likely reflects frustrations with the continued inability to rein in the spread of the virus.</p>
<h2>Effects on the political system and health policy</h2>
<p>Respondents also offered a particularly grim view of the long-term implications of the failed coronavirus response for the United States. </p>
<p>Survey after survey has shown that partisanship influences individuals’ perceptions of the coronavirus pandemic. Early research indicates that <a href="https://doi.org/10.1017/S0008423920000396">right-leaning media</a> and <a href="https://doi.org/10.1215/03616878-8641506">presidential communication</a> may have significantly contributed to these discrepancies and increased polarization. </p>
<p>And according to scholars in our study, these stirred-up partisan differences may lead to increases in distrust in government, a lack of faith in political institutions and even further growth in political polarization in the long term. </p>
<p>Overall, <a href="https://doi.org/10.1002/wmh3.371">scholars were generally skeptical</a> about any major progressive changes like the adoption of universal health care, paid sick leave, or basic income in the aftermath of the pandemic. At the same time, they also do not expect popular conservative changes like the <a href="https://archives.cjr.org/campaign_desk/medicare_vouchers_explained.php">privatization of Medicare</a> or <a href="https://khn.org/news/5-things-to-know-about-trumps-medicaid-block-grant-plan">block grant Medicaid</a>, which restricts expenditures from the federal government to states to a set lump sum.</p>
<p>Once more, hyperpartisanship, combined with the cumbersome political process, is seen as the major culprit here.</p>
<p>There is one major exception: adoption of a federal <a href="https://www.milkenreview.org/articles/much-ado-about">public option</a>, a government-run health plan to compete with private insurers. Here, more than 60% of scholars initially thought that adoption would be somewhat or very likely in the next five years; however, this number dropped to 50% by September. This expectation appears to be driven by the expectation of a Biden presidency.</p>
<p>Two-thirds of respondents expected public health, health infrastructure, and pandemic preparedness to take on more prominent roles going forward. Just under half expected a larger focus on inequalities and inequities. Yet, with major reforms unlikely, scholars are generally skeptical about much progress on the issues.</p>
<p><iframe id="F9zYa" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/F9zYa/6/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<h2>Looking Ahead</h2>
<p>There is <a href="http://www.DOI.org/10.1056/NEJMp2014836">ample</a> <a href="https://www.jsonline.com/in-depth/news/2020/10/14/america-had-worlds-best-pandemic-response-plan-playbook-why-did-fail-coronavirus-covid-19-timeline/3587922001/">evidence</a> that the U.S. has fared significantly worse than its peers in handling the coronavirus pandemic. </p>
<p>To health policy and politics scholars, this came as no surprise. In the U.S., the pandemic collided with a <a href="https://www.pewresearch.org/topics/political-polarization/">political system rife with distrust and polarization</a>. Both pathologies are mirrored among the American public. Large parts of the population are <a href="https://www.pewresearch.org/science/2019/08/02/trust-and-mistrust-in-americans-views-of-scientific-experts/">wary of the role scientists play in policy</a>. Many subscribe to <a href="https://www.pewresearch.org/fact-tank/2020/07/24/a-look-at-the-americans-who-believe-there-is-some-truth-to-the-conspiracy-theory-that-covid-19-was-planned/">conspiracy theories</a>. </p>
<p>This combination, together with poor leadership, has put coordinated and sustained policy response out of reach. </p>
<p>[<em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>.]</p>
<p>To make things worse, the coronavirus has also highlighted the <a href="https://www.ucsf.edu/magazine/covid-inequality">ubiquitous inequities in American society</a>. It has also laid bare the <a href="https://theconversation.com/experts-agree-that-trumps-coronavirus-response-was-poor-but-the-us-was-ill-prepared-in-the-first-place-133674">inadequacies of the safety net or other social protections like paid sick leave</a>.</p>
<p>In our view, no matter the outcome of the elections, the impacts of the failed coronavirus response will likely reverberate through the U.S. political system for decades. Much rebuilding will need to be done.</p><img src="https://counter.theconversation.com/content/148963/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder is a Fellow in the Interdisciplinary Research Leaders Program, a national leadership development program supported by the Robert Wood Johnson Foundation to equip teams of researchers and community partners in applying research to solve real community problems.</span></em></p><p class="fine-print"><em><span>Sarah E. Gollust is an Associate Director of the Interdisciplinary Research Leaders Program, a program supported by the Robert Wood Johnson Foundation. She also receives research grants to support her work analyzing media communication and health policy from the Robert Wood Johnson Foundation and the Russell Sage Foundation.</span></em></p>Health policy and politics scholars expect political fallout from the federal response to the pandemic will play out for years, with trust in government taking a big hit.Simon F. Haeder, Assistant Professor of Public Policy, Penn StateSarah E. Gollust, Associate Professor of Health Policy and Management, University of MinnesotaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/902932018-01-18T17:48:26Z2018-01-18T17:48:26ZTime to stop using 9 million children as a bargaining CHIP<figure><img src="https://images.theconversation.com/files/202459/original/file-20180118-158522-dsq1l0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Funding for the Children’s Health Insurance Program (CHIP) has run out.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-bandaged-plush-teddy-bear-stethoscope-257952542?src=2KKyHHfqXu_2KhR3jSAjIg-1-12">stockcreations/shutterstock.com</a></span></figcaption></figure><p>Since the inauguration of President Donald Trump, <a href="https://theconversation.com/how-the-latest-effort-to-repeal-obamacare-would-affect-millions-84317">health care has been front and center in American politics</a>. Yet attention has almost exclusively focused on the Affordable Care Act and congressional Republicans’ <a href="https://theconversation.com/how-the-latest-effort-to-repeal-obamacare-would-affect-millions-84317">slew of attempts</a> to <a href="https://theconversation.com/how-trump-and-tom-price-can-kill-obamacare-without-the-senate-76489">repeal and replace it</a>.</p>
<p>These efforts, combined with a variety of other steps taken by the Trump administration, have increased the number of uninsured Americans by more than <a href="http://news.gallup.com/poll/225383/uninsured-rate-steady-fourth-quarter-2017.aspx">3 million since last January</a>.</p>
<p>With Congress so preoccupied, little attention has been paid to a bipartisan program that has been in place since the late 1990s: the <a href="https://www.cambridge.org/core/journals/journal-of-policy-history/article/inching-toward-universal-coverage-statefederal-healthcare-programs-in-historical-perspective/E94A03DD1F60F9DCBE3DDE9728DA3224">Children’s Health Insurance Program</a>. Often referred to simply as CHIP, it provides health coverage to <a href="http://www.kff.org/other/state-indicator/annual-chip-enrollment/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">9 million American children</a> whose families earn too much to qualify for Medicaid but cannot afford private health coverage.</p>
<p>Funding for CHIP <a href="https://theconversation.com/clock-running-out-on-health-program-for-9-million-kids-84404">ran out at the end of last September</a>, leaving both state governments and families with great uncertainty. So far, congressional Republicans have refused to offer a clean renewal of CHIP, but have consistently raised demands to undermine the ACA in return. <a href="http://docs.house.gov/billsthisweek/20180115/BILLS-115SAHR195-RCP115-55.pdf">Their latest measure</a> offers to fund CHIP in exchange for avoiding a government shutdown and a deal with Democrats over <a href="https://theconversation.com/how-daca-affected-the-mental-health-of-undocumented-young-adults-83341">Dreamers</a>. </p>
<p>Holding 9 million children and their families as bargaining chips has gone on much too long. </p>
<h2>What is CHIP?</h2>
<p>Since its <a href="https://www.cambridge.org/core/journals/journal-of-policy-history/article/inching-toward-universal-coverage-statefederal-healthcare-programs-in-historical-perspective/E94A03DD1F60F9DCBE3DDE9728DA3224">creation by a bipartisan coalition under the Clinton administration</a>, CHIP has been crucial for the health of millions of American children, their families and their communities. It has also proven <a href="https://www.nytimes.com/2017/12/05/health/childrens-health-insurance-program.html">tremendously popular</a> with families and their doctors, as well as with state and federal level policymakers.</p>
<p>CHIP fills in the gap for those children who fall just above the Medicaid threshold, determined by family income, but still do not have access to affordable, employer-sponsored insurance. Almost all CHIP children live in households where <a href="https://www.macpac.gov/wp-content/uploads/2015/03/State-Children%E2%80%99s-Health-Insurance-Program_CHIP-Fact-Sheet.pdf">at least one parent works</a>. <a href="https://www.macpac.gov/wp-content/uploads/2017/01/Recommendations-for-the-Future-of-CHIP-and-Childrens-Coverage.pdf">Ninety percent</a> live in households that are 200 percent below the federal poverty line.</p>
<p>At cost of just below <a href="https://www.macpac.gov/wp-content/uploads/2015/03/State-Children%E2%80%99s-Health-Insurance-Program_CHIP-Fact-Sheet.pdf">US$14 billion</a>, CHIP, together with Medicaid, has been crucial in ensuring that more than <a href="https://www.macpac.gov/wp-content/uploads/2017/01/Recommendations-for-the-Future-of-CHIP-and-Childrens-Coverage.pdf">95 percent of American children</a> are covered by health insurance today. This compares to 89 percent at the time the program was created.</p>
<p>States have a <a href="https://www.cambridge.org/core/journals/journal-of-policy-history/article/inching-toward-universal-coverage-statefederal-healthcare-programs-in-historical-perspective/E94A03DD1F60F9DCBE3DDE9728DA3224">significant amount of flexibility</a> in terms of eligibility levels, benefit design, copayments, premiums, enrollment and administrative structure. At the same time, the financial contribution of the federal government is significantly above what’s offered for <a href="https://www.macpac.gov/wp-content/uploads/2017/01/Recommendations-for-the-Future-of-CHIP-and-Childrens-Coverage.pdf">Medicaid</a>, making participation particularly enticing for states. Not surprisingly, with large amount of flexibility and generous financial support, states have long looked favorably toward the program.</p>
<p>Yet CHIP, unlike Medicaid, is not an entitlement but rather a block grant. As a block grant, CHIP requires periodic appropriation of funding to maintain the program. </p>
<h2>Why is CHIP so important?</h2>
<p><a href="http://www.kff.org/medicaid/issue-brief/the-impact-of-the-childrens-health-insurance-program-chip-what-does-the-research-tell-us/">The benefits for families and communities of CHIP are many</a>. CHIP is crucial in providing financial security, preventing families from suffering catastrophic losses. </p>
<p>Moreover, the program does a tremendous job at ensuring that children’s health needs are met comprehensively. Healthier children are more <a href="https://www.macpac.gov/wp-content/uploads/2017/01/Recommendations-for-the-Future-of-CHIP-and-Childrens-Coverage.pdf">likely to attend school and graduate from high school and college</a>. Healthier children also <a href="https://www.macpac.gov/wp-content/uploads/2017/01/Recommendations-for-the-Future-of-CHIP-and-Childrens-Coverage.pdf">prevent parents from forgoing their own care or missing time at work</a>. </p>
<p>CHIP also serves a <a href="https://www.macpac.gov/wp-content/uploads/2015/03/State-Children%E2%80%99s-Health-Insurance-Program_CHIP-Fact-Sheet.pdf">large number of children with special</a> and costly health needs, such as ADHD and asthma.</p>
<p>The crucial role of CHIP has been repeatedly emphasized by <a href="https://www.usnews.com/news/best-states/west-virginia/articles/2017-09-07/wvu-speakers-panelists-to-examine-child-health-care-policy">health policy experts</a>. Not surprisingly, MACPAC, the commission that provides Congress with advice on Medicaid and CHIP, <a href="https://www.macpac.gov/wp-content/uploads/2017/01/Recommendations-for-the-Future-of-CHIP-and-Childrens-Coverage.pdf">recommended last January</a> to continue and further enhance the program.</p>
<h2>How should we move forward?</h2>
<p>Between the Medicaid expansions of the 1990s, the creation of CHIP and the ACA, America has made great strides in providing health insurance to its most vulnerable, including America’s children. Indeed, insurance enrollment rates for children are at historic <a href="https://www.kff.org/other/state-indicator/children-0-18/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">highs, hovering around 95 percent</a>. Congressional inaction has endangered these historic gains.</p>
<p>Since funding ran out in September, Congress provided a limited lifeline by providing <a href="https://ccf.georgetown.edu/wp-content/uploads/2018/01/When-Will-States-Run-Out-of-Federal-CHIP-FundsFINAL.pdf">temporary funding</a> to states. Similarly, the Department of Health and Human Services has been able to <a href="https://ccf.georgetown.edu/wp-content/uploads/2018/01/When-Will-States-Run-Out-of-Federal-CHIP-FundsFINAL.pdf">reallocate funding</a> to those states most in need. Yet, without further Congressional action, <a href="https://ccf.georgetown.edu/wp-content/uploads/2018/01/When-Will-States-Run-Out-of-Federal-CHIP-FundsFINAL.pdf">almost half the states expected to run out of funding in February</a>.</p>
<p>Already, states have been confronted with daunting challenges on <a href="https://ccf.georgetown.edu/wp-content/uploads/2018/01/When-Will-States-Run-Out-of-Federal-CHIP-FundsFINAL.pdf">how to possibly maintain or phase out the program</a>. Several states will automatically terminate their programs if federal funding for the program falls below a certain threshold. Moreover, state budgets have assumed that the program will <a href="http://nashp.org/state-chip-changes-are-coming-soon/">continue in its current form</a>. Failure to reauthorize the program at current levels would pose tremendous problems for all states.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/186856/original/file-20170920-16420-1u3z7aq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/186856/original/file-20170920-16420-1u3z7aq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/186856/original/file-20170920-16420-1u3z7aq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/186856/original/file-20170920-16420-1u3z7aq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/186856/original/file-20170920-16420-1u3z7aq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/186856/original/file-20170920-16420-1u3z7aq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/186856/original/file-20170920-16420-1u3z7aq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Senators Ron Wyden and Orrin Hatch at a Senate Finance Committee meeting Sept. 14, 2017.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/Search?query=orrin+hatch+wyden&ss=10&st=kw&entitysearch=&toItem=15&orderBy=Newest&searchMediaType=excludecollections">AP Photo/Jacquelyn Martin</a></span>
</figcaption>
</figure>
<p>The <a href="http://docs.house.gov/billsthisweek/20180115/BILLS-115SAHR195-RCP115-55.pdf">continuing resolution introduced by congressional Republicans</a> the week of Jan. 15 once more attempts to bargain CHIP for further erosion of the ACA by suspending or delaying several of its tax provisions. Ironically, Republican efforts to undo the ACA are expected to drive up premiums in the insurance markets so much that renewing <a href="https://www.cbo.gov/publication/53459">CHIP for 10 years would likely save the federal government money</a>.</p>
<p>Yet, even at the current cost, I firmly believe CHIP is a tremendous bargain. Its great benefits allow children to reach their potential. It’s time for Congress to get their act together and pass a stand-alone long-term renewal of CHIP. </p>
<p><em>Editor’s Note: This is an updated version of an <a href="https://theconversation.com/clock-running-out-on-health-program-for-9-million-kids-84404">article</a> that originally ran on Sept. 21, 2017.</em></p><img src="https://counter.theconversation.com/content/90293/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Funding for a children’s health insurance program ran out at the end of last September. Despite the program’s clear benefits, plans to renew it have been caught in partisan bickering.Simon F. Haeder, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/891142018-01-04T04:31:57Z2018-01-04T04:31:57ZFor richer or poorer: 4 economists ponder what 2018 has in store<figure><img src="https://images.theconversation.com/files/200762/original/file-20180103-26163-rc8vst.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">At least one economist worries we'll be mostly poorer. </span> <span class="attribution"><span class="source">AP Photo/Go Nakamura</span></span></figcaption></figure><p><em>Editor’s note: We asked four economists to offer their thoughts and insights on what they expect to be a key theme or issue in 2018.</em></p>
<h2>The Gilded Age returns</h2>
<p><strong>Greg Wright, assistant professor of economics, University of California, Merced</strong></p>
<p>Income and wealth inequality are currently at levels last seen during the Gilded Age – when the top 10 percent of Americans owned nearly three-fourths of overall wealth, and the bottom 40 percent had virtually no wealth – and 2018 will see things get a whole lot worse. </p>
<p>Now, the richest 1 percent of Americans <a href="https://www.washingtonpost.com/news/wonk/wp/2017/12/06/the-richest-1-percent-now-owns-more-of-the-countrys-wealth-than-at-any-time-in-the-past-50-years/?utm_term=.d5667081375e">own</a> 40 percent of U.S. wealth, more than the bottom 90 percent of Americans combined.</p>
<p>In spite of this, Congress just <a href="https://www.bloomberg.com/view/articles/2017-12-15/this-tax-bill-is-a-trillion-dollar-blunder?utm_medium=email&utm_source=newsletter&utm_term=171215&utm_campaign=sharetheview">significantly reduced taxes</a> on capital and on high-earning individuals. Other income earners got smaller, temporary cuts. </p>
<p>Meanwhile, the government <a href="http://www.cnn.com/2017/12/14/politics/chip-extended-states-funds-kimmel-authorization/index.html">has yet to renew</a> federal funding for the Children’s Health Insurance Program, a program affecting 9 million poor families, and the tax bill <a href="http://thehill.com/policy/healthcare/365185-final-gop-tax-bill-repeals-obamacare-mandate">repealed</a> the Affordable Care Act’s individual insurance mandate, which may ultimately lead to a loss of coverage for millions of low- and middle-income Americans. </p>
<p>Other policies that will be enacted or pursued in 2018 that could further widen the income gap include <a href="https://www.washingtonpost.com/news/wonk/wp/2017/12/01/gop-eyes-post-tax-cut-changes-to-welfare-medicare-and-social-security/?utm_term=.47b9ba4d34f5">cuts in important programs</a> like Social Security and Medicare and a continuing rollback of financial, environmental and other regulations that benefit a few companies at the expense of all Americans’ living standards. </p>
<p>Why does widening inequality matter? </p>
<p>While some argue that inequality is irrelevant as long as all incomes are rising, even that has not been true in the U.S. for decades. The average income for the bottom 50 percent of Americans <a href="https://www.theguardian.com/inequality/2017/dec/14/inequality-is-not-inevitable-but-the-us-experiment-is-a-recipe-for-divergence?CMP=share_btn_tw">has been unmoved</a> at US$16,000 since 1980. In addition, <a href="https://www.nytimes.com/2017/12/03/opinion/lost-einsteins-innovation-inequality.html?_r=1">recent evidence</a> indicates that family income in childhood is a strong predictor of the likelihood that an individual will produce innovations as an adult. Poverty and social inequality thus lead to “<a href="http://www.equality-of-opportunity.org/assets/documents/inventors_summary.pdf">lost Einsteins</a>.”</p>
<p>Not long after accepting the Nobel prize in economics in 2014, <a href="http://www.businessinsider.com/shiller-on-inequality-and-taxes-2014-4">Robert Schiller stated</a>, “If we wait until income inequality is much more severe, we will have a whole class of new superrich who will … feel entitled to their wealth and will have the means to defend their interest.” </p>
<p>In 2018 we may begin to put these fears to the test.</p>
<hr>
<h2>War on poverty, revisited</h2>
<p><strong>Patricia Smith, professor of economics, University of Michigan</strong></p>
<p>By many measures, such as <a href="http://www.oecdbetterlifeindex.org/topics/income/">GDP, income and wealth per household</a>, the U.S. is among the richest countries in the world.</p>
<p>At least one measure, however, makes the U.S. look not so rich: its poverty rate. The share of American households living on less than half of the national median income, a commonly used measure for international comparisons, is the <a href="http://www.oecd.org/social/society-at-a-glance-19991290.htm">second-highest in the developed world</a>, at 17.5 percent. While the <a href="https://www.census.gov/library/publications/2017/demo/p60-259.html">official U.S. poverty rate</a> puts that lower, at 12.7 percent, even by that measure <a href="https://www.ers.usda.gov/topics/rural-economy-population/rural-poverty-well-being/poverty-demographics.aspx#byage">over a quarter</a> of children under 5 lived in poverty in 2016. </p>
<p>Past presidents have tried several ways to fight poverty. Lyndon Johnson <a href="https://www.washingtonpost.com/news/wonk/wp/2014/01/08/everything-you-need-to-know-about-the-war-on-poverty/?utm_term=.0731c94acd9d">declared “unconditional war”</a> in 1964 and championed anti-poverty programs such as Medicare and Medicaid. Bill Clinton <a href="https://royce.house.gov/uploadedfiles/the%201996%20welfare%20reform%20law.pdf">changed the battle strategy</a> 32 years later by pushing people to work more. </p>
<p>House Speaker Paul Ryan has once again reopened the debate on how best to win the fight by <a href="https://www.cbsnews.com/videos/paul-ryan-talks-gop-tax-bill-denies-rumors-of-him-leaving-congress/">declaring</a> poverty will be a focus in 2018. The rhetoric of the <a href="https://abetterway.speaker.gov/?page=poverty">Republican plan</a> sounds promising, beginning with “If the American Dream isn’t true for everyone, it isn’t true for anyone.” It would make work more rewarding in anti-poverty programs and improve education and training. </p>
<p>But Ryan <a href="https://www.washingtonpost.com/news/wonk/wp/2017/12/01/gop-eyes-post-tax-cut-changes-to-welfare-medicare-and-social-security/?utm_term=.4753bd1e7f26">has also made clear</a> he plans to cut Medicaid, Medicare and other anti-poverty programs to reduce the national debt, all of which were central to reducing the official poverty rate from 22 percent in the early 1960s.</p>
<p>Part of the argument supporting a focus on cutting debt is that it <a href="http://www.heritage.org/budget-and-spending/report/cutting-the-us-budget-would-help-the-economy-grow">spurs growth</a>, which in turn reduces poverty. The U.S. did experience this prior to the mid-1970s, when growth <a href="http://www.epi.org/publication/raising-americas-pay/">appeared correlated with less poverty</a>. Since then, however, the poverty rate has responded little to economic growth.</p>
<p>In fact, the correlation may work the other way around because research suggests that lowering poverty rates cuts health care costs and federal spending and boosts growth. Specifically, improving health and nutrition for the poor <a href="http://blogs.reuters.com/nicholas-wapshott/2013/06/13/robert-fogel-and-the-economics-of-good-health/">is critical</a> to long-term growth, leading to <a href="http://science.sciencemag.org/content/287/5456/1207.full">higher productivity</a> and incomes. For example, economists estimate that the cost of childhood poverty in terms of <a href="https://confrontingpoverty.org/wp-content/uploads/2017/02/PAPER15.pdf">lost economic productivity approaches $294 billion</a> annually. </p>
<hr>
<h2>Economic optimism and health care</h2>
<p><strong>Christos Makridis, Ph.D. candidate in labor and public economics, Stanford University</strong></p>
<p>Americans began 2018 <a href="https://www.cnbc.com/2017/12/18/economic-optimism-soaring-helping-trump-cnbc-survey.html">more optimistic about the economy</a> than they’ve been in at least a decade.</p>
<p>How can the government sustain and build on this hopefulness – a <a href="http://stanford.edu/%7Ecmakridi/Makridis%20-%20Sentimental%20business%20cycles">key driver of consumer spending</a> – among individuals and <a href="https://www.colorado.edu/business/sites/default/files/attached-files/lbci_q1_2018.pdf">small businesses</a> in 2018? </p>
<p>In my view, one of the most important ways to do this is by reforming health care in a financially stable way. Rising health care costs and the tax plan’s <a href="http://fortune.com/2017/12/20/tax-bill-individual-mandate-obamacare/">repeal of the Affordable Care Act’s individual mandate</a> mean it’s urgent that Congress tackle this in 2018. Health care exchanges <a href="https://www.nytimes.com/2017/12/18/us/politics/tax-cut-obamacare-individual-mandate-repeal.html">may implode</a> without the mandate. </p>
<p>Health care spending made up a record <a href="https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html">18 percent of U.S. gross domestic product</a> in 2016, up from 17.3 percent five years earlier. While spending has slowed a bit from previous decades, it’s beginning to accelerate and is forecast to reach <a href="https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/proj2016.pdf">20 percent of the economy</a> by 2025. </p>
<p>Following last year’s tax cut, <a href="https://www.nytimes.com/2017/12/15/us/politics/republican-tax-bill.html">some in Congress</a> – perhaps ironically – are arguing that the focus now needs to be on reducing the budget deficit in the short term. But the deficit is a long-term problem that is nearly impossible to balance without figuring out a way to rein in health care spending in part because it makes up so much of the economy. </p>
<p>Scholars from <a href="https://bipartisanpolicy.org/library/future-of-health-care-bipartisan-policies-and-recommendations/">both sides</a> of the aisle agree the status quo is problematic: There is far <a href="https://www.brookings.edu/research/making-health-care-markets-work-competition-policy-for-health-care/">too little competition</a>, and <a href="https://hbr.org/2016/12/health-care-needs-real-competition">incentives are too weak</a>. While there is no easy answer, structural changes like <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3054172">introducing penalties</a> for poor hospital performance in Medicare reimbursement claims could help. </p>
<p>Health care is one of the few items that matters to literally everyone, from small business owners and corporate executives to households of all incomes. It’s also one of the trickiest because of its life and death nature, with quality of service difficult to gauge and costs often not borne directly by patients.</p>
<p>I believe the tax cut President Trump signed into law in December will help turn the current economic optimism into tangible reality for tens of millions of families. By tackling health care next, the government could continue that momentum. Delaying reform will only make things tougher down the road. </p>
<hr>
<h2>Trade takes center stage</h2>
<p><strong>William Hauk, associate professor of economics, University of South Carolina</strong></p>
<p>President Trump <a href="https://www.cbsnews.com/videos/trump-calls-nafta-a-disaster/">made it clear during the 2016 presidential campaign</a> that he intended to either renegotiate or withdraw from most of the United States’ international trade agreements. In 2018, he may finally focus his energy on these campaign promises, which would put our prosperity at risk.</p>
<p>Early on in 2017, he announced the U.S. withdrawal from the Trans-Pacific Partnership. We’re <a href="https://www.voanews.com/a/4100538.html">already</a> <a href="https://www.cnbc.com/2017/11/11/trans-pacific-trade-deal-advances-without-united-states.html">beginning</a> to see the negative impact of that decision. Our economic and political influence in Asia may decline in 2018 and the years ahead.</p>
<p>He has also set his sights on the North American Free Trade Agreement and began <a href="https://www.news.virginia.edu/content/nafta-20-primer-tense-negotiations-between-us-canada-and-mexico">renegotiating</a> its terms. Talks are likely to accelerate in 2018, with the pact’s unraveling a real possibility.</p>
<p>And in interviews, he has <a href="https://www.yahoo.com/news/trump-says-us-could-pull-world-trade-organization-154808319.html">declared the World Trade Organization</a> “a disaster.” </p>
<p>International trade deals are an often misunderstood part of U.S. economic policy. However, they can have a large impact on the economy.</p>
<p>Since the end of World War II, the U.S. has taken the lead in setting up a multilateral, rules-based system of international trade. <a href="https://www.wto.org/english/thewto_e/whatis_e/tif_e/fact4_e.htm">Central to this system</a> was the General Agreement on Tariffs and Trade. In 1994, this agreement was transformed into the WTO.</p>
<p>Under this system, world trade has expanded dramatically over the last 70 years. In 1947, <a href="http://www.hamiltonproject.org/charts/u.s._imports_and_exports_1947_2016">trade accounted for</a> approximately 6 percent of U.S. gross domestic product, whereas it now accounts for approximately 15 percent. Today, U.S. exports <a href="https://ustr.gov/about-us/benefits-trade">support over 11 million jobs</a>, while imports of many staples from overseas <a href="http://americastradepolicy.com/aafa-imports-benefit-the-u-s-worker-and-consumer/#.WkIw8VWnEqM">increase the purchasing power of domestic households</a>.</p>
<p>A retreat from a multilateral rules-based system of trade brings with it many problems. Domestically, it increases the probability of “trade wars” with our major trading partners. Relatively minor disputes could easily escalate into trade sanctions and counter-sanctions, like in the <a href="http://money.cnn.com/2016/07/07/news/economy/trump-trade-smoot-hawley/index.html">aftermath of the Depression-era Smoot-Hawley Tariff</a>, which raised tariffs on hundreds of imports.</p>
<p>Internationally, it could make it more difficult for developing countries to engage in trade relations with their much larger and wealthier counterparts.</p>
<p>While the Trump administration has drawn attention to the U.S.’s large trade deficit, most economists agree that <a href="https://piie.com/blogs/trade-investment-policy-watch/free-trade-agreements-and-trade-deficits">trade agreements have little to no effect on that</a>. </p>
<p>Certainly, some aspects of institutions such as NAFTA and the WTO can be questioned. However, a general retreat from the postwar system of trade could be a dangerous path for both the U.S. and the broader world economy.</p><img src="https://counter.theconversation.com/content/89114/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christos Makridis has received funding from the National Science Foundation. </span></em></p><p class="fine-print"><em><span>William Hauk has received funding from the Center for International Business Education and Research. </span></em></p><p class="fine-print"><em><span>Greg Wright and Patricia Smith do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>We asked four of our regular economics writers to examine a key theme they expect to flare up in 2018 and why.Greg Wright, Assistant Professor of Economics, University of California, MercedChristos A. Makridis, Ph.D. Candidate in Labor and Public Economics, Stanford UniversityPatricia Smith, Professor of Economics, University of MichiganWilliam Hauk, Associate Professor of Economics, University of South CarolinaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/865082017-11-01T14:06:31Z2017-11-01T14:06:31ZSurprise! How Obamacare is beginning to look a lot like Medicaid<figure><img src="https://images.theconversation.com/files/192739/original/file-20171031-18730-19ccz6y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A computer screen showing the Healthcare.gov website for this year's open enrollment.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Trump-Free-Insurance/aa9277cffbeb4673b17465c291dbeaa4/1/0">AP Photo/Alex Brandon</a></span></figcaption></figure><p>In a great irony, the Republicans, who promised to eliminate the Affordable Care Act and roll back Medicaid expansions, are in essence about to do the reverse – at a huge cost to the U.S. Treasury. This year Obamacare will become what could be seen as an expanded version of Medicaid.</p>
<p>From my perspective as a finance professor and former insurer CEO, I predicted trouble when President Trump said last summer that he would <a href="https://theconversation.com/whats-ailing-the-aca-insurers-or-congress-64151">let Obamacare fail</a>. He didn’t say at the time that he’d help make sure that happens by driving up premiums – or that millions will rejoin the ranks of the uninsured while the federal government spends billions more in the process. Yet that almost certainly is in the cards now.</p>
<h2>How could this be?</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/192745/original/file-20171031-32602-fpm0uz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/192745/original/file-20171031-32602-fpm0uz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=404&fit=crop&dpr=1 600w, https://images.theconversation.com/files/192745/original/file-20171031-32602-fpm0uz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=404&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/192745/original/file-20171031-32602-fpm0uz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=404&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/192745/original/file-20171031-32602-fpm0uz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=507&fit=crop&dpr=1 754w, https://images.theconversation.com/files/192745/original/file-20171031-32602-fpm0uz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=507&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/192745/original/file-20171031-32602-fpm0uz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=507&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Senators Bill Cassidy, left, Lindsey Graham, center, and Mitch McConnell tried but failed to pass a bill to replace Obamacare.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/Search?query=mitch+mcconnell+health+care+bill&ss=10&st=kw&entitysearch=&toItem=15&orderBy=Newest&searchMediaType=excludecollections">AP Photo/J. Scott Applewhite</a></span>
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<p>An ineffectual Congress unable to pass even minimal corrective legislation and bullying actions from the White House have produced an <a href="http://avalere.com/expertise/managed-care/insights/silver-exchange-premiums-rise-34-on-average-in-2018">enormous increase</a> in nominal premiums of at least 34 percent for 2018 plans offered on the individual exchanges. The increases came about as plans scrambled to cover the higher risk of expensive care. Meanwhile, large group premiums continue to grow at a little over <a href="https://www.pwc.com/us/en/health-industries/health-research-institute/behind-the-numbers.html">6 percent</a>.</p>
<p>But not all marketplace consumers will pay for those increases – taxpayers will. The average subsidy for Obamacare consumers will grow by <a href="https://aspe.hhs.gov/system/files/pdf/258456/Landscape_Master2018_1.pdf">45 percent</a>, making the net premium costs even lower for many! </p>
<p>This anomalous result comes from the way that Obamacare subsidies are calculated. Subsidies are determined by taking the difference between stated premiums and a fixed percent of an enrollee’s income (2 percent for those just above the poverty level; up to 9.5 percent for at the top). </p>
<p>Premium prices rose this year not only because insurers left the marketplace. Insurers also had to incorporate losses caused by Pres. Trump’s suspension of cost-sharing subsidies into their premiums and uncertainty about who would enroll.</p>
<p>The president would want us to see the rising premiums as signs of the Obamacare “implosion” he predicted. But in reality, they are steps leading to a redefinition of the exchanges. Originally, sliding-scale subsidies based on income were to make access affordable for everyone. But sky-high premiums mean that only those qualifying for these subsidies are likely to purchase insurance on the exchanges, while others are priced out. </p>
<h2>So Obamacare becomes an extended Medicaid expansion</h2>
<p>This latest scenario looks a lot like the Republican plans for Medicaid under the waivers, as enacted by Indiana and <a href="http://www.healthaffairs.org/doi/pdf/10.1377/hlthaff.2017.0688">planned widely in red states</a>. </p>
<p>These Medicaid waiver programs for the poor require enrollees to pay some portion of premiums and cost of care to independent private insurers, just like the exchange plans do. But the level of eligibility for subsidized exchange plans goes far beyond Medicaid range for states that took the option to expand. These states cover enrollees up to 138 percent of the poverty level (US$16,623 for an individual) while the exchange plans subsidize coverage up to 400 percent of the poverty level ($48,240).</p>
<p>The typical conventional working-age Medicaid enrollee qualifies for care for <a href="https://ccf.georgetown.edu/2013/02/11/the-medicaid-expansion-a-one-step-plan-to-improve-coverage-and-care/">less than nine months</a> until he or she gets a job and loses coverage (kids and the elderly stay on far longer). These enrollees typically regain Medicaid coverage after a “spend down” period when they have a medical event that they can’t afford which eats up their cash or dumps them out of the job market. </p>
<p>Effectively, many of the same people rotate between conventional Medicaid and the Obamacare insurance exchange. Thanks to the subsidies under the ACA, these folks will not suffer the 34 percent increase in premiums and will stay with exchange plans. Since subsidies are rising, many of them may pay far less, or even <a href="https://www.wsj.com/articles/more-aca-plans-to-come-with-no-premiums-in-2018-1509096602">zero premiums</a>.</p>
<p>As over three-quarters of those on the exchange receive substantial subsidies, the enrollment on the exchanges will not drop precipitously although government outlays will jump.</p>
<h2>Who loses?</h2>
<p>However, the other quarter are out of luck. They will have to pay far more. Thanks to lax enforcement of the individual mandate to acquire health insurance or face tax penalties and President Trump’s executive order allowing lower-priced, stripped down, non-exchange options, these folks are almost certain to exit the exchanges.</p>
<p>So the bottom line is that most folks left in Obamacare will be those still receiving significant subsidies. These are the people who look a lot like conventional Medicaid enrollees – because they were enrolled before or are on the edge of eligibility now. Effectively, we have expanded the Medicaid program to them through the back door.</p>
<p>Unfortunately, this is a very expensive way to expand Medicaid. </p>
<p>There are two big losers. One is those individuals who relied on exchange plans but don’t receive subsidies. The other is the federal deficit. The former often are the near-elderly or those with preexisting conditions who couldn’t get coverage before at a reasonable rate. They are stuck with high premiums necessary to cover the extra risk induced by the chaos of repeal and replace efforts. The second are the taxpayers, who have to <a href="https://www.urban.org/urban-wire/what-could-happen-if-federal-government-stops-reimbursing-insurers-acas-cost-sharing-reductions">absorb the higher subsidies</a>, amounting to over $7 billion.</p>
<p>The winners are certainly not the insurance companies, in spite of Mr. Trump’s statement that the subsidies are a “bailout” payment allowing them to “make a killing” on their ACA policies. In fact, almost all report <a href="https://www.nytimes.com/2017/04/07/health/insurers-stem-losses-and-may-soon-profit-from-obamacare-plans.html">significant losses on their exchange products</a>, and many have left or failed financially. And even if they were to make windfall profits, the extra must be rebated to their customers under a little-reported provision of the ACA <a href="https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/Medical-Loss-Ratio.html">limiting the amount they can retain</a> beyond direct medical costs. </p>
<h2>Does anyone win?</h2>
<p>The only winners here may be those low-income people who now have higher subsidies and a lower net cost of insurance. Virtually no one else comes out ahead – not insurers, not other individuals, not the government.</p>
<p>If they knew this, even rock-ribbed conservatives might well join their liberal friends in opposing this incremental approach to health policy, even though the alternatives they favor would differ greatly.</p><img src="https://counter.theconversation.com/content/86508/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>J.B. Silvers is a board member of MetroHealth Medical Center which receives Medicaid payment.</span></em></p>With open enrollment for the Obamacare exchanges under way, big changes could occur. Insurers raised their premiums, but most Obamacare consumers won’t pay big increases. Taxpayers will.J.B. Silvers, Professor of Health Finance, Weatherhead School of Management & School of Medicine, Case Western Reserve UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/857862017-10-23T00:42:20Z2017-10-23T00:42:20ZWill Obamacare marketplaces suffer as open enrollment begins?<figure><img src="https://images.theconversation.com/files/190681/original/file-20171017-30422-sk8ah.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Pres. Trump shows off an executive order he signed Oct. 12, 2017 to undo parts of the Affordable Care Act. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Trump/8d286a68f4ce438b97afaa2a4a21d501/16/0">AP Photo/Evan Vucci</a></span></figcaption></figure><p>The Trump administration’s <a href="https://theconversation.com/why-trumps-executive-order-may-compound-the-health-insurance-industrys-problems-85640">executive order</a> changing some elements of the Affordable Care Act’s administration are creating uncertainty as open enrollment for the health insurance marketplaces is set to start Nov. 1. </p>
<p>How will the executive order affect individual insurance and open enrollment this year? </p>
<p>With one very important exception – the elimination of subsidies to help low-income people pay for co-payments and other out-of-pocket expenses – the likely answer is: not much. </p>
<p>However, as a professor of health policy who has extensively studied the ACA, I believe that exception could have big ripple effects.</p>
<h2>Changes ahead</h2>
<p>The <a href="https://www.whitehouse.gov/the-press-office/2017/10/12/presidential-executive-order-promoting-healthcare-choice-and-competition">executive order of Oct. 12, 2017</a> focused on three relatively unknown features of how the ACA affects premiums and enrollment. These three are <a href="http://content.healthaffairs.org/content/25/6/1591.full">association health plans</a>, <a href="https://www.healthcare.gov/glossary/health-reimbursement-account-hra/">health reimbursement accounts</a> and short-term health insurance policies. </p>
<p><a href="http://content.healthaffairs.org/content/25/6/1591.full">Association health plans</a>, which have been proposed since the 2000s, are insurance plans offered by associations rather than employers and that would be exempt from state insurance laws. </p>
<p>For example, small law firms might be able to buy health insurance through the American Bar Association. Association health plan regulations would seek to exempt the bar association from the many differing state insurance regulations arguably lowering costs and increasing insurer competition.</p>
<p>There are two reasons to think this effort would have “not much” of an effect. First, small employers can already become <a href="https://www.shrm.org/resourcesandtools/hr-topics/benefits/pages/self-insurance-aca.aspx">self-insured</a> and buy coverage that limits their risk beyond a certain dollar amount, or what is called stop-loss coverage. They can therefore rather easily become exempt from state insurance regulations.</p>
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<img alt="" src="https://images.theconversation.com/files/191107/original/file-20171019-1082-mjpoty.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/191107/original/file-20171019-1082-mjpoty.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=270&fit=crop&dpr=1 600w, https://images.theconversation.com/files/191107/original/file-20171019-1082-mjpoty.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=270&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/191107/original/file-20171019-1082-mjpoty.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=270&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/191107/original/file-20171019-1082-mjpoty.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=339&fit=crop&dpr=1 754w, https://images.theconversation.com/files/191107/original/file-20171019-1082-mjpoty.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=339&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/191107/original/file-20171019-1082-mjpoty.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=339&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Doctors, hospitals and pharmacies often combine to establish networks to bargain with insurers.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/group-hospital-doctors-health-care-banner-329975945?src=79x5SIBH9so25urvsjPopg-1-52">kurhan/Shutterstock.com</a></span>
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<p>The second reason to expect “not much” impact is that modern insurance requires networks of hospital, physician and drugstore networks. Our <a href="https://www.brookings.edu/wp-content/uploads/2017/02/summary-report-final.pdf">field research</a> on the effectiveness of competition in the exchanges leads us to believe that the proposed multi-state associations are unlikely to be able to negotiate meaningfully low prices with providers that will allow them to compete with locally based insurers. </p>
<p>So, few get established and even fewer are successful.</p>
<h2>Employer-based savings accounts</h2>
<p>The next proposal is to allow health reimbursement account funds to be used for a broader array of services and, particularly, to buy private individual coverage through the exchange. </p>
<p>Health reimbursement accounts are similar to the tax-sheltered flexible spending accounts that many people currently have through their employers. Unlike an FSA, however, the employer funds the health reimbursement account and defines what the funds can be used for. </p>
<p>One fear is that the employers most likely to adopt the new-version health reimbursement account are those with a history of high medical claims. They would, it’s feared, dump their expensive workers on the insurance exchange, leading to higher exchange premiums. </p>
<p>It is very unclear the extent to which employers would move toward the new health reimbursement accounts. Traditionally, money to buy private coverage was a not uncommon model used by small employers in the pre-ACA era. These would seem to be the most likely to adopt the new health reimbursement account model. </p>
<p>But, currently uninsured workers in small firms are more likely to be low utilizers of health care services, so they don’t cost much. If so, their enrollment in the exchanges would lower average claims costs, and, by extension, premiums as well. While there is the potential for larger effects, I believe the mostly likely impact seems to be “not much.” </p>
<h2>Short-term policies</h2>
<p>The order also proposed expanding the time limit on short-term policies from 90 days to 365 days. This has a potentially bigger impact – particularly when tied to the elimination of payments for cost-sharing subsidies.</p>
<p>Traditionally, state laws limited short-term policies to approximately 365 days of coverage. The Obama administration shortened that to 90 days. The short-term individual market is (and was) minuscule; the entire individual market is only about 7 percent and the short-term market was only a slice of that. It focused on those who wanted coverage between jobs, or before new employer coverage began, or before Medicare began. Those with preexisting health conditions paid more. Coverage could also be tailored to exclude, say, maternity care. </p>
<p>However, a reasonably healthy individual may buy such a plan “just in case.” These are the very folks the ACA wants in the exchanges. They would help balance out the high cost people with ongoing health problems.</p>
<p>Thus, some opponents fear that expanding the length of short-term policies would take away healthy buyers from the exchange marketplaces and result in higher premiums for those who remain. </p>
<p>Advocates of the short-term policies would argue that these are precisely the folks who aren’t buying coverage now. </p>
<p>Given the strongly disproportionate enrollment into the exchanges by those with preexisting conditions and other health concerns, I’m of the view that this proposal increases the number of people with coverage, by means of the short-term policies, without having much impact on the exchanges.</p>
<p>But, there is a complication!</p>
<h2>Higher premiums almost a certainty</h2>
<p>The complication is the administration’s decision to stop payments to insurers for cost-sharing subsidies. These are subsidies to help low income people pay for co-payments, deductibles and other out-of-pocket expenses.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/191109/original/file-20171019-1059-13etrkf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/191109/original/file-20171019-1059-13etrkf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=403&fit=crop&dpr=1 600w, https://images.theconversation.com/files/191109/original/file-20171019-1059-13etrkf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=403&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/191109/original/file-20171019-1059-13etrkf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=403&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/191109/original/file-20171019-1059-13etrkf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=507&fit=crop&dpr=1 754w, https://images.theconversation.com/files/191109/original/file-20171019-1059-13etrkf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=507&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/191109/original/file-20171019-1059-13etrkf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=507&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">There are many expenses, including lab work, not covered by some health insurance policies, and consumers are responsible for the balance of the bill.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/medical-objects-on-doctors-table-731250901?src=ZKPex4UbxRNaweOLwOpcMQ-2-83">sfam_photos/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>These subsidies differ from those to help consumers pay for insurance premiums. The administration’s decision order doesn’t change those premium subsidies. </p>
<p>What does change is that the administration is arguing that Congress never appropriated the payments of the cost-sharing subsidies to the insurers and as a result these payments will now stop.</p>
<p>This presents a problem. Insurers in the marketplace must honor the effectively lower deductibles and co-pays. To offset losses from the administration’s action, they ordinarily would raise premiums or leave the market. </p>
<p>But under the ACA, the insurers can’t just raise premiums. Insurers had to submit their proposed premiums last summer and signed contracts in October. Some insurers assumed the administration would end these subsidy payments; they raised their proposed premiums to reflect this assumption, and the regulators approved the higher rates. </p>
<p>Blue Cross Blue Shield of Texas reported that its 2018 rates reflect this assumption. Other states, such as California, directed insurers to assume that the subsidy payments would go away, it also approved higher rates. Other states may allow insurers to revise their rates; still others may not. </p>
<p>So, in some states, premiums are already higher due to the anticipation of the administration’s action. In others, premiums will increase to reflect the new action. In still others, insurers may be simply out of luck; these are the states where some or all insurers may withdraw from the exchanges.</p>
<h2>A new group would be vulnerable</h2>
<p>This sets up a second set of consumers who will be affected by the short-term policies. It’s not the folks who have the premium subsidies. As long as their incomes don’t change, the premiums they pay are unaffected. Under the ACA, taxpayers pay for their higher premiums.</p>
<p>No, the second affected group consists of those who are not eligible for a premium subsidy. Whether they buy coverage through the exchange or through an off-exchange, ACA-compliant policy, they will face the higher premiums. </p>
<p>In my view, many of these will be tempted by the short-term policies. Some will be pleased that they can get “just in case” coverage at a lower premium. Some will be pleased that they can buy coverage that doesn’t include features they don’t value, maternity care perhaps, at a much lower price. Others will make the trade-off of lower-priced coverage, but exclusion of coverage for their heart condition. They hope and trust that they can make it to the next ACA open enrollment period if they need such care. These folks all expand enrollment in the short-term market segment.</p>
<p>It isn’t clear, however, how big an impact this enrollment shift might have on the exchanges. To the extent that these are disproportionately healthy folks who withdraw, their withdrawal will mean that those who remain in the exchanges are those with higher average medical costs, resulting in higher premiums next year.</p>
<p>So, while most of the actions in the president’s executive order are likely to have “not much” impact, the real story is likely to be the shift to short-term policies in the face of the elimination of the payments for the cost-sharing subsidy.</p><img src="https://counter.theconversation.com/content/85786/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Morrisey received funding from the Brookings Institution to study the ACA.</span></em></p>Frustrated with Congress for its failure to replace Obamacare, President Trump took matters into his own hands and issued an executive order to nix parts of it. How his order will play out is unknown.Michael Morrisey, Professor, Health Policy and Management, Texas A&M UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/852522017-10-18T23:33:04Z2017-10-18T23:33:04ZUS health care system: A patchwork that no one likes<figure><img src="https://images.theconversation.com/files/189035/original/file-20171005-14904-1jsbs7s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Senator Majority Leader Mitch McConnell, considered a powerful dealmaker, failed to get the necessary votes to repeal and replace the Affordable Care Act. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Congress-Republicans-The-Abyss-Analysis/4ce0032bcb224804a6fa19ffe4c5679f/123/0">AP Photo/Andrew Harnik</a></span></figcaption></figure><p>Almost all parties agree that the health care system in the U.S., which is responsible for about <a href="https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet.html">17 percent of our GDP</a>, is badly broken. Soaring costs, low quality, insurance reimbursements and co-payments confusing even to experts, and an ever-growing gap between rich and poor are just some of the problems.</p>
<p>And yet, this broken system reflects <a href="https://www.cambridge.org/core/journals/journal-of-policy-history/article/inching-toward-universal-coverage-statefederal-healthcare-programs-in-historical-perspective/E94A03DD1F60F9DCBE3DDE9728DA3224">the country’s constitutional foundation and its political culture</a>. At the very core of both is a strong suspicion of governmental intervention and a disdain for concentrated power, paired with an exaltation of individual liberty and personal responsibility.</p>
<p>Translating this ideology into a modern state is a complex endeavor that often leads to constructs that resemble creations envisioned by Rube Goldberg. Perhaps nowhere else is this more obvious as in the American health care system. The result has been the creation of an uncoordinated, often inefficient, patchwork of programs that <a href="https://theconversation.com/how-the-latest-effort-to-repeal-obamacare-would-affect-millions-84317">does not cover everyone, is excessively costly and often provides low-quality care</a>. </p>
<p>The conflicts of the past linger into the present, as seen in the dozens of Republican unsuccessful <a href="http://onlinelibrary.wiley.com/doi/10.1111/puar.12065/full">attempts to repeal and replace</a> the Affordable Care Act, the Obama administration’s signature, if maligned, law. </p>
<p>More generally, ideologically, the country has failed to reach a consensus about the appropriate role of government in the provision of health care for its citizens. Politically, reforming any part of the health care system becomes a third rail. Yet practically, while often left unacknowledged, government involvement is ubiquitous. Indeed, over time, governments, at both the state and federal level, <a href="https://www.cambridge.org/core/journals/journal-of-policy-history/article/inching-toward-universal-coverage-statefederal-healthcare-programs-in-historical-perspective/E94A03DD1F60F9DCBE3DDE9728DA3224">have come to influence every component of the American health care system</a>.</p>
<h2>A fragmented ‘system’</h2>
<p>Governments have three major options to provide benefits. They can regulate the conduct of private entities, provide services directly or merely provide financing while having services provided by other entities. In the United States, state and federal governments rely on all three options.</p>
<p>Today, <a href="https://www.kff.org/other/state-indicator/total-population/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">half of all Americans</a> obtain their insurance through an employer. Depending on the nature of the arrangement, these are subject to an <a href="http://www.sciencedirect.com/science/article/pii/S0168851014002607">often complex web of state and federal regulations</a>.</p>
<p>However, over time, the federal government has taken on an ever-larger role in the regulation of insurance, most recently <a href="https://www.degruyter.com/view/j/for.2013.11.issue-3/for-2013-0056/for-2013-0056.xml">culminating with the passage of the Affordable Care Act</a> in 2010. The federal government also provides generous tax incentives to encourage the employer-sponsored provision of insurance at an annual cost <a href="http://www.taxpolicycenter.org/briefing-book/how-does-tax-exclusion-employer-sponsored-health-insurance-work">exceeding US$260 billion</a>.</p>
<p>Yet, even despite regulatory action and financial support, more than half of all Americans are not covered through employer-sponsored insurance, thus requiring other, more active forms of government involvement.</p>
<h2>Different plans for the old, the poor and veterans</h2>
<p>Elderly Americans and some of those afflicted with disabilities and end-stage renal disease, about <a href="https://www.kff.org/other/state-indicator/total-population/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">14 percent of the population</a>, are covered by a purely federal, social insurance, single-payer arrangement, <a href="https://www.cms.gov/Medicare/Medicare.html">Medicare</a>. </p>
<p>Antiquated in its design because it separates hospital coverage from physician coverage, all <a href="https://www.cms.gov/Medicare/Medicare-General-Information/MedicareGenInfo/index.html">working-age Americans are required to pay into the system that entitles them to hospital insurance at age 65</a>. <a href="https://www.cms.gov/Medicare/Medicare-General-Information/MedicareGenInfo/index.html">Voluntary physician and prescription drug coverage</a> are subject to a combination of individual premiums and government subsidies. Many elderly choose to <a href="https://www.medicare.gov/supplement-other-insurance/medigap/whats-medigap.html">buy additional insurance</a> protection to make up for the often limited benefits under these programs. Alternatively, eligible individuals can choose to obtain comprehensive coverage through private insurers in a program called <a href="https://www.medicarefaq.com/original-medicare/medicare-parts/medicare-part-c/medicare-advantage-plan-types/">Medicare Advantage</a>.</p>
<p>Coverage for the poor and near-poor has been established through a joint state-federal program called <a href="https://theconversation.com/not-just-for-the-poor-the-crucial-role-of-medicaid-in-americas-health-care-system-78582">Medicaid</a>, providing coverage for <a href="https://www.kff.org/other/state-indicator/total-population/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">almost 20 percent of Americans</a>. Lacking the constitutional power to force states into action, the federal government necessarily seeks to <a href="http://jhppl.dukejournals.org/content/40/2/281.short">entice states into cooperation by shouldering a majority of the cost and allowing states broad authority</a> in structuring their individual programs. As a result, <a href="http://jhppl.dukejournals.org/content/40/2/281.short">programs vary significantly across the states</a> in terms of who is eligible and what benefits they have access to.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/190679/original/file-20171017-30417-1q08z8q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/190679/original/file-20171017-30417-1q08z8q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=350&fit=crop&dpr=1 600w, https://images.theconversation.com/files/190679/original/file-20171017-30417-1q08z8q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=350&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/190679/original/file-20171017-30417-1q08z8q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=350&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/190679/original/file-20171017-30417-1q08z8q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=440&fit=crop&dpr=1 754w, https://images.theconversation.com/files/190679/original/file-20171017-30417-1q08z8q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=440&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/190679/original/file-20171017-30417-1q08z8q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=440&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A veterans hospital in Ann Arbor, Michigan.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/success?src=95raD-KyAxJLNJdCqKEVTw-1-6">Susan Montgomery/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>One peculiar exception is the way America provides health care to its <a href="https://www.va.gov/health/">veterans</a>. Inherently ironic, in an arrangement that can only be described as socialistic, America’s veterans are able to obtain access to comprehensive services, often at no cost, through a national network of clinics and hospitals fully owned and operated by the federal government. Similar arrangements are in place for <a href="https://www.ihs.gov/">Native Americans</a>.</p>
<p>Those left out of the <a href="https://search.proquest.com/openview/acb042605925be5851f59fba137301ed/1?pq-origsite=gscholar&cbl=18750&diss=y">various, decidedly limited, arrangements are left</a> to seek coverage on their own from private insurers. Indeed, with the insurance market reforms and financial support of the ACA, today about <a href="https://www.kff.org/other/state-indicator/total-population/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">7 percent of Americans</a> are able to purchase insurance privately, while <a href="https://www.kff.org/other/state-indicator/total-population/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">9 percent remain uninsured</a>. Another patchwork of programs seeks to provide decidedly limited benefits to these individuals including through <a href="https://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/">emergency rooms</a>, <a href="https://search.proquest.com/openview/acb042605925be5851f59fba137301ed/1?pq-origsite=gscholar&cbl=18750&diss=y">government-supported</a> private community health centers and hundreds of clinics and hospitals owned by cities, counties, states and state-university systems.</p>
<h2>Has the ACA changed anything?</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/190680/original/file-20171017-30390-t0coi3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/190680/original/file-20171017-30390-t0coi3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/190680/original/file-20171017-30390-t0coi3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/190680/original/file-20171017-30390-t0coi3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/190680/original/file-20171017-30390-t0coi3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/190680/original/file-20171017-30390-t0coi3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/190680/original/file-20171017-30390-t0coi3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A woman shows her support for the Affordable Care Act at a 2017 rally in Asheville, North Carolina.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/asheville-north-carolina-usa-february-25-645796120?src=3tJorM5k1R6WjRe1GePMpA-1-43">J. Bicking/Shutterstock.com</a></span>
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<p>When the <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1541-0072.2012.00446.x/full">ACA was passed in 2010</a>, supporters hailed it for moving the United States in line with its industrialized peers. <a href="http://www.nationalreview.com/article/418322/obamacare-horror-story-young-americans-diana-furchtgott-roth-jared-meyer">Detractors demonized</a> it by saying it was the final step toward socialism in America. </p>
<p>Neither side was <a href="https://www.cambridge.org/core/journals/journal-of-policy-history/article/inching-toward-universal-coverage-statefederal-healthcare-programs-in-historical-perspective/E94A03DD1F60F9DCBE3DDE9728DA3224">correct in its assessment</a>.</p>
<p>Within the American system, particularly as it has been used to expand access to health care, the ACA was a very substantial, but nonetheless natural, continuation of a long series of <a href="https://www.cambridge.org/core/journals/journal-of-policy-history/article/inching-toward-universal-coverage-statefederal-healthcare-programs-in-historical-perspective/E94A03DD1F60F9DCBE3DDE9728DA3224">incremental, trial-and-error adjustments to new circumstances hailing back to the early 1900s</a>. For the most part, the ACA perpetuates a system patched together from various private and public components by merely pairing some, albeit important, insurance market reforms with additional funding.</p>
<p>With regard to <a href="http://jhppl.dukejournals.org/content/40/2/281.short">Medicaid</a>, it simply added more, mostly federal, funding to bring more individuals into the program. For those <a href="http://jhppl.dukejournals.org/content/40/2/281.short">buying insurance on their own</a>, it facilitated purchasing insurance by establishing online marketplaces and by providing funding for lower-income individuals in the form of <a href="http://jhppl.dukejournals.org/content/40/2/281.short">subsidies for premiums and out-of-pocket costs</a>. Most importantly, it initiates meaningful insurance market reforms intended to facilitate access including the requirement to provide insurance <a href="http://jhppl.dukejournals.org/content/40/2/281.short">regardless of preexisting conditions</a>, by limiting how much consumer could be charged based on gender and age, and by requiring a minimum amount of services included, among others.</p>
<p>Yet even if the ACA were to be fully implemented, millions of Americans will be left without insurance, and the <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1541-0072.2012.00446.x/full">thorny issues of quality and costs</a> will largely be left untouched.</p>
<h2>The future is…uncertain</h2>
<p>The American health care system is a complex amalgam. <a href="http://jhppl.dukejournals.org/content/40/2/281.short">Evolving over time</a>, we can see incremental, haphazard adjustments to changing circumstances over time, without much rationality or overarching forethought.</p>
<p>Conceptually, one can easily imagine a simpler approach. For example, the U.S. could adopt a single-payer system similar to those in many other wealthy industrialized countries. Practically, however, limited national authority, stark ideological divisions over the appropriate role of the national government in the provision of health care, and the creation of vested interests make other than a continued evolutionary approach politically unlikely, if not wholly implausible.</p>
<p>In such a system, exploiting the shortcomings of the American health care system and blaming it on the other party becomes a political imperative. No one party alone can truly reform the system by itself without risking the wrath of the electorate. Indeed, no underlying ideological consensus even exists about what kind of health care system the United States should have. </p>
<p>Under these conditions, neither party has much incentive to cooperate to initiate the <a href="https://theconversation.com/how-the-latest-effort-to-repeal-obamacare-would-affect-millions-84317">meaningful reforms necessary to improve quality, access and costs</a>. Thus, we are left with a system that is excessively costly and often of inferior quality that denies millions of American from accessing adequate care.</p><img src="https://counter.theconversation.com/content/85252/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Many Western, industrialized nations provide health insurance. The US has repeatedly balked at universal coverage. So what kind of system are we left with? A very unpopular one.Simon F. Haeder, Assistant Professor of Public Policy, Penn StateLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/853062017-10-11T00:37:00Z2017-10-11T00:37:00ZHow Obamacare has helped poor cancer patients<figure><img src="https://images.theconversation.com/files/189226/original/file-20171006-25752-178qbu0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Sen. Lindsey Graham (R-S.C.) flanked by Sen. Bill Cassidy (R-La.), left, and Senate Majority Leader Mitch McConnell (R-Ky.) as they addressed the unpopularity of their replacement bill. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Congress-Health-Overhaul/c43ca590cf234042be58a3ca4af079d8/8/0">AP Photo/J. Scott Applewhite</a></span></figcaption></figure><p>Two weeks ago, Senate Majority Leader Mitch McConnell <a href="https://www.nytimes.com/2017/09/26/us/politics/mcconnell-obamacare-repeal-graham-cassidy-trump.html">pulled the vote</a> for the latest measure to repeal the Affordable Care Act (ACA). </p>
<p>Cancer patients across the U.S. likely breathed a sigh of relief with the knowledge that, at least for now, they no longer had to fear losing <a href="https://theconversation.com/essential-health-benefits-suddenly-at-center-of-health-care-debate-but-what-are-they-75125">essential health benefits</a> or being denied coverage due to a preexisting condition. But the <a href="http://talkingpointsmemo.com/dc/zombie-obamacare-repeal-budget-tax-cuts-trump">effort to repeal continues</a>. </p>
<p>I am a radiation oncologist who studies the gaps in care between rich and poor and those who have access and those who don’t. Cancer changed my life when it claimed my husband’s. We had health insurance, but even standard coverage is often not enough with cancer. Imagining how those without insurance could possibly manage, I ended up in medical school to learn how to treat cancer and also how to address coverage gaps. </p>
<p>My colleagues and I recently completed <a href="https://www.astro.org/News-and-Publications/News-and-Media-Center/News-Releases/2017/Uninsured-cancer-patients-saw-increased-coverage-for-care-following-Medicaid-expansion/">the first study</a> to show that the ACA narrowed the gap for cancer patients who are poor.</p>
<h2>Cancer and uninsurance</h2>
<p>The ACA fundamentally changed the insurance landscape in the U.S. </p>
<p>When the ACA was passed in 2010, 16.3 percent of the U.S. population was uninsured. Being uninsured is never good, but it’s particularly bad for cancer patients. It can affect their survival. It also can wreck their finances and that of their families. </p>
<p>Uninsured patients with cancer are more likely to be diagnosed later and have <a href="https://doi.org/10.1016/S1470-2045(08)70032-9">advanced stages of disease</a>. They’re significantly less likely to receive the most effective cancer treatments, including <a href="https://doi.org/10.1164/rccm.2009-038ST">radiation therapy and surgery</a>. Uninsured cancer patients are also more likely to <a href="https://doi.org/10.1200/JCO.2014.55.6258">die of their disease</a>. </p>
<p>Due to a 2012 Supreme Court ruling, individual states were allowed to choose whether to expand Medicaid as intended under the ACA. Expansion gave families with limited income – up to 133 percent of the federal poverty level – access to government health care. To date, 32 states, including the District of Columbia, have opted to expand Medicaid in some way.</p>
<h2>Rates of uninsured cancer patients dropped</h2>
<p>Our study evaluated the actual effects of the 2014 Medicaid expansion under the ACA by focusing on real patient data from cancer patients treated for their disease within the first year of expansion. The <a href="https://seer.cancer.gov/">Surveillance, Epidemiology and End Results Program</a> database is maintained by the National Cancer Institute and represents an authoritative source on cancer incidence and survival in the United States.</p>
<p>We examined the records of almost 200,000 adult cancer patients who received radiation treatments for cancer from 2011 to 2014. We looked at changes in insurance status, comparing the years immediately prior to expansion to the year of expansion. </p>
<p>We also specifically assessed differences between states that <a href="https://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/">fully expanded Medicaid</a> according to ACA guidelines versus those that chose to not expand. </p>
<p>Overall, we found uninsurance rates dropped significantly across both expanded and nonexpanded states. However, uninsurance rates dropped far more in states with full expansion. </p>
<p>States that expanded Medicaid cut the rate of uninsured cancer patients receiving radiation by more than 50 percent. In states that did not expand Medicaid, the rate of uninsurance decreased by a relative 5 percent.</p>
<p>In states that had expanded Medicaid, the proportion of Medicaid recipients rose from 15.2 to 18 percent. In states that did not expand Medicaid, Medicaid coverage dropped by one point.</p>
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<h2>Disparities in care</h2>
<p>Our study also found that there were already significant baseline differences in care and coverage across states.</p>
<p>Before the ACA was in effect, states that did not expand Medicaid had over twice the rate of uninsured cancer patients. They also had a much higher rate of patients living in the areas of highest poverty. </p>
<p>The 2014 Medicaid expansion aimed to increase coverage for all populations, but particularly for the poor. That appeared to work: The states that expanded Medicaid saw uninsurance rates for those cancer patients living in the poorest areas drop by 60 percent. </p>
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<p>But in states that did not expand Medicaid, the benefits primarily went to white patients and those living in areas of relative wealth. We saw no improvements in uninsured rates for black patients and residents of high-poverty areas in the states that did not expand. </p>
<p>These populations in the nonexpanded group likely represent people who could buy private health insurance on the health care exchanges that were established by the ACA. It’s unclear whether these patients would have qualified for Medicaid expansion in the first place.</p>
<p>It appears that full Medicaid expansion really did most benefit those at highest risk for gaps in health care, such as African-Americans and the poor. In states that did not expand Medicaid, these at-risk populations only saw their insurance coverage worsen during the study period.</p>
<h2>Why this matters so much</h2>
<p>High rates of uninsurance can create a <a href="https://doi.org/10.1377/hlthaff.26.5.1304">“spillover” effect</a>, resulting in reduced health care quality for insured patients living in the same community.</p>
<p>The ACA helped increase insurance coverage, but it clearly isn’t perfect. Research shows that patients with Medicaid may fare worse than those with <a href="http://onlinelibrary.wiley.com/doi/10.1002/cncr.30431/full">non-Medicaid insurance</a>, although it can be difficult to separate their cancer outcomes from relevant social factors such as poverty, education and access. </p>
<p>There are also potential coverage gaps under the ACA, as <a href="https://doi.org/10.1200/JCO.2016.69.9835">only 41 percent of plans</a> include in-network access to a NCI Designated Cancer Center. These treatment facilities undergo rigorous screening to receive research funding for clinical trials that can result in treatment advances and greater understanding of the disease.</p>
<p>More research is needed to better understand specific changes in access, health care delivery and quality of care under the ACA. We still need to evaluate whether the changes in insurance coverage seen will affect cancer survival.</p>
<p>The debate over health care reform is ongoing. Regardless of the recent demise of Graham-Cassidy – the fourth ACA repeal bill this year – there are legislative legs for at least a substantive reform of the ACA, if not direct repeal. Studies such as ours, which show a clear benefit in insurance coverage changes for our most vulnerable populations, provide essential information in this debate.</p><img src="https://counter.theconversation.com/content/85306/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Fumiko Chino does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Poor people who have cancer are one of the most financially vulnerable groups in the US. Obamacare aimed to improve their access to care. A recent study shows how it did.Fumiko Chino, Resident in Radiation Oncology, Duke UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/844042017-09-22T00:42:47Z2017-09-22T00:42:47ZClock running out on health program for 9 million kids<figure><img src="https://images.theconversation.com/files/186843/original/file-20170920-16437-1dz7p5t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Close to 9 million children could be affected if funding for health insurance for them expires. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-child-641076409?src=GkB7rmCXsrFhefQ03u13Ag-1-1">Billion Photos/www.shutterstock.com</a></span></figcaption></figure><p>Since the inauguration of President Trump, health care has been front and center in American politics. Yet, attention has almost exclusively been focused on the Affordable Care Act, most recently in the form of <a href="https://theconversation.com/how-the-latest-effort-to-repeal-obamacare-would-affect-millions-84317">Graham-Cassidy</a>. With Congress preoccupied with a series of Republican efforts to repeal and replace the ACA, little attention has been paid to a long-running bipartisan program providing insurance coverage to millions of American children: the <a href="https://www.cambridge.org/core/journals/journal-of-policy-history/article/inching-toward-universal-coverage-statefederal-healthcare-programs-in-historical-perspective/E94A03DD1F60F9DCBE3DDE9728DA3224">Children’s Health Insurance Program</a>, often referred to simply as CHIP, which provides coverage to <a href="http://www.kff.org/other/state-indicator/annual-chip-enrollment/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">nine million American children</a>.</p>
<p>Since its <a href="https://www.cambridge.org/core/journals/journal-of-policy-history/article/inching-toward-universal-coverage-statefederal-healthcare-programs-in-historical-perspective/E94A03DD1F60F9DCBE3DDE9728DA3224">creation by a bipartisan coalition under the Clinton administration</a>, CHIP has been crucial for the health and well-being of millions of American children, their families and their communities. </p>
<p>Yet funding for CHIP is running out at the end of September, leaving both state governments and families with great uncertainty. On September 18, Senators Orrin Hatch (R-Utah) and Ron Wyden (D-Ore.) announced an <a href="https://www.hatch.senate.gov/public/index.cfm/releases?ID=071428C9-0FD3-4C76-B3E1-734F93B46CF4">agreement</a> to continue funding for the program, albeit at greater costs to the states because it would phase out the additional funding provided by the ACA. Yet, the <a href="https://theconversation.com/how-the-latest-effort-to-repeal-obamacare-would-affect-millions-84317">renewed efforts by Republicans to repeal the ACA</a> could derail this agreement. </p>
<h2>What Is CHIP?</h2>
<p>Today, CHIP serves <a href="https://www.macpac.gov/wp-content/uploads/2015/03/State-Children%E2%80%99s-Health-Insurance-Program_CHIP-Fact-Sheet.pdf">about nine million children</a> at a cost just below <a href="https://www.macpac.gov/wp-content/uploads/2015/03/State-Children%E2%80%99s-Health-Insurance-Program_CHIP-Fact-Sheet.pdf">US$14 billion</a>. Together with Medicaid, it serves as the source of insurance for more than <a href="https://ccf.georgetown.edu/2017/02/06/about-chip/">46 million children</a> annually. CHIP has been crucial in ensuring that more than <a href="https://www.macpac.gov/wp-content/uploads/2017/01/Recommendations-for-the-Future-of-CHIP-and-Childrens-Coverage.pdf">95 percent of American children</a> are covered by health insurance today. This compares to 89 percent at the time the program was created.</p>
<p>Like most <a href="http://jhppl.dukejournals.org/content/40/2/281.short">other health care programs</a>, <a href="https://www.cambridge.org/core/journals/journal-of-policy-history/article/inching-toward-universal-coverage-statefederal-healthcare-programs-in-historical-perspective/E94A03DD1F60F9DCBE3DDE9728DA3224">CHIP is a collaborative program between the federal government and the states</a>. Indeed, states have the option to use the CHIP funding to expand their Medicaid program, create a standalone program or establish a hybrid arrangement. </p>
<p>CHIP fills in the gap for those children who fall just above the Medicaid threshold, determined by family income, but still do not have access to affordable, employer-sponsored insurance. Indeed, almost all CHIP children live in households where at least one parent is <a href="https://www.macpac.gov/wp-content/uploads/2015/03/State-Children%E2%80%99s-Health-Insurance-Program_CHIP-Fact-Sheet.pdf">working</a>. <a href="https://www.macpac.gov/wp-content/uploads/2017/01/Recommendations-for-the-Future-of-CHIP-and-Childrens-Coverage.pdf">Ninety percent</a> live in households 200 percent below the federal poverty line.</p>
<p>Created on a <a href="https://www.cambridge.org/core/journals/journal-of-policy-history/article/inching-toward-universal-coverage-statefederal-healthcare-programs-in-historical-perspective/E94A03DD1F60F9DCBE3DDE9728DA3224">bipartisan basis in the late 1990s</a>, the program has been popular with both parties. It has been renewed multiple times, and eligibility and federal support have been increased multiple times. Indeed, the most recent extension made the federal government the <a href="https://www.macpac.gov/wp-content/uploads/2015/03/State-Children%E2%80%99s-Health-Insurance-Program_CHIP-Fact-Sheet.pdf">sole funder of the program in 11 states</a>.</p>
<p>States have been given <a href="https://www.cambridge.org/core/journals/journal-of-policy-history/article/inching-toward-universal-coverage-statefederal-healthcare-programs-in-historical-perspective/E94A03DD1F60F9DCBE3DDE9728DA3224">significant leeway in implementing the program</a>. For one, states have been able to set a diverse range of eligibility guidelines, ranging from just below 200 percent of the federal poverty line in states like North Dakota and Wyoming to more than 400 percent in New York. </p>
<p>They also have a significant amount of flexibility in terms of benefit design, copayments, premiums, enrollment and administrative structure. At the same time, the federal matching rate, or the financial contribution of the federal government, is significantly above the Medicaid match, ranging <a href="https://www.macpac.gov/wp-content/uploads/2017/01/Recommendations-for-the-Future-of-CHIP-and-Childrens-Coverage.pdf">from 88 to 100 percent</a>, making participation particularly enticing for states. Not surprisingly, with large amount of flexibility and generous financial support, states have long looked favorably toward the program.</p>
<p>CHIP is complementary to Medicaid but differs from it in several respects. Most crucially, it is not an entitlement but rather a block grant. This means that qualifying individuals who meet all the requirements are not legally entitled to receive the benefits provided by program in case no funding is available. Once federal funding is spent down for a given year, no more funds are available unless states choose to pay for the program in its entirety.</p>
<h2>Why is CHIP so important?</h2>
<p><a href="http://www.kff.org/medicaid/issue-brief/the-impact-of-the-childrens-health-insurance-program-chip-what-does-the-research-tell-us/">The benefits for families and communities of CHIP are many</a>. For one, CHIP is crucial in providing financial security and prevents families from suffering catastrophic losses. </p>
<p>Moreover, the program’s benefit design does a tremendous job at ensuring that children’s health needs are met comprehensively. Healthier children are more <a href="https://www.macpac.gov/wp-content/uploads/2017/01/Recommendations-for-the-Future-of-CHIP-and-Childrens-Coverage.pdf">likely to attend school and graduate from high school and college</a>. Healthier children also <a href="https://www.macpac.gov/wp-content/uploads/2017/01/Recommendations-for-the-Future-of-CHIP-and-Childrens-Coverage.pdf">prevent parents from forgoing their own care or missing time at work</a>. CHIP also serves a <a href="https://www.macpac.gov/wp-content/uploads/2015/03/State-Children%E2%80%99s-Health-Insurance-Program_CHIP-Fact-Sheet.pdf">large number of children with special</a> and costly health needs, such as ADHD and asthma.</p>
<p>The crucial role of CHIP has been repeatedly emphasized by <a href="https://www.usnews.com/news/best-states/west-virginia/articles/2017-09-07/wvu-speakers-panelists-to-examine-child-health-care-policy">health policy experts</a>. Most recently, MACPAC, the congressionally chartered commission that provides Congress with advice on Medicaid and CHIP, <a href="https://www.macpac.gov/wp-content/uploads/2017/01/Recommendations-for-the-Future-of-CHIP-and-Childrens-Coverage.pdf">recommended</a> the continuation and further enhancement of the program.</p>
<h2>How should we move forward?</h2>
<p>As a block grant, CHIP requires periodic appropriation of funding to maintain the program. The most recent extension, the Medicare and CHIP Reauthorization Act, funded the program through September 2017.</p>
<p>Without additional funding, <a href="http://thehill.com/policy/healthcare/347884-congress-facing-deadline-to-renew-healthcare-for-children">states will run out of money over the next few months</a>. Moreover, without a quick congressional action, states will be confronted with daunting administrative and planning challenges on how to possibly maintain or phase out the program. Indeed, several states will automatically terminate their programs in case federal funding for the program falls below a certain threshold. Moreover, state budgets have assumed that the program will be <a href="http://nashp.org/state-chip-changes-are-coming-soon/">continued in its current form</a>. Failure to reauthorize the program at current levels would pose tremendous problems for all states.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/186856/original/file-20170920-16420-1u3z7aq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/186856/original/file-20170920-16420-1u3z7aq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/186856/original/file-20170920-16420-1u3z7aq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/186856/original/file-20170920-16420-1u3z7aq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/186856/original/file-20170920-16420-1u3z7aq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/186856/original/file-20170920-16420-1u3z7aq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/186856/original/file-20170920-16420-1u3z7aq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Senators Ron Wyden and Orrin Hatch at a Senate Finance Committee meeting Sept. 14, 2017.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/Search?query=orrin+hatch+wyden&ss=10&st=kw&entitysearch=&toItem=15&orderBy=Newest&searchMediaType=excludecollections">AP Photo/Jacquelyn Martin</a></span>
</figcaption>
</figure>
<p>The agreement announced by Senators Hatch and Wyden to provide CHIP funding for the next five years brought hope to America’s children, their families and child advocates. Yet it has also raised concerns. While the proposal leaves the eligibility threshold untouched, it begins to reduce federal support for states from the aforementioned 88 to 100 percent to the original 65 to 82 percent in 2020. Perhaps must crucially, <a href="https://theconversation.com/how-the-latest-effort-to-repeal-obamacare-would-affect-millions-84317">the reemergence of Republican efforts to abolish the ACA seems to have put all CHIP efforts on hold</a>.</p>
<p>Moreover, it is unclear whether the Republican majority in Congress supports the program as it is currently implemented. Indeed, <a href="https://theconversation.com/beyond-the-cbo-score-how-trump-budget-and-the-ahca-are-dismantling-americas-safety-net-78308">President Trump in his first budget</a> proposed a reduction in both federal support and eligibility. </p>
<p>Between the Medicaid expansions of the 1990s, the creation of CHIP and the ACA, America has made great strides in providing health insurance to its most vulnerable, including America’s children. Indeed, insurance enrollment rates for children are at historic highs, currently hovering around 95 percent.</p>
<p>However, the reduced federal funding may pose a significant challenge for states like West Virginia and Arizona, which may move to reduce or eliminate the program as a result. Indeed, concerns led <a href="https://www.macpac.gov/wp-content/uploads/2017/01/Recommendations-for-the-Future-of-CHIP-and-Childrens-Coverage.pdf">MACPAC to recommend against any federal funding cuts</a>. It may be that these very cuts will eliminate some of the historic gains made in children’s coverage. Yet, the Hatch-Wyden compromise, given the current political situation in Washington, D.C., could well be the most beneficial outcome for child advocates.</p><img src="https://counter.theconversation.com/content/84404/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Funding for the children’s health insurance program is in jeopardy if Congress does not act by September 30. Here’s a look at what’s at stake, and how Congress could act to secure funding for CHIP.Simon F. Haeder, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/843172017-09-20T03:14:08Z2017-09-20T03:14:08ZHow the latest effort to repeal Obamacare would affect millions<figure><img src="https://images.theconversation.com/files/186610/original/file-20170919-16985-113283u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">From left, Sen. Dean Heller, R-Nev., Sen. Bill Cassidy, R-La., Sen. Ron Johnson, R-Wis., and Sen. Lindsey Graham, R-S.C., hold a press conference on Capitol Hill in Washington, Wednesday, Sept. 13, 2017. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Congress-Health-Overhaul/62e533c109554ce28adbfb4e275e46a6/1/0">AP Photo/Andrew Harnik</a></span></figcaption></figure><p>At the end of July, the nation held its collective breath as Senate Majority Leader Mitch McConnell (R-Ky.) looked poised to achieve his most formidable parliamentary accomplishment: the <a href="https://www.nytimes.com/2017/07/27/us/politics/senate-health-care-vote.html?mcubz=0&_r=0">repeal and replacement of the Affordable Care Act</a>.</p>
<p>But Republican hopes were dashed by one of their own, Sen. John McCain (R-Ariz.), who <a href="https://www.washingtonpost.com/powerpost/the-night-john-mccain-killed-the-gops-health-care-fight/2017/07/28/f5acce58-7361-11e7-8f39-eeb7d3a2d304_story.html?utm_term=.00c807d2ce92">cast the deciding vote</a> that appeared to decisively derail the multi-year effort. </p>
<p>McCain called to return to “regular order,” to work through committees, to bring in and listen to experts, to be open and transparent, and perhaps most importantly, to at least listen to both parties.</p>
<p>And indeed, Senators Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) went to work, bringing together demands from Republicans like <a href="https://www.axios.com/murray-makes-big-concession-in-bipartisan-health-talks-2486922713.html">more flexibility for states to waive certain provisions of the ACA</a>, and demands from Democrats to provide cost-sharing subsidies, for example, to <a href="http://thehill.com/policy/healthcare/350643-senate-health-panel-aims-for-deal-on-stabilizing-markets-early-next-week">stabilize health care markets</a>. The bipartisanship appeared to be spreading as <a href="https://www.hatch.senate.gov/public/index.cfm/releases?ID=071428C9-0FD3-4C76-B3E1-734F93B46CF4">Orrin Hatch (R-Utah) and Ron Wyden (D-Ore.)</a> appeared to have reached an agreement on the future of the Children’s Health Insurance Program.</p>
<p>Now Republican hopes of repealing the ACA have been rekindled with the <a href="http://files.kff.org/attachment/Summary-of-Graham-Cassidy-Heller-Johnson-Amendment">Graham-Cassidy-Heller-Johnson Amendment</a> led by Senators Lindsey Graham (R-S.C.) and Bill Cassidy (R-La). </p>
<p>Like all health care legislation, the bill is complex, but the broad outlines of it are rather clear: It would undo much of the reforms implemented through the ACA and then go a step further.</p>
<h2>What’s in the bill?</h2>
<p>Senate Republicans are rushed once more as they want to achieve health care reform by September 30, the deadline to pass the bill through the <a href="http://www.politifact.com/truth-o-meter/article/2017/jun/22/senate-health-care-bills-two-front-war-policy-and-/">reconciliation process</a> which requires only a simple majority. Indeed, due to their haste, the Congressional Budget Office <a href="https://www.cbo.gov/publication/53116">will not be able to provide any estimates of the bill’s effects on the deficit, health insurance coverage or premiums</a>.</p>
<p>Graham-Cassidy seeks to undo many of the reforms initiated by the ACA. For one, by 2020 it would eliminate the ACA’s Medicaid expansion, which has provided coverage <a href="http://www.kff.org/health-reform/state-indicator/medicaid-expansion-enrollment/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">for 12 million Americans</a> for <a href="http://jhppl.dukejournals.org/content/40/2/281.short">states that chose to expand their program</a>. However, it would prevent new states from expanding their program by 2017. It would also eliminate the insurance marketplace subsidies to assist individuals purchase coverage and with out-of-pocket costs. </p>
<p>To soften states’ financial losses, Graham-Cassidy partially replaces funding for both components with a temporary block grant to states that would run out in 2026. Yet even with the block grant, states would see their funding reduced by a combined <a href="https://www.cbpp.org/research/health/cassidy-graham-plans-damaging-cuts-to-health-care-funding-would-grow-dramatically-in">US$239 billion over six years</a>, according to an analysis by the left-leaning Center on Budget and Policy Priorities. </p>
<p>Graham-Cassidy also significantly alters the regulatory reforms implemented via the ACA. The much-maligned individual and employer mandates would be repealed retroactively. The individual mandate requires that all people of a certain income buy insurance or face a penalty. The employer mandate requires that all employers of a certain size provide insurance to their employees.</p>
<p>While individuals still could not be turned down based on their health status, states could also obtain waivers to weaken or wholly eliminate <a href="https://theconversation.com/how-pre-existing-conditions-became-front-and-center-in-health-care-vote-77138">preexisting condition protections</a>. For example, the Center for American Progress has estimated that individuals could face insurer premium <a href="https://www.americanprogress.org/issues/healthcare/news/2017/09/18/439091/graham-cassidy-aca-repeal-bill-cause-huge-premium-increases-people-pre-existing-conditions/">surcharges of $140,000 for metastatic cancer, $17,000 for being pregnant and $26,000 for rheumatoid arthritis</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/186642/original/file-20170919-22701-b07sdf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/186642/original/file-20170919-22701-b07sdf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=317&fit=crop&dpr=1 600w, https://images.theconversation.com/files/186642/original/file-20170919-22701-b07sdf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=317&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/186642/original/file-20170919-22701-b07sdf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=317&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/186642/original/file-20170919-22701-b07sdf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=398&fit=crop&dpr=1 754w, https://images.theconversation.com/files/186642/original/file-20170919-22701-b07sdf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=398&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/186642/original/file-20170919-22701-b07sdf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=398&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In one analysis, states could choose to not cover well visits to doctors.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/senior-doctor-patient-giving-prescription-medication-334498577?src=ywBZ1LFStjWJgkk4IwaquA-1-26">rocketclips/www.shutterstock.com</a></span>
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<p>Similarly, states would be able to waive the ACA’s <a href="https://theconversation.com/essential-health-benefits-suddenly-at-center-of-health-care-debate-but-what-are-they-75125">Essential Health Benefit</a> provisions that required insurers to cover cost for expenditures like ambulance transport, prescription drugs and inpatient services. This would affect all individuals in the respective states because lifetime and annual limits apply only to the Essential Health Benefits. States could also waive the requirement to cover preventive services like immunizations and well-child visits.</p>
<p>Yet like most of the previous efforts to repeal the ACA over the past several months, Graham-Cassidy goes well beyond addressing changes brought about by the ACA. Most severely, the bill moves to dramatically slash and transform the Medicaid program. It would do so by establishing severe per capita caps: that is, it would provide a set amount of money for each enrolled individual compared to an open-ended federal match. These caps, which would affect children, seniors and individuals with disabilities, would also begin in 2020. They would be adjusted by inflation, but not the much larger medical inflation. They would thus result in further reductions over time. The resulting cuts would amount to $175 billion by 2026. </p>
<p>It would also allow states to establish work requirements for the program, defund Planned Parenthood and further expand <a href="https://theconversation.com/why-health-savings-accounts-are-a-bust-for-the-poor-but-a-boost-for-the-privileged-81013">Health Savings Accounts</a>, among other things.</p>
<p>However, unlike most of its <a href="http://files.kff.org/attachment/Summary-of-the-Better-Care-Reconciliation-Act-Updated-072017">predecessors</a>, Graham-Cassidy provides political protections for its supporters because the full extent and severity of its cuts would not fully emerge until 2027, at least two elections away for most senators. The Center on Budget and Policy Priorities has estimated that the effect in 2027 alone, the cliff year, would amount to <a href="https://www.cbpp.org/research/health/cassidy-graham-plans-damaging-cuts-to-health-care-funding-would-grow-dramatically-in">$300 billion</a>. California alone would lose $58 billion, while the state of West Virginia would lose $2 billion. The Center on Budget and Policy Priorities also expects that <a href="https://www.cbpp.org/research/health/cassidy-graham-plans-damaging-cuts-to-health-care-funding-would-grow-dramatically-in">more than 32 million</a> Americans would lose their insurance.</p>
<h2>A step backward … and not addressing the real issues</h2>
<p>In my reading, Graham-Cassidy, just like all its predecessors, does little to fix the problems of the American health care system.</p>
<p>Our system is generally of low quality. Medical errors kill more than <a href="http://www.bmj.com/content/353/bmj.i2139">250,000 Americans each year, making it the third leading cause of death</a>. Prescription errors alone are responsible for more than <a href="https://www.forbes.com/sites/leahbinder/2013/09/03/the-shocking-truth-about-medication-errors/#6e7c907510ab">7,000 deaths</a>. Virtually the entire developed world, and many less-developed countries, are ahead of us with regard to <a href="https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html">infant mortality</a>. The list goes on.</p>
<p>Despite these obvious shortcomings, our health care system is also, by far, the most expensive system in the world. We spend more than <a href="http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective">17 percent of our GDP, or well over $9,000 per person</a>, on health care. This compares to <a href="http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective">10 percent and $3,700 for Japan</a>, <a href="http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective">11 percent and $4,900 for Germany</a>, and <a href="http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective">9 percent and $3,300 for the United Kingdom</a>.</p>
<p>And yet, even after the coverage expansions of the Affordable Care Act, and <a href="http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective">after spending more money from the public’s purses than all but two countries</a>, our uninsurance rates just <a href="http://www.dailynews.com/2017/09/16/healthcare-uninsured-rate-in-us-falls-to-record-low-of-8-8/">inched below 10 percent, and more than 28 million Americans are without insurance</a>.</p>
<p>Indeed, we do not even cover all children in this country, although the rate of insurance from children reached a <a href="http://www.kff.org/other/state-indicator/children-0-18/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">historic high of 95 percent</a>.</p>
<p>With low quality, high costs and lack of universal coverage, much needs to be improved about the American health care system. Unfortunately, Graham-Cassidy as currently written does nothing to improve quality, and it does nothing to reduce the underlying drivers of excessive costs. Indeed, it reverses the significant progress achieved under the ACA in offering coverage to all Americans.</p>
<p>Large-scale changes to the American health care system cannot and should not be quickly patched together without input from the Congressional Budget Office, policy experts, the public and the other party. Many lives and one-sixth of our economy hang in the balance. The American public deserves better.</p><img src="https://counter.theconversation.com/content/84317/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A Senate vote in July seemed to signal the end of efforts to kill the Affordable Care Act. With a Sept. 30 deadline looming, though, a new bill has real possibilities. Here’s why that could be bad.Simon F. Haeder, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/817332017-08-17T01:28:51Z2017-08-17T01:28:51ZWhy state-level single-payer health care efforts are doomed<figure><img src="https://images.theconversation.com/files/182320/original/file-20170816-17661-1c68rpc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Senate Majority Leader Mitch McConnell at an Aug. 1 press conference, the first he held after the defeat of his health care bill.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Health-Overhaul-Poll/2b6c5069484149cf8c8f0815330ab23e/15/0">AP Photo/J. Scott Applewhite</a></span></figcaption></figure><p>As members of Congress return from their summer recess, Republican efforts to do away with President Obama’s signature legislative achievement, the Affordable Care Act (ACA), appear stalled, at least temporarily. </p>
<p>However, the Trump administration still appears <a href="https://theconversation.com/trump-isnt-letting-obamacare-die-hes-trying-to-kill-it-81373">committed to unraveling the ACA</a>. Most prominent are the threats to withhold cost-sharing reductions, which reduce out-of-pocket payments for low-income consumers on the insurance marketplaces. <a href="https://www.cbo.gov/system/files/115th-congress-2017-2018/reports/53009-costsharingreductions.pdf">According to the Congressional Budget Office</a>, cutting these payments would drive up health insurance premiums by 20 percent while costing the federal government close to US$200 billion over a decade.</p>
<p>Ultimately, the future of the ACA remains murky at best, leaving blue states scrambling for alternatives. One of progressives’ favorite solutions was floated by the California legislature at the height of Republican efforts to repeal the ACA: a <a href="http://thehill.com/homenews/state-watch/340319-battle-breaks-out-in-california-over-single-payer-healthcare">plan to develop a single-payer health insurance system</a>. <a href="https://townhall.com/tipsheet/mattvespa/2017/07/05/eating-their-own-california-democrats-facing-death-threats-from-progressives-for-n2350030">Enthusiastic progressives</a>, reeling from a series of defeats since the election of President Trump, quickly hailed the efforts as a path forward in Trump’s America.</p>
<p>Policy experts like me were not surprised <a href="http://www.latimes.com/politics/la-pol-sac-anthony-rendon-single-payer-progressives-20170626-htmlstory.html">when efforts in California petered out</a>, not the least due to the <a href="http://www.latimes.com/politics/la-pol-sac-anthony-rendon-single-payer-progressives-20170626-htmlstory.html">massive price tag of $400 billion annually</a>. Californians had been subjected to similar experiences <a href="http://www.chcf.org/publications/2011/03/health-insurance-history">over the decades</a>, going back to the 1910s. Time and time again, efforts at comprehensive health reform have <a href="http://www.chcf.org/publications/2011/03/health-insurance-history">failed in the Golden State</a> and elsewhere, such as <a href="http://www.npr.org/sections/health-shots/2017/07/27/539588546/states-have-already-tried-versions-of-skinny-repeal-it-didn-t-go-well">Washington and Kentucky</a>.</p>
<p>To the dismay of progressives, future efforts are likely equally doomed to failure. While states have been innovators with regards to many policies, fiscal issues and regulatory limitations will most likely preclude states from pursuing sweeping health reform. Here is why.</p>
<h2>Financing health reform is challenging</h2>
<p>Providing insurance to those who cannot afford it is a costly endeavor, particularly in the United States. Without the financial support from the ACA, which <a href="http://onlinelibrary.wiley.com/doi/10.1111/puar.12065/full">currently provides subsidies in the individual marketplaces and pays for well over 90 percent of the Medicaid expansions</a>, states would be required to allocate funds for this purpose. This would be undeniably challenging.</p>
<p>For one, many states are <a href="https://www.cnbc.com/2017/07/11/states-in-crisis-the-worst-budget-battles-since-the-great-recession.html">still recovering from the Great Recession</a>. Moreover, other important state functions like <a href="http://www.nasbo.org/mainsite/reports-data/state-expenditure-report">K-12 and higher education and criminal justice</a> are taking up large parts of states’ budgets.</p>
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<img alt="" src="https://images.theconversation.com/files/182323/original/file-20170816-17680-1hdobei.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/182323/original/file-20170816-17680-1hdobei.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/182323/original/file-20170816-17680-1hdobei.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/182323/original/file-20170816-17680-1hdobei.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/182323/original/file-20170816-17680-1hdobei.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/182323/original/file-20170816-17680-1hdobei.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/182323/original/file-20170816-17680-1hdobei.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">States have priorities, such as education, that conflict with health care.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/school-kids-classroom-cute-faces-classes-509235532?src=3Ys81oKx-ENfnMWQY8Yppw-1-7">TalaZeitawi/Shutterstock.com</a></span>
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<p>Perhaps most crucially, unlike the federal government, <a href="http://www.ncsl.org/research/fiscal-policy/state-balanced-budget-requirements.aspx">states are generally not allowed to carry a deficit</a> so budgets need to be balanced in any given year.</p>
<p>This leaves tax increases as the only solution for states seeking to get more of their residents insured. From an institutional perspective, increasing taxes is a significant obstacle because in most cases this would require a <a href="https://www.cbpp.org/research/policy-basics-state-supermajority-rules-to-raise-revenues">supermajority of the legislature, as well as a willing governor to accomplish</a>. With Republicans by and large unwilling to go this route, this seems exceedingly unlikely in the foreseeable future.</p>
<p>Yet even for those states finding a path to increasing taxes, significant obstacles remain. Unlike for health reform at the federal level, residents and businesses have a degree of <a href="https://www.unc.edu/%7Efbaum/teaching/PLSC541_Fall08/tiebout_1956.pdf">mobility that allows them to select their location of residency</a>. So increasing state taxes to fund health care expansion could prompt businesses and individuals to locate to other states with lower taxes.</p>
<p>It would likely also mean that poorer and sicker individuals seeking access to health coverage, particularly from neighboring states, would relocate to these states.</p>
<p>Over time, health reform would thus be financially unsustainable.</p>
<h2>Health reform in a federal system is complex</h2>
<p>Finances aside, there are also <a href="http://www.sciencedirect.com/science/article/pii/S0168851014002607">significant intergovernmental regulatory realities</a> preventing states from moving forward on health reform on their own. Two issues stand out.</p>
<p>For one, a little-known law called the <a href="https://www.dol.gov/general/topic/retirement/erisa">Employee Retirement Income Security Act of 1974</a>, commonly referred to as ERISA, poses the most crucial obstacle. While mostly intended to address retirement and pensions, ERISA also preempts states from regulating companies that choose to self-insure with regard to health care. </p>
<p>Self-insurance refers to arrangements where companies, instead of relying on insurance company like Blue Cross or Cigna, pay their employees’ medical claims directly. While companies generally contract for the administration of these arrangements, the employing company bears the entire risk. A striking <a href="https://www.siia.org/i4a/pages/index.cfm?pageID=4546">50 million</a> employees, particularly in large companies, are subject to these arrangements. </p>
<p>Second, states also do not have full regulatory authority over <a href="https://www.cambridge.org/core/journals/journal-of-policy-history/article/inching-toward-universal-coverage-statefederal-healthcare-programs-in-historical-perspective/E94A03DD1F60F9DCBE3DDE9728DA3224">individuals obtaining coverage through Medicaid and Medicare</a>. States are virtually excluded from regulation for the latter and require the cooperation of the federal government for the former.</p>
<p>Combined, this puts <a href="http://www.kff.org/other/state-indicator/total-population/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">more than 50 percent of insurance markets</a> out of reach for state-based health reform efforts, making it inherently unviable.</p>
<h2>So how did Massachusetts do it?</h2>
<p>Given these limitations, how was Massachusetts able to implement state-based health reform? It took a confluence of fortuitous circumstances.</p>
<p>First, there was <a href="http://content.healthaffairs.org/content/25/6/w432.full">bipartisan cooperation</a> at both the state and federal level. </p>
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<img alt="" src="https://images.theconversation.com/files/182325/original/file-20170816-17657-6zjbn0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/182325/original/file-20170816-17657-6zjbn0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=629&fit=crop&dpr=1 600w, https://images.theconversation.com/files/182325/original/file-20170816-17657-6zjbn0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=629&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/182325/original/file-20170816-17657-6zjbn0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=629&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/182325/original/file-20170816-17657-6zjbn0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=790&fit=crop&dpr=1 754w, https://images.theconversation.com/files/182325/original/file-20170816-17657-6zjbn0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=790&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/182325/original/file-20170816-17657-6zjbn0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=790&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Mitt Romney in 2016.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/bedminster-new-jersey-19-november-2016-518613382?src=xbh1i-U3g3yrmMiyhYHoIg-1-1">a katz/Shutterstock.com</a></span>
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<p>Massachusetts Gov. Mitt Romney, President George Bush and Secretary of Health and Human Services Mike Leavitt, all Republicans, were able to come to an agreement with Sen. Ted Kennedy (Democrat of Masachusetts) and Democrats in the state legislature.</p>
<p>Bipartisanship also meant that everyone was invested in the project, at the state and federal level, and sought to make a success.</p>
<p>Second, the <a href="http://content.healthaffairs.org/content/25/6/w432.full">federal government was willing to foot most of the bill</a> and provided regulatory support for the state’s effort.</p>
<p>Third, Massachusetts is a <a href="http://content.healthaffairs.org/content/25/6/w432.full">relatively wealthy state that already covered a large percentage of its population</a>. </p>
<p>A confluence like this appears highly unlikely under current political realities.</p>
<h2>Moving forward with GOP health reform</h2>
<p>States have a long history of developing sound policy solutions. For example, <a href="https://www.wisconsinhistory.org/turningpoints/tp-045/?action=more_essay">Wisconsin pioneered</a> both unemployment insurance and pension schemes that laid the foundation for federal policies during the New Deal.</p>
<p>Yet states are not equally well-equipped to address all policy issues. Comprehensive health reform is one of those issues.</p>
<p>Current GOP proposals would do little to overcome the financial and regulatory barriers to state-based reform.</p>
<p>Indeed, states would be further inhibited by <a href="https://theconversation.com/not-just-for-the-poor-the-crucial-role-of-medicaid-in-americas-health-care-system-78582">significant cuts to the Medicaid</a> program. Moreover, <a href="https://theconversation.com/how-pre-existing-conditions-became-front-and-center-in-health-care-vote-77138">waivers</a> included in the various proposal, in a marked contrast to the ACA, are focused on allowing states to provide less coverage and fewer benefits.</p>
<p>Allowing policies to be <a href="http://www.commonwealthfund.org/publications/blog/2017/apr/selling-health-insurance-across-state-lines">sold across state lines</a>, if successful, would further restrict the sovereignty of states to regulate their insurance markets.</p>
<p>Republican efforts to repeal and potentially replace the ACA may not be dormant for long. The Democratic victory in the Senate in July was a shaky one that could be quickly undone, for example, if <a href="http://thehill.com/policy/energy-environment/346264-manchin-floated-as-potential-pick-for-energy-secretary-report">Sen. Joe Manchin</a> (Democrat of West Virginia) or Sen. John McCain (Republican of Arizona) choose to leave the Senate. The <a href="http://www.cnn.com/2017/04/29/politics/senate-2018-chuck-schumer/index.html">2018 election for the Senate also puts Democrats at a significant disadvantage</a> and Republicans may further enlarge their majority.</p>
<p>Unquestionably, progressive legislators will continue to introduce bills aimed at comprehensive reforms. Yet, history and economics tell us that these efforts are unlikely to make much headway. The structural limitations of states in a federal system may confine their efforts to <a href="https://www.cambridge.org/core/journals/journal-of-policy-history/article/inching-toward-universal-coverage-statefederal-healthcare-programs-in-historical-perspective/E94A03DD1F60F9DCBE3DDE9728DA3224">filling in the gaps until the federal government further extends coverage</a>.</p><img src="https://counter.theconversation.com/content/81733/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>With Obamacare in peril and no health care plan in sight, it’s logical to ask whether states could design their own single-payer health insurance plans. Efforts in California show why it’s unlikely.Simon F. Haeder, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/821222017-08-10T00:08:05Z2017-08-10T00:08:05ZWhy Medicaid matters to you<figure><img src="https://images.theconversation.com/files/181451/original/file-20170808-28656-1ru15jh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">As more and more seniors need care, their budgets will be strained. As a result, they may rely on Medicaid.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/african-nurse-assisting-elderly-man-walker-577126336?src=u-MYQeKxls4Ds_4JAAM_JQ-1-2">gagliardiImages/Shutterstock.com</a></span></figcaption></figure><p>Efforts to repeal and <a href="http://www.cnn.com/2017/07/25/politics/senate-health-care-vote/index.html">replace Obamacare</a> have been suspended for the time being, and many Americans are breathing a sigh of relief. But Obamacare is far from safe, and the same is true for one of the key programs – Medicaid – that the law used to expand health care coverage for millions of Americans.</p>
<p>While many people may think of Medicaid as a government program that helps only the nation’s poor, that is not accurate. <a href="https://longtermcare.acl.gov/medicare-medicaid-more/medicaid/index.html">Medicaid helps pay for</a> – and is indeed part of estate planning strategies for – nursing home care and other forms of long-term care. Since all Americans live in communities with elderly people, will grow old themselves or have aging parents, long-term care and how to pay for it is a matter that affects us all, even if we do not realize it.</p>
<p>I am a professor of law and bioethics who sits on a hospital ethics committee in Cleveland and has researched aging and long-term care extensively for my <a href="http://scholarlycommons.law.case.edu/faculty_publications/1471/">scholarship</a>. I have learned a great deal about the cost of care and the importance of Medicaid, which not enough people appreciate.</p>
<h2>A rising expense, a growing population</h2>
<p>Long-term care in the United States is extraordinarily expensive. The median annual cost of a private room in a nursing home is over <a href="https://www.genworth.com/about-us/industry-expertise/cost-of-care.html">US$92,000</a>, and a shared room costs over <a href="https://www.genworth.com/about-us/industry-expertise/cost-of-care.html">$82,000</a>. These prices will only increase in the coming years, as costs have risen by almost <a href="http://www.modernhealthcare.com/article/20160510/NEWS/160519999">19 percent</a> since 2011. </p>
<p>The median price for care in an assisted living facility, which provides residents with meals and other forms of assistance but not with skilled nursing care, is over <a href="https://www.genworth.com/about-us/industry-expertise/cost-of-care.html">$43,500</a>. Those who want to remain at home with the help of an in-home aide from a home care agency will pay approximately <a href="https://www.genworth.com/dam/Americas/US/PDFs/Consumer/corporate/131168_050516.pdf">$20</a> an hour, which translates into $175,000 per year for round-the-clock care.</p>
<p>According to the U.S. Department of Health and Human Services, “<a href="https://longtermcare.acl.gov/the-basics/who-needs-care.html">70 percent of people turning age 65 can expect to use some form of long-term care during their lives</a>.” It is important to understand that despite its high cost, long-term care is generally <a href="https://longtermcare.acl.gov/the-basics/who-pays-for-long-term-care.html">not paid for</a> by Medicare, the government program that covers seniors, or by private health insurance policies.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/181455/original/file-20170808-22949-8icqr2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/181455/original/file-20170808-22949-8icqr2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=364&fit=crop&dpr=1 600w, https://images.theconversation.com/files/181455/original/file-20170808-22949-8icqr2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=364&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/181455/original/file-20170808-22949-8icqr2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=364&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/181455/original/file-20170808-22949-8icqr2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=457&fit=crop&dpr=1 754w, https://images.theconversation.com/files/181455/original/file-20170808-22949-8icqr2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=457&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/181455/original/file-20170808-22949-8icqr2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=457&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Nursing home care is extraordinarily expensive, and its costs are projected only to grow.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/552635602?src=e0bScTO4aHgp6tiDQGmX0A-1-24&size=small_jpg">Lighthouse/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>So are most Americans financially equipped to pay on their own for nursing homes and other types of assistance when they are elderly? The answer is a resounding “no.” </p>
<p>A 2015 U.S. Government Accountability Office report found that “<a href="http://www.gao.gov/assets/680/670153.pdf">about half of households age 55</a> and older have no retirement savings (such as in a 401(k) plan or an IRA).” </p>
<p>The National Institute on Retirement Security concluded that American households had a median retirement savings account balance of just <a href="http://www.nirsonline.org/storage/nirs/documents/RSC%202015/final_rsc_2015.pdf">$2,500</a>, and the median for those nearing retirement was a mere <a href="http://www.nirsonline.org/storage/nirs/documents/RSC%202015/final_rsc_2015.pdf">$14,500</a>. Such meager savings make it extremely difficult for retirees to cover their out-of-pocket medical costs for co-pays, deductibles, and noncovered items such as hearing aids, which often reach <a href="http://www.urban.org/sites/default/files/publication/28361/412026-Will-Health-Care-Costs-Bankrupt-Aging-Boomers-.PDF">several thousands of dollars per year</a>. A prolonged period of long-term care on top of these costs is certainly not in most people’s budgets.</p>
<h2>Medicaid and seniors</h2>
<p>Enter Medicaid. While many may think Medicaid primarily covers poor people, about <a href="http://www.kff.org/medicaid/report/medicaid-and-long-term-services-and-supports-a-primer/">28 percent of its overall budget</a> is spent on long-term care. </p>
<p>That money is vital to seniors and to the nursing homes they live in. In 2014, Medicaid paid for <a href="http://www.kff.org/medicaid/report/nursing-facilities-staffing-residents-and-facility-deficiencies-2009-through-2015/">62 percent</a> of nursing home residents. Increasingly, it covers <a href="https://www.payingforseniorcare.com/medicaid-waivers/assisted-living.html">assisted living</a> and <a href="http://www.kff.org/medicaid/state-indicator/personal-care-services/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">in-home care</a>, which many elderly people prefer. </p>
<p>Medicaid is still a program that serves only financially disadvantaged individuals and has strict <a href="https://longtermcare.acl.gov/medicare-medicaid-more/medicaid/medicaid-eligibility/">eligibility requirements</a>, but people who need long-term care, including some who were <a href="http://khn.org/news/in-the-end-even-the-middle-class-would-feel-gop-cuts-to-nursing-home-care/">middle-class</a>, end up “<a href="https://www.eldercaredirectory.org/medicaid-long-term-care.htm">spending down</a>” their money by paying for nursing homes or other assistance out of pocket and then qualify for Medicaid. This includes many who worked hard and supported themselves and their families their entire lives but simply did not have enough retirement savings to cover the exorbitant costs of medical care and long-term care. Those who spend down are <a href="https://www.forbes.com/sites/howardgleckman/2013/04/24/do-seniors-hide-assets-to-get-medicaid-long-term-care-benefits/#1a2b434a4298">very rarely wealthy</a>, with about 85 percent barely hanging on economically before “spending down.” </p>
<p>Republican proposals to repeal and replace Obamacare targeted Medicaid for significant cuts that <a href="https://www.nytimes.com/2017/06/24/science/medicaid-cutbacks-elderly-nursing-homes.html">would have affected</a> seniors receiving long-term care. Many in Congress still <a href="http://www.foxnews.com/politics/2017/07/28/conservatives-hold-out-hope-on-obamacare-repeal-as-gop-leaders-move-to-tax-reform.html">hold out hope</a> of eliminating Obamacare, and this should make all of us worried.</p>
<h2>Medicaid and all of us</h2>
<p>What might happen if frail and elderly people cannot receive needed care? Some will have to turn to loved ones for extra support. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/181456/original/file-20170808-17173-1dni5p6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/181456/original/file-20170808-17173-1dni5p6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=381&fit=crop&dpr=1 600w, https://images.theconversation.com/files/181456/original/file-20170808-17173-1dni5p6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=381&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/181456/original/file-20170808-17173-1dni5p6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=381&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/181456/original/file-20170808-17173-1dni5p6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=479&fit=crop&dpr=1 754w, https://images.theconversation.com/files/181456/original/file-20170808-17173-1dni5p6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=479&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/181456/original/file-20170808-17173-1dni5p6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=479&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Family and friends try to step in and take care of a senior in need, but often at great costs.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/horizontal-view-caring-about-old-person-302485955?src=ADF0tcAe378MJu1_56wt-g-1-24">Photographee.eu/Shutterstock.com</a></span>
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<p>Family and friends already bear much of the burden of caring for the elderly. According to the <a href="http://www.alz.org/documents_custom/2016-facts-and-figures.pdf">Alzheimer’s Association</a>, over 15 million Americans tended to dementia patients in 2016, supplying an estimated 18.1 billion hours of unpaid care. Overall, <a href="https://www.caregiver.org/caregiver-statistics-demographics">older adults receive $470 billion worth of unpaid care</a> each year. Without Medicaid, the elderly will often need to ask more of their relatives or even to move in with them. </p>
<p>Caring full-time for someone who is physically disabled or has dementia can be <a href="https://www.caregiver.org/caregiver-health">emotionally exhausting and can lead to anxiety, depression and other mental and physical health problems</a>; create conflicts within families; and be financially draining, especially if it affects caregivers’ ability to work outside the home.</p>
<p>Other elderly people will try to continue living independently without the help they need. This can create dangers for other members of their communities. They may have to drive in order to get groceries and supplies, and this can lead to more car accidents. Indeed, The American Medical Association and National Highway Traffic Safety Association state that <a href="http://www.aarp.org/content/dam/aarp/livable-communities/plan/transportation/older-drivers-guide.pdf">“on the basis of estimated annual travel, the fatality rate for drivers 85 and older is nine times higher than the rate for drivers 25 to 69</a>.” They will cook alone and perhaps forget to turn off the oven or burners, which can cause fires. And they will be at high risk of falling and needing care in emergency rooms. As more patients flood emergency rooms, the wait times for everyone will increase, and already <a href="https://www.scientificamerican.com/article/widespread-understaffing-of-nurses-increases-risk-to-patients/">understaffed hospitals</a> may provide less attentive care.</p>
<p>These problems will only grow in the future. In 2015, <a href="https://www.census.gov/newsroom/facts-for-features/2017/cb17-ff08.html">14.9 percent of the population, or 47.8 million people</a>, were 65 and over. The number of seniors is projected to expand to almost 73 million by 2030 and to represent over <a href="https://www.census.gov/content/dam/Census/library/publications/2014/demo/p25-1140.pdf">20 percent</a> of total U.S. residents. Society will not be able to ignore their needs.</p>
<p>We will all be affected if elderly members of our communities cannot get needed care. Moreover, many of us will find that long-term care is unaffordable for our own loved ones or for ourselves. None of us knows whether we will develop dementia or another serious chronic condition that requires intensive care for many years.</p>
<p>Medicaid is not just about the poor. It is about all of us, and we should all care deeply about maintaining and strengthening it for the future.</p><img src="https://counter.theconversation.com/content/82122/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sharona Hoffman received financial support from Case Western Reserve University for publication of her book "Aging with a Plan: How a Little Thought Today Can Vastly Improve Your Tomorrow" (Praeger 2015). </span></em></p>Medicaid, a state-federal entitlement program that people associate only with the poor, pays for care for more than six in 10 nursing home residents. That could be you, or someone you love.Sharona Hoffman, Professor of health law and bioethics, Case Western Reserve UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/818002017-08-04T01:58:33Z2017-08-04T01:58:33ZWhat does choice mean when it comes to health care?<figure><img src="https://images.theconversation.com/files/180948/original/file-20170803-29097-xc6w41.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">For many, the heart of the health care debate is the ability of patients to choose their own health care, including whether to buy insurance and which doctor to see. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-patient-665808985?src=Pdsi6uHSlIvHgSRUUk28lA-2-79">Alpa Prod/Shutterstock.com</a></span></figcaption></figure><p>President Trump <a href="http://www.newyorker.com/news/john-cassidy/trumps-health-care-threats-are-nothing-but-spite-and-fury">continues to threaten</a> millions of Americans who now have health insurance with loss of coverage by <a href="https://theconversation.com/trump-isnt-letting-obamacare-die-hes-trying-to-kill-it-81373">undermining the Affordable Care Act</a>, commonly known as “Obamacare.” His goal has been to repeal the ACA, or to have it repealed by a version of congressional bills. </p>
<p>A <a href="https://www.washingtonpost.com/powerpost/the-night-john-mccain-killed-the-gops-health-care-fight/2017/07/28/f5acce58-7361-11e7-8f39-eeb7d3a2d304_story.html?utm_term=.974c84f7b967">July 28 vote killed the Senate bill</a> temporarily, but the threat to those with coverage through the ACA is not over.</p>
<p>As we await the next proposals and rounds of debates, now is a good time to reflect on what the <a href="https://www.forbes.com/sites/theapothecary/2017/01/20/obamacares-individual-mandate-is-really-inefficient/#5ef651ef3ecb">Republicans most detested about Obamacare</a> – the individual mandate, which they argued took away personal choice. The mandate was an essential part of the law, however, by guaranteeing insurers that they would have a large enough pool of healthy people to offset the costs of insuring large numbers of unhealthy people.</p>
<p>As a philosopher of health policy, I think it could be instructional to assess their recent proposals through their lens of “choice.” </p>
<h2>Universal access and choice</h2>
<p>The public debate on proposed health care laws has focused largely on the number of uninsured, which would be lower if we moved to universal coverage. Many experts, advocates and nonprofit research groups, such as Kaiser Family Foundation, use the proportion of people who are covered as a quick way to test whether people have real access to health care. We got partway there with the ACA, with the percentage of <a href="http://www.kff.org/other/state-indicator/total-population/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">uninsured dropping to 9 percent</a> in 2015. </p>
<p>After Trump was elected, Republicans tried to come up with bills, however, that focused not on reducing the number of uninsured but on ensuring that people had a choice about whether to buy insurance. They fought the mandate from the law’s beginnings, filing a lawsuit that reached the U.S. Supreme Court. Chief Justice John Roberts, a George W. Bush appointee, wrote the <a href="http://www.nytimes.com/2012/06/29/us/supreme-court-lets-health-law-largely-stand.html">majority opinion that the mandate did not violate</a> the commerce clause of the Constitution.</p>
<p>If we take them at their word, the system the Republicans aim to replace the ACA with should be focused more on the choices people have, not the number of people who gain insurance. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/180944/original/file-20170803-4947-fxl5km.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/180944/original/file-20170803-4947-fxl5km.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=470&fit=crop&dpr=1 600w, https://images.theconversation.com/files/180944/original/file-20170803-4947-fxl5km.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=470&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/180944/original/file-20170803-4947-fxl5km.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=470&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/180944/original/file-20170803-4947-fxl5km.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=590&fit=crop&dpr=1 754w, https://images.theconversation.com/files/180944/original/file-20170803-4947-fxl5km.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=590&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/180944/original/file-20170803-4947-fxl5km.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=590&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">President Trump and House Speaker Paul Ryan celebrated at the White House on May 5, when the House of Representatives passed Ryan’s version of a health care bill.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Trump-Health-Care-Key-Moments/826c4035d73941b294a6089984bb81a9/1/0">AP Photo/Evan Vucci</a></span>
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</figure>
<p>The public should take seriously, at least for the sake of argument, the words of<a href="http://www.newsweek.com/resistance-resists-too-often-paul-ryan-health-care-trump-trumpcare-629479"> Paul Ryan</a>, when he said that no one should have to do something they do not want to do. <a href="https://www.usatoday.com/story/opinion/2017/03/13/paul-ryan-cbo-health-care-editorials-debates/99143928/">“Our plan is not about forcing people to buy expensive, one-size-fits-all coverage</a>. It is about giving people more choices and better access to a plan they want and can afford,” Ryan said in a statement issued in March 2017. </p>
<p>Their intent is to replace the goal of universal coverage with an alternative which some have called <a href="https://www.nytimes.com/2016/12/15/us/politics/paul-ryan-affordable-care-act-repeal.html?_r=0">“universal access.”</a> Universal access aims to give people the “choice” of having coverage or foregoing that coverage for other priorities they may have.</p>
<h2>What would a real choice require?</h2>
<p>To have a real choice, people would have to be able to buy insurance plans that meet their possible health needs, both for prevention and treatment. They could compare that choice with the choice to forego coverage. </p>
<p>This means they are not in the position of having only a forced choice. If they have a real choice, they no longer are choosing between a plan they can afford, whose reduced cost reflects the fact that it fails to provide access to preventive or treatment services they want and need, and one they cannot afford at all, though it provides access to the preventive and treatment needs they come to have. </p>
<p>Millions in the U.S. faced such a forced “choice” when they bought in the individual health insurance that preceded the ACA marketplaces.</p>
<p>Such a choice is not a real choice. It is forced because the outcome is determined by limited resources and the lack of freedom that the situation creates.</p>
<h2>Paying for real choice</h2>
<p>Of course, since some goods we want, like cars, come in different brands with different prices, we may not see buying a Chevy instead of a Mercedes as a loss of freedom. If we only want a way to get from A to B, we might not care that the Mercedes provides a better ride and is more prestigious.</p>
<p>But, in buying access to health care, we all want the best care. We all, correctly, think that we are valuable in the ways that health care systems should respect even if we have other preferences and priorities regarding cars. In short, people generally accept ability to pay as a principle for car purchases, but not as a principle for buying access to needed health care.</p>
<p>Accordingly, the Republican effort to avoid coercion and take choice seriously would cost more than their plans allow. </p>
<p>The plans they have offered significantly reduce subsidies to the poor and throw people out of Medicaid, resulting in an <a href="http://healthaffairs.org/blog/2017/06/26/cbo-projects-that-22-million-would-lose-coverage-under-senate-bill/">estimated 22 million people losing insurance</a> coverage. The result is a forced choice, not a real choice, especially for people who want some coverage and perhaps need it but have limited resources that would have qualified them for Medicare or subsidies.</p>
<h2>What happens when some people ‘choose’ to forego coverage?</h2>
<p>The Republican approach does not seem to take into account that even a real choice to forego coverage imposes harms on third parties. It does so by raising the cost and thus limiting the availability of insurance to other people. </p>
<p>Since the Republican plans purport to care about the choices for everyone, these consequences – the harms they impose – are ethical reasons to oppose them on their own terms. Young, healthy people should not be able to “choose” to forego coverage when older, sicker people face only forced choices.</p>
<p>Many people want coverage. What happens to the costs of insurance if the system allows people, who save money by foregoing coverage while they are young and healthier than the average older, sicker person, to receive needed emergency care when they need it? </p>
<p>Consider “free riders,” who may be anyone who foregoes buying insurance coverage but later can get needed health care. The cost of a system that allows people to join it when they have not shared in the cost of providing that care is greater than the cost of a system that excludes such “free riders.” </p>
<p>So allowing those who free ride not to die in the streets when they need care, which is what the existing system of emergency medical care (EMTALA) intends and which Republican plans do not challenge, means that free riding imposes higher costs on those who buy insurance coverage. This is a harm to those who have a real choice to buy coverage. This harm to others involves a cost that goes beyond the unfairness of allowing those who do not contribute their fair share to enjoy the benefit of health care when they need it.</p>
<p>Creating this incentive to free ride is part of what creating “choice” – as envisioned by Republicans – involves. </p>
<h2>Skimpy plans</h2>
<p>Similarly, the <a href="http://thehill.com/policy/healthcare/340570-cruz-plan-could-be-key-to-unlocking-healthcare-votes">Cruz amendment</a>, proposed by Sen. Ted Cruz (R-Texas), to the recent Senate bill would have allowed insurers to market less expensive plans that skimp on needed health care as long as the insurer also markets less skimpy plans at higher prices.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/180945/original/file-20170803-17289-ofxbpa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/180945/original/file-20170803-17289-ofxbpa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/180945/original/file-20170803-17289-ofxbpa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/180945/original/file-20170803-17289-ofxbpa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/180945/original/file-20170803-17289-ofxbpa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/180945/original/file-20170803-17289-ofxbpa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/180945/original/file-20170803-17289-ofxbpa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Sen. Ted Cruz (R-Texas).</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/sioux-center-iowa-january-5-2016-358800029?src=GaOBgP2LzPVylfb9248ecg-1-0">Rich Koele/Shutterstock.com</a></span>
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<p>But the increasing stratification that this amendment produces means greater costs to those who buy less skimpy insurance, harming them. (At the same time, those people facing a forced choice of the skimpy insurance or less skimpy but unaffordable insurance are said to simply “choose” it.)</p>
<p>In sum, the “choice” underlying the congressional plans not only is not really paid for, but exercising that “choice” would harm others in a way that undercuts any appeal it has. Universal access is worse than universal coverage because of the “choice” it creates. </p>
<p><em>Brendan Saloner, assistant professor at the Bloomberg School of Public Health at Johns Hopkins University and a former student of Prof. Daniels, contributed to research for this article.</em></p><img src="https://counter.theconversation.com/content/81800/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Norman Daniels does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The Republican position on health care has been based upon a belief in individual choice. Here’s how their own versions of health care bills eroded choice, however, and how they also did harm.Norman Daniels, Professor of Population Ethics and Professor of Ethics and Population Health, Harvard UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/813732017-07-28T17:57:24Z2017-07-28T17:57:24ZTrump isn’t letting Obamacare die; he’s trying to kill it<figure><img src="https://images.theconversation.com/files/180214/original/file-20170728-23754-1el4bnb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Sen. John McCain (R-Ariz.) cast the pivotal vote to nix the Senate version of a bill to repeal Obamacare, only days after returning to Washington after surgery.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Congress-Russia-Sanctions/498f07707a7f4e3991703224cf28dcd4/3/0">AP Photo/Cliff Owen </a></span></figcaption></figure><p>Early on the morning of July 28, Republicans were dealt a surprising blow when Sen. John McCain (R-AR), along with Sen. Susan Collins (R-ME) and Sen. Lisa Murkowski (R-AK), voted against the latest installment of GOP efforts to repeal the Affordable Care Act (ACA).</p>
<p>In light of Republicans’ failure to undo the ACA, President Trump was quick to react on Twitter, stating that he would simply “<a href="https://twitter.com/realDonaldTrump/status/890820505330212864">let ObamaCare implode</a>” and have Democrats own the consequences. With Republicans holding all positions of power in Washington, D.C., these statements are startling by themselves.</p>
<p>However, with Congressional efforts in limbo, the Trump Administration seems to be going a step further than “letting” Obamacare fail. Indeed, it has emphasized an alternative strategy: actively sabotaging the Affordable Care Act.</p>
<h2>Cutting outreach … and misdirecting it</h2>
<p>From the get-go, the Trump Administration quickly sought to impair the success of the Affordable Care Act. In one of its first moves, the Department of Health and Human Services under the direction of Secretary Tom Price <a href="http://www.cnbc.com/2017/01/26/trump-administration-kills-obamacare-ads-for-healthcaregov.html">pulled advertising</a> for the federal government’s enrollment entity, healthcare.gov.</p>
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<img alt="" src="https://images.theconversation.com/files/180234/original/file-20170728-4582-zrfw6v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/180234/original/file-20170728-4582-zrfw6v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/180234/original/file-20170728-4582-zrfw6v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/180234/original/file-20170728-4582-zrfw6v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/180234/original/file-20170728-4582-zrfw6v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/180234/original/file-20170728-4582-zrfw6v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/180234/original/file-20170728-4582-zrfw6v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">People in their twenties are more likely to not buy health insurance, in large part because they are healthy and do not think they need it.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-adults-laughing-they-talk-table-521227855?src=J3b358_DldpCQAMBlD6-Cg-1-0">Monkey Business Images/Shutterstock.com</a></span>
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<p>The advertising has proven important to reach <a href="http://www.cnbc.com/2017/01/26/trump-administration-kills-obamacare-ads-for-healthcaregov.html">18 to 34-years-olds</a>. Enrolling these “young invincibles” is crucial for stabilizing risk pools because they are generally healthier and seek less medical care. States running independent campaigns, like California and its insurance marketplace <a href="http://healthaffairs.org/blog/2016/10/24/making-marketplaces-work-californias-ingredients-for-success/">Covered California</a>, have been <a href="http://content.healthaffairs.org/content/35/7/1160.short">very successful</a> in recruiting young people. </p>
<p>In an ironic twist, the Trump Administration used advertising funding intended for the promotion of the Affordable Care Act for a series of social media <a href="http://www.thedailybeast.com/team-trump-used-obamacare-money-to-run-ads-against-it">promotions attacking the law</a>.</p>
<p>Also, in mid-July, the Administration moved to <a href="http://www.pbs.org/newshour/rundown/trump-administration-ends-affordable-care-act-assistance-contracts-18-cities/">end contracts for enrollment assistance</a> in 18 major cities. Contractors helped individuals navigate the often challenging enrollment process in such places as libraries, businesses and urban neighborhoods in these cities which had been identified by the Obama Administration as high priority.</p>
<p>Finally, the window for the next open enrollment period has been <a href="https://www.healthcare.gov/quick-guide/dates-and-deadlines/">cut in half</a> compared to previous years, thus making it difficult for time-pressed people and those who need enrollment help to enroll. </p>
<p>Many of these actions have triggered <a href="http://www.thedailybeast.com/team-trump-used-obamacare-money-to-run-ads-against-it">calls for inquiries into potential malfeasance by Congress and the Government Accountability Office (GAO)</a>.</p>
<h2>Spreading misinformation</h2>
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<img alt="" src="https://images.theconversation.com/files/180236/original/file-20170728-30401-1dnju0o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/180236/original/file-20170728-30401-1dnju0o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/180236/original/file-20170728-30401-1dnju0o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/180236/original/file-20170728-30401-1dnju0o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/180236/original/file-20170728-30401-1dnju0o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/180236/original/file-20170728-30401-1dnju0o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/180236/original/file-20170728-30401-1dnju0o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Vice President Mike Pence is playing a part in the effort to end Obamacare.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/chesterfield-mo-usa-september-06-2016-479350561?src=nnolSxkHTssScpAVYwKADQ-1-0">Gino Santa Maria/Shutterstock.com</a></span>
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</figure>
<p>Trump Administration officials have been actively <a href="https://www.bizjournals.com/milwaukee/news/2017/06/10/vice-president-pence-vows-new-health-care-plan-to.html">traveling the country</a> and pushing talking points that are often false, or, at the very least, highly misleading and incomplete. Prominently featured in these efforts has been <a href="http://www.politifact.com/truth-o-meter/statements/2017/jul/17/mike-pence/pence-falsely-ties-medicaid-expansion-disability-w/">Vice President Mike Pence</a>, who blamed Medicaid expansion for the backlog of disability cases in Ohio. </p>
<p>A favorite focus has been on <a href="https://twitter.com/SecPriceMD/status/888107504076439554">increasing insurance premiums</a>. While it is true that premiums have risen in many places, <a href="http://www.modernhealthcare.com/article/20160311/NEWS/160319974">well over 80 percent of individuals purchasing insurance in the ACA marketplaces</a> are eligible to receive premium subsidies that shield them from these costs. Moreover, <a href="https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Marketplace-Products/Plan_Selection_ZIP.html">59 percent of enrollees</a> are also eligible to receive cost-sharing subsidies that shield consumers from rising out-of-pocket costs, another favorite Republican talking point.</p>
<p>Efforts to spread misinformation about the ACA has been coupled with equally misleading information about Republican repeal-and-replace efforts. For example, Republicans consistently argue that <a href="https://www.nytimes.com/2017/06/27/us/politics/republicans-medicaid-health-care-affordable-care-act.html">draconian reductions to the Medicaid program</a> are not actual cuts, a position that virtually all health experts disagree with.</p>
<p>Republicans have repeatedly and persistently argued that the ACA is facing imminent implosion. Again, this <a href="http://www.kff.org/health-reform/press-release/analysis-insurer-financial-indicators-show-signs-of-stabilizing-after-transition-to-aca-marketplaces/">position is in direct opposition</a> to that of most health policy experts.</p>
<p>Trump Administration officials’ preferred vehicle for outreach has been social media. For example, there has been a nearly constant stream on <a href="https://twitter.com/SecPriceMD">Twitter by HHS Secretary Tom Price</a> focusing on “<a href="https://twitter.com/SecPriceMD/status/890623080338513921">collapsing exchanges</a>”, <a href="https://twitter.com/SecPriceMD/status/890645975324278786">rising premiums</a>, and how the ACA is “<a href="https://twitter.com/SecPriceMD/status/889573331124486145">wreaking havoc</a>” on America. These claims are in <a href="http://www.kff.org/health-reform/press-release/analysis-insurer-financial-indicators-show-signs-of-stabilizing-after-transition-to-aca-marketplaces/">direct contradiction to expert analyses or at very least incomplete and highly selective</a>.</p>
<h2>Spreading uncertainty</h2>
<p>Far from providing a major overhaul of the American healthcare and insurance system, the ACA provided a mere <a href="https://doi.org/10.1111/puar.12065">extension of the existing system</a>, a system that relies extensively on private businesses to implement government policy.</p>
<p>Arguably, one of the most crucial components of the ACA is the <a href="https://theconversation.com/as-republicans-ready-to-dismantle-aca-insurers-likely-to-bolt-70317">active cooperation of insurance companies</a>. And unlike with previous health reform efforts, insurance companies have been on board with Obamacare from the beginning.</p>
<p>Yet, insurance companies, both for-profits and non-profits, are first and foremost businesses that need to generate profits to stay afloat. Crucial in this endeavor is legal and regulatory certainty, which allows for long-term planning and helps guide investment decisions.</p>
<p>The constant undermining talk by the Trump Administration has done much to shake the confidence of insurance companies in the ACA. Entering a new market and spending resources to seek new enrollees require significant investments. Insurers do not want to see these potential investments wasted.</p>
<p>One of the most prominent issues in this regard has been the Administration’s lack of commitment to <a href="http://www.politico.com/story/2017/07/21/trumps-war-of-attrition-against-obamacare-240777">paying the ACA’s cost sharing subsidies</a>. These subsidies help low-income consumers in the insurance marketplaces to shoulder out-of-pocket costs like co-payments for prescription drugs and doctor visits. Most importantly, the ACA requires insurers to cover these costs for their low-income enrollees. Insurers are then reimbursed by the federal government. Last year, reimbursements amounted to <a href="https://www.washingtonpost.com/news/wonk/wp/2017/07/19/trump-says-he-wants-to-let-obamacare-fail-heres-how-he-could-make-it-fail/?utm_term=.2bc7da71c74b">$7 billion</a>. </p>
<p>Failure to pay these subsidies would be damaging to insurance markets. Insurers would still be required to make the payments for qualified individuals. However, they would not receive federal reimbursements. This would likely lead to <a href="http://xpostfactoid.blogspot.com/2017/07/go-ahead-trump-cut-off-csr-payments.html?m=1">massive premium increases</a> as insurers are seeking to recover their payments. It could also potentially trigger an exodus by insurers.</p>
<p>Not surprisingly, given these uncertainties, insurance companies have <a href="http://www.politico.com/story/2017/07/21/trumps-war-of-attrition-against-obamacare-240777">left many markets and refused to enter new ones</a>.</p>
<p>The situation is made worse by the Administration’s <a href="http://www.insurancejournal.com/news/national/2017/02/16/442006.htm">announcement only days after taking office that it would not enforce the ACA’s individual mandate</a> and the associated tax penalty. While the Administration <a href="http://www.politico.com/story/2017/05/03/trump-obamacare-mandate-enforcement-237937">has reversed that decision</a> for the 2016 tax year, it is unclear what will happen next tax season.</p>
<h2>A flawed law doesn’t mean it’s horrible</h2>
<p>As <a href="http://www.businessinsider.com/chuck-schumer-john-mccain-speech-skinny-repeal-bill-vote-2017-7">Minority Leader Chuck Schumer (D-NY) reightfully pointed out</a> on the last day of the vote-arama on the Republican health care plan, Obamacare is not without its flaws. It does little to contain health care costs or improve the quality of health care provided in this country. Millions of Americans are left without insurance. Some parts of the country <a href="http://www.kff.org/health-reform/press-release/map-counties-at-risk-of-zero-insurers-offering-plans-in-the-2018-marketplace/">lack insurers</a>. </p>
<p>Yet, undeniably, the ACA has done much good by providing coverage to more than 20 millions of Americans and added benefits to millions more.</p>
<p>Republican efforts in Congress to do away with the Obama Administration’s signature accomplishment have been rather bumpy. While Republicans may still be successful, they have certainly taken much longer than President Trump’s promise to repeal the ACA on Day One.</p>
<p>The verdict about the effectiveness of the Trump Administration’s effort to actively undermine the ACA is still out. Yet the efforts appear deliberate and they have been ongoing since the Administration took over the White House and the Department of Health and Human Services. </p>
<p>Actively seeking to bring hardship to millions of Americans by sabotaging their health coverage is certainly highly questionable from a moral and ethical perspective. Future inquiries may also prove that they are illegal. </p>
<p>Perhaps most concerning, in my opinion, when the President of the United States and his closest advisers consistently spread false and misleading information, Americans are bound to lose. They may not only lose their health care coverage. They may also lose trust in their government and their elected leaders, and, eventually, in democratic government itself.</p><img src="https://counter.theconversation.com/content/81373/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>After the Senate nixed a repeal of Obamacare, Pres. Trump turned to Twitter, vowing to let the law die. But he’s actually doing much more. Here’s how he’s taking an active part in destroying the law.Simon F. Haeder, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/816492017-07-27T01:59:18Z2017-07-27T01:59:18ZWhen Pat and Bob nearly saved health care reform: A lesson in Senatorial bedside manner<figure><img src="https://images.theconversation.com/files/179899/original/file-20170726-17560-17v9o4w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Sen. Robert Dole, Republican of Kansas, left, with Sen. Daniel Patrick Moynihan, Democrat of New York, on Capitol Hill in 1993.</span> <span class="attribution"><span class="source">AP Photo/John Duricka</span></span></figcaption></figure><p>With <a href="https://www.usatoday.com/story/news/politics/2017/07/25/mccain-battling-cancer-returns-senate-critical-health-care-vote/508685001/">Senator John McCain’s heroic return</a> and Vice President Mike Pence’s tie-breaking vote on a health care bill July 25, Senate Republicans managed to cobble together <a href="http://www.wsj.com/livecoverage/senate-obamacare-repeal-and-replace-vote">51 votes simply to agree to debate health care reform</a>. This razor’s edge victory is diagnostic. Hyperpartisan debate is convulsive. It endangers the body politic and needs to give way to more tempered discussions across the aisle.</p>
<p>Just as doctors need to learn how to talk to patients, members of the Senate need to learn how to talk to each other again. And like young medical students, they can learn from those who have mastered the art.</p>
<p>For a quick course in senatorial bedside manner, I encourage both parties to recall a time when bipartisan health care reform nearly happened: when the late Sen. Daniel Patrick Moynihan (Democrat of New York) and Senate Minority Leader Bob Dole (Republican of Kansas) almost achieved the bipartisan compromise – which could have prevented our current troubles – during the debate over the Clinton plan in 1994.</p>
<h2>In the archives</h2>
<p>I learned how central bipartisanship was to Moynihan from my research in the Daniel P. Moynihan Papers at the Library of Congress for a paper on the senator’s defense of academic medicine during <a href="http://alphaomegaalpha.org/pharos/2017/Spring/2017-2-Fins.pdf">the debate over health care</a>. It was a central feature of his political biography. Moynihan had served in both <a href="http://www.nytimes.com/books/first/h/hodgson-newyork.html">Democratic</a> and <a href="https://www.brookings.edu/book/the-professor-and-the-president/">Republican</a> administrations. This was despite his being <a href="https://www.nationalaffairs.com/publications/detail/moynihan-and-the-neocons">a lifelong Democrat and old-fashioned liberal</a>, as Greg Weiner, the author of <a href="http://www.tandfonline.com/doi/abs/10.1080/10457097.2015.1081536?src=recsys&journalCode=vpps20">“American Burke: The Uncommon Liberalism of Daniel Patrick Moynihan</a>,” reminds us. </p>
<p>Moynihan’s willingness to cross the aisle was epitomized by his relationship with Dole. The two senators were good-faith adversaries and sometimes collaborators. Together they saved Social Security in an epic <a href="http://doleinstitute.org/about-bob-dole/a-legacy-of-leadership/social-security/">bipartisan deal in 1983</a> and passed NAFTA in 1993.</p>
<p>Moynihan and Dole’s attempt at collaboration speaks to their deep respect for the legislative process. Despite their differences, they appreciated the need to work across the aisle to achieve a consensus. They seemed to instinctively understand that anything less would be perilous. Senator leaders and the rank and file should reflect on this lesson. The notion of good-faith adversaries seems to have been lost entirely.</p>
<p>Indeed, Moynihan anticipated the demise of the Clinton plan, warning that laws as ambitious as health care reform <a href="http://www.politico.com/story/2013/10/government-shutdown-barack-obama-obamacare-aca-097687">“pass 70 to 30 or they fail.”</a> The author of a <a href="https://www.foreignaffairs.com/reviews/capsule-review/1999-05-01/secrecy-american-experience-daniel-patrick-moynihan-intellectual">monograph on secrecy in government</a>, Moynihan also warned of crafting such massive legislation in secret, as Senate Majority Leader Mitch McConnell (Republican of Kentucky) has done.</p>
<h2>A Moynihan-Dole bill?</h2>
<p>As far back as the fall of 1993, expert Senate observers felt that health care reform, the top priority for the Clinton administration, was a nonstarter unless Moynihan and Dole worked together. As Haynes Johnson and David Broder observed in their brilliant volume <a href="http://www.nejm.org/doi/full/10.1056/NEJM199608223350819#t=article">“The System</a>,” “For all their differences, Democrats and Republicans knew that if the Senate were to produce a health care reform bill, Moynihan and Dole would have to create it … no two men understood or appreciated each other’s abilities more.”</p>
<p>In an extended interview with me at his MSNBC offices several summers ago, <a href="http://www.msnbc.com/the-last-word">Lawrence O’Donnell</a> – who was Moynihan’s chief of staff on the Senate Finance Committee – told me of their constructive, and sometimes mutually beneficial, alliance. “It was quite normal to include [Dole] in these things before he became a presidential candidate.” At the staff level, O’Donnell and Sheila Burke, Dole’s chief of staff, were in routine contact to prepare for a bipartisan compromise.</p>
<p>Early on, both Moynihan and Dole spoke confidently that together they would get a bill through the Senate. They also both recognized that it would be over the objections of the far right and left. As Johnson and Broder recount, <a href="http://www.nejm.org/doi/full/10.1056/NEJM199608223350819#t=article">Dole was quick to add that</a> “…even people on the far right and the far left get sick and need health care. And there are probably a lot of good conservative people out there without health care. And there are things we can do to make it better.”</p>
<p>Moynihan recalled their rapprochement in <a href="http://www.newyorker.com/magazine/2010/10/25/politics-and-prose">a letter to New York Times publisher</a> Arthur Sulzberger. “On the morning of May 12, Bob Dole, Minority Leader, passed me a note. ‘Pat, Are we ready for the Moynihan-Dole Bill?’ I literally put down the gavel and rushed into the back room to call the White House.”</p>
<h2>And then… ‘health care died’</h2>
<p>In his memoir, <a href="http://www.nytimes.com/books/00/09/17/reviews/000917.17margolt.html">“Eyewitness to History</a>,” David Gergen, a former presidential adviser, recounts President Clinton’s response. “‘As long as I am president,’ he said, ‘I plan to keep fighting for serious reform. I did not get elected to compromise on the issue. We can’t trust the Republicans and I am not backing down! We won’t compromise.’”</p>
<p>It was that simple, and Gergen knew it. He looked down at his watch and made a note to himself that “At 10:22 p.m., health care died.” He was right, and the lingering debate over Obamacare speaks to the prescience of that postmortem.</p>
<p>This, too, is a lesson for the current generation of political leadership.</p>
<h2>It could have been different</h2>
<p>So, what might have been the alternative history if Moynihan and Dole had their way and sought the compromise that continues to elude us? We can’t know for sure, but we do know what Moynihan hoped to bring to the table.</p>
<p>It was simple, elegant and eminently workable, as O’Donnell told me.</p>
<p>Moynihan shared his plan with O’Donnell during a Finance Committee hearing: “… he puts his hand over the microphone, as they do so they won’t be heard, and he leans over his shoulder to me and says ‘Why don’t we just strike the words over 65 from the Medicare schedule?’ And that was our health care reform idea.”</p>
<p>Whether or not Medicare for all is the solution on which leaders can agree, it is time to resurrect a bipartisan approach. To be sure, this may seem quaint given our current polarization, but what alternative do we have? Vice presidential tiebreakers on health care are not a sustainable model to govern <a href="https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html">17.8 percent of our GDP</a>.</p>
<p>It seems clear that neither the Democrats nor Republicans can do this alone. As the debate moves to more regular order, each party needs the other to succeed. The health of our people and our democracy depends on their shared success.</p><img src="https://counter.theconversation.com/content/81649/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr. Fins received funding from the New York-Presbyterian Hospital Foundation for his research leading to the publication of Primum Non Nocere: Daniel Patrick Moynihan and the Defense of Academic Medicine published earlier this year in The Pharos. Dr. Fins is also The Solomon Center Distinguished Scholar in Medicine, Bioethics and the Law at Yale Law School. He is a board member of The Hastings Center and a trustee emeritus of Wesleyan University and an Ambassador Fellow of the New York Academy of Medicine.</span></em></p>While current congressional leaders are digging in their heels along party lines, it might be good to take a step back and consider how two Senate leaders in the 1980s reached across the aisle.Joseph J. Fins, E. William Davis Jr, MD Professor of Medical Ethics, Professor of Medicine and Chief, Division of Medical Ethics, Weill Cornell Medicine, Cornell UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/815962017-07-26T01:51:04Z2017-07-26T01:51:04ZGlioblastoma, a formidable foe, faces a ‘reservoir of resilience’ in McCain<figure><img src="https://images.theconversation.com/files/179704/original/file-20170725-30157-1sy59ui.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Sen. John McCain (R-Ariz.) returned to the Capitol July 25 to cast what was a tie-breaking vote to proceed to debate a bill to repeal Obamacare.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/McCain-Congress-Health-Overhaul/beabc3277b7f47e5a1e4b4fad2f38f59/11/0">AP Photo/Andrew Harnik</a></span></figcaption></figure><p>As a naval aviator, John McCain was shot down during the Vietnam War and spent five and a half years as a <a href="https://www.washingtonpost.com/news/retropolis/wp/2017/07/20/sen-john-mccain-faced-death-twice-as-a-navy-fighter-pilot-and-survived-brutal-years-as-a-pow/?utm_term=.f7dab4600e6a">prisoner of war</a>. He received inadequate medical care for injuries that nearly killed him, enduring years of unimaginable deprivation and torture.</p>
<p>He persevered with a remarkable resilience and fighting attitude that made him an American hero and helped him grow into the role of public servant and, as a United States senator, a leader on a national stage.</p>
<p>Now, McCain faces another remorseless enemy that will again test him in body and spirit – glioblastoma, a <a href="http://www.irsa.org/glioblastoma.html">malignant brain cancer</a> that kills about 13,000 Americans each year.</p>
<p>As the co-director of the Preston A. Wells Jr. Center for Brain Tumor Therapy at the University of Florida, I engage continually with patients and their families in the battle against glioblastoma. And I know firsthand how patients can often be swept into despair by the devastating diagnosis.</p>
<p>The news of McCain’s condition – and his return to Washington July 25 to participate in the health care vote – provides an opportunity to remind the public about important and potentially game-changing research into therapies with the promise of greatly extending survivability for those with glioblastoma. Some of these therapies are in clinical trials and offer the ultimate hope of someday turning a cancer perceived as a quick killer into a curable disease.</p>
<h2>Stats are one thing, but people are another</h2>
<p>One thing often misunderstood by the public when talking about cancer in general is survivability. Projections for how long a person might be expected to survive are just that – projections. Each person is different, and each person’s cancer is different.</p>
<p>In the case of glioblastoma, <a href="http://www.irsa.org/glioblastoma.html">survivability is 15 to 18 months</a>, with standard treatments such as surgery, chemotherapy, radiation and, recently, alternating electric field therapy. These very short survival times cast an understandable pall over talk of the disease.</p>
<p>We also know, however, that some patients with the cancer, with even just standard treatments, have lived very long – even decades after their diagnosis. Granted, those numbers are a small subset of patients. But we do measure two- to three-year survival rates, and now from some promising clinical trials, five- and 10-year survival rates.</p>
<p>Glioblastomas typically arise from genetic changes to cells inside the brain. There is no behavior that contributes to their random appearance, and there are no clear risk factors. </p>
<p>And, there is no definitively curative therapy for glioblastoma. It is a relentlessly aggressive tumor. What makes these cancer cells so challenging is the fact that they migrate in the brain, very far from the origin of the tumor. Though surgeons can remove a large percentage of the tumor cells, unfortunately, islands of invasive cells remain. They often move into other areas of the brain that we cannot eradicate with surgery. Radiation and chemotherapy can slow the growth of invasive brain tumor cells, but limitations on the intensity of these treatments that can be tolerated within the brain and the existence of resistant tumor cells hinder the overall effectiveness.</p>
<h2>Enlisting the immune system</h2>
<p>While patients with glioblastoma, like all patients with cancer, often feel as if they have been betrayed by their own bodies, it is one of the most remarkable aspects of every person’s physical makeup that provides perhaps the greatest promise in fighting the disease: the immune system.</p>
<p>Using the immune system to fight cancer is not a new concept. The idea that the immune system could be goaded into potentially recognizing cancers and lead to their rejection was advanced more than a century ago. But the science and our understanding of the immune system and human genomics required time to catch up to our ambitions.</p>
<p><a href="https://theconversation.com/immunotherapy-training-the-body-to-fight-cancer-71870">Immunotherapy</a>, combined with an ever-increasing understanding of genomics, leaves us on a cusp of a revolution in cancer treatment.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/179705/original/file-20170725-30103-1xyr1js.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/179705/original/file-20170725-30103-1xyr1js.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/179705/original/file-20170725-30103-1xyr1js.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/179705/original/file-20170725-30103-1xyr1js.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/179705/original/file-20170725-30103-1xyr1js.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/179705/original/file-20170725-30103-1xyr1js.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/179705/original/file-20170725-30103-1xyr1js.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A pipette and test tubes in a lab such as those used to research immunotherapy.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pipette-fluid-test-tubes-cancer-immunotherapy-576532450?src=zCyCMePG6g7cJfjkp_gXOQ-1-31">CI Photos/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>In genomics, we seek to understand how genes are altered in cancer. We can profile a patient’s tumor and understand the landscape of alterations that are present in those cancer cells. That has allowed us in some cases to predict how those tumors are likely to behave. It also allows us in some cases to select therapies that may be more effective in targeting those cancers.</p>
<p>We can also identify specific proteins produced by these tumor cells and essentially program immune cells to home in on them and kill the cancer. This leads to a personalized treatment approach where you direct a patient’s immune system against a cancer, boosting or enhancing a patient’s immune response against specific alterations found in their tumor.</p>
<p>At the University of Florida, one of the immunotherapy approaches we are advancing is called adoptive T cell therapy. In this work, we generate large numbers of “killer T cells” designed to recognize a patient’s specific tumor and transfer those T cells back to the patient with the hope that these activated cells can seek out and destroy remaining tumor cells. We have active clinical trials exploring this approach in patients with aggressive brain tumors.</p>
<p>Additionally, we are exploring new ways to take advantage of drugs called immune checkpoint inhibitors, which elevate the activation state of the immune system of a patient so that it can more effectively combat cancer.</p>
<p>We currently do not have any immunotherapies that are approved by the Food and Drug Administration for the treatment of brain cancer, although a number are being investigated in clinical trials at UF and other leading medical centers.</p>
<p>One of the things we know about our immune system is that it is essentially designed to handle almost an infinite number of unknown external threats. It’s a remarkable system that, once harnessed, might be the most effective tool in battling brain cancers.</p>
<h2>A matter of heart</h2>
<p>But perhaps one of the most critical tools fighting glioblastoma is the one that is in McCain’s own heart. It is the will to fight and engage an enemy. It is the resilient spirit to battle against great odds.</p>
<p>We all have experienced in the field of clinical research or clinical care those patients whose outlook and approach to tackling their disease seems to lead to better outcomes. We don’t necessarily have a quantitative assessment of how these factors impact the duration and quality of life in patients battling cancer, but we seem to agree that they matter.</p>
<p>With glioblastoma, we can’t ignore what the data and the numbers tell us about its aggressiveness. But I think bringing to bear all your personal resources, spiritual and emotional support and the obstinate will to fight can lead to better outcomes.</p>
<p>And nobody doubts John McCain’s deep reservoir of resilience.</p><img src="https://counter.theconversation.com/content/81596/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Duane A. Mitchell, M.D., Ph.D., holds patents related to brain tumor immunotherapy that have been licensed by Celldex Therapeutics, Inc., Annias Immunotherapeutics, Inc., and Immunomic Therapeutics, Inc. He is the co-founder of, iOncologi, Inc., a biotechnology company focused on cancer immunotherapy treatment. He serves as an advisor/consultant for Bristol-Myers Squibb, Inc., Tocagen, Inc., and Oncorus, Inc. He receives funding from the National Cancer Institute, Department of Defense, and several private foundations focused on brain tumor research and treatment. </span></em></p>A diagnosis of glioblastoma did not keep John McCain from the Capitol to cast a crucial vote that could end Obamacare. His actions are a reminder that stats are one thing but human beings, another.Duane Mitchell, Professor of Neurosurgery, University of FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/799912017-07-25T01:12:50Z2017-07-25T01:12:50ZHow killing the ACA could lead to more opioid deaths in West Virginia and other Trump states<figure><img src="https://images.theconversation.com/files/179502/original/file-20170724-11666-1wuw0pn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A neighborhood in Huntington, West Virginia, where more than two dozen opioid overdoses occurred within four hours in August, 2016. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Drug-Overdoses-Four-Hours-in-Huntington/5b517c23a3e3498f9262ba9610a9ff30/33/0">AP Photo/Claire Galofino</a></span></figcaption></figure><p>President Trump spoke at the National Scout Jamboree in West Virginia on July 24, joining a long list of presidents who have spoken to the huge meeting of Boy Scouts, troop leaders and volunteers. The visit was not surprising, as West Virginia, in the center of Appalachia, is overwhelmingly Trump Country. </p>
<p>It is also at the center of the nation’s opioid epidemic, with a rate of <a href="https://www.hcp.med.harvard.edu/sites/default/files/Key%20state%20SMI-OUD%20v3.pdf">42 overdose deaths per 100,000</a>, more than double the national average. Indeed, on Aug. 15, 2016, Huntington, home of Marshall University, experienced more than two dozen overdoses in a <a href="http://www.cnn.com/2016/08/17/health/west-virginia-city-has-27-heroin-overdoses-in-4-hours/index.html">span of just four hours</a>. </p>
<p>West Virginia is also a state that has been aggressive in taking advantage of <a href="http://onlinelibrary.wiley.com/doi/10.1111/puar.12065/full">opportunities offered by the federal government under the Affordable Care Act</a>, including the ACA insurance marketplaces and the Medicaid expansion. </p>
<p>While about <a href="https://www.nytimes.com/elections/results/west-virginia">two-thirds of voters supported</a> Trump in the election, support for expanding Medicaid has largely been bipartisan. At least until now.</p>
<p>With GOP repeal-and-replace efforts still very much up in the air, one thing has become clear: All proposals made public by congressional Republicans have significant, detrimental effects on West Virginia’s and America’s ability to combat the opioid epidemic.</p>
<h2>An escalating problem</h2>
<p>The opioid addiction crisis in America is growing worse. An analysis in June 2017 by The New York Times showed a <a href="https://www.nytimes.com/interactive/2017/06/05/upshot/opioid-epidemic-drug-overdose-deaths-are-rising-faster-than-ever.html">19 percent increase in drug overdose deaths </a>from 2015 to 2016, and experts cited opioids as the likely reason for the increase.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/179507/original/file-20170724-16930-1p3t7e1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/179507/original/file-20170724-16930-1p3t7e1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/179507/original/file-20170724-16930-1p3t7e1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/179507/original/file-20170724-16930-1p3t7e1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/179507/original/file-20170724-16930-1p3t7e1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/179507/original/file-20170724-16930-1p3t7e1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/179507/original/file-20170724-16930-1p3t7e1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Opioid overdose is blamed for a sharp increase in deaths due to drug overdose. Prescription opioids used to treat pain have contributed to the epidemic.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/hydrocodone-prescription-bottle-generic-medication-name-523921741?src=_Co2MOkNI9QylEAVo8GWUA-1-4">Sherry Yates Young/Shutterstock.com</a></span>
</figcaption>
</figure>
<p><a href="https://www.addictioncenter.com/addiction/addiction-statistics/">More than 20 million Americans</a> suffer from an addiction. Close to <a href="https://www.addictioncenter.com/addiction/addiction-statistics/">seven million of these addicts</a> also have a mental illness. The Surgeon General’s office has estimated that the yearly losses in productivity, health care costs and criminal justice expenses for alcohol misuse and illicit drug abuse amount to <a href="https://addiction.surgeongeneral.gov/executive-summary">US$442 billion</a>. </p>
<p>In 2015, the most recent year for which figures are available from the Centers for Disease Control and Prevention (CDC), more than <a href="https://www.cdc.gov/mmwr/volumes/65/wr/mm655051e1.htm">52,000 Americans died from drug overdoses</a>. More than <a href="https://www.cdc.gov/mmwr/volumes/65/wr/mm655051e1.htm">33,000 of these</a> were due to opioids. This means that, compared to 1999, the number of opioid <a href="https://www.cdc.gov/mmwr/volumes/65/wr/mm655051e1.htm">deaths nearly tripled</a>. </p>
<p>This epidemic is not only killing people and ripping apart families. It also has created an enormous drain on America’s health and social systems.</p>
<p>Drug overdoses lead to more than <a href="https://www.addictioncenter.com/addiction/addiction-statistics/">five million emergency department visits</a> per year.</p>
<p>In towns in West Virginia and many other states, school systems, fire and police departments, and city governments spend ever-growing funds on providing emergency <a href="http://www.emsworld.com/news/12317582/w-v-departments-footing-the-bill-for-naloxone">overdose treatments such as Naloxone</a>.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/179509/original/file-20170724-24759-10768vd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/179509/original/file-20170724-24759-10768vd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/179509/original/file-20170724-24759-10768vd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/179509/original/file-20170724-24759-10768vd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/179509/original/file-20170724-24759-10768vd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/179509/original/file-20170724-24759-10768vd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/179509/original/file-20170724-24759-10768vd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Emergency responders and departments have been taxed in dealing with opioid overdoses.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/patient-emergency-team-transfer-ambulance-blur-536327245?src=wFt5BIh2PTn5FAZfgUnBKQ-1-1">Chaikom/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Indeed, Medicaid spending on the drug has increased by <a href="http://www.urban.org/sites/default/files/publication/91521/2001386-rapid-growth-in-medicaid-spending-on-medications-to-treat-opioid-use-disorder-and-overdose_3.pdf">90,000 percent</a> in just five years.</p>
<p>A West Virginia program to <a href="https://www.washingtonpost.com/news/wonk/wp/2017/03/07/drugs-are-killing-so-many-people-in-west-virginia-the-state-cant-keep-up-with-the-funerals/?utm_term=.f143feb25dce">support needy families with burial expenses</a> has run out of funds for five years straight.</p>
<p>The epidemic has also created tremendous problems for <a href="http://www.governing.com/topics/health-human-services/gov-opioid-epidemic-child-welfare.html">child welfare system and schools</a>, which have to deal with the drug-addicted parents and abandoned children.</p>
<p>Perhaps the saddest part of the story is the <a href="http://wvpublic.org/post/born-addicted-race-treat-ohio-valley-s-drug-affected-babies">growing number of newborns delivered by addicted mothers</a>, who have to undergo addiction treatment from the minute they are born.</p>
<h2>How Obamacare helped</h2>
<p>The ACA called for states to expand Medicaid coverage to more lower-income people. Not all states did this; the 19 who bucked expansion were Republican states.</p>
<p>But not all Republican states resisted expansion. West Virginia, desperate for help for its laid-off miners and for its thousands of people addicted to opioids, was one of <a href="http://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Current%20Status%20of%20Medicaid%20Expansion%20Decision%22,%22sort%22:%22asc%22%7D">the more than a dozen states that voted for the president and expanded Medicaid</a>.</p>
<p>The expansion of Medicaid has been crucial in two ways. For one, providing insurance coverage for an <a href="https://www.hcp.med.harvard.edu/sites/default/files/Key%20state%20SMI-OUD%20v3.pdf">additional 180,000 West Virginians</a> has proven critical to getting many of them into treatment.</p>
<p>Moreover, the expansion population was subject to the ACA’s <a href="http://www.sciencedirect.com/science/article/pii/S0168851014002607">Essential Health Benefit provisions</a>. This required states to make available substance abuse and mental health treatment to them.</p>
<p>Finally, the <a href="http://www.sciencedirect.com/science/article/pii/S0168851014002607">ACA’s Essential Health Benefit</a> provisions required policies sold in the individual market to cover addiction and mental health services. It also eliminated annual and lifetime limits on <a href="https://theconversation.com/essential-health-benefits-suddenly-at-center-of-health-care-debate-but-what-are-they-75125">these benefits</a>.</p>
<p>Overall, <a href="https://www.hcp.med.harvard.edu/sites/default/files/Key%20state%20SMI-OUD%20v3.pdf">more than 210,000 West Virginians</a> with substance abuse or mental health problems gained coverage under the ACA.</p>
<h2>Epidemic would escalate</h2>
<p>While the exact nature of Republican repeal-and-replace efforts remains unclear at this moment, all proposals made public so far would pose enormous challenges for states like West Virginia to turn the tide on the devastating opioid epidemic.</p>
<p>One of the most essential tools in fighting the epidemic, the expansion of Medicaid, would be rolled back either immediately or over several years. Furthermore, the entire Medicaid program, the <a href="https://www.theatlantic.com/politics/archive/2017/07/opioid-medicaid-health-care/533451/?utm_source=twb">backbone of states’ efforts to provide treatment and services</a> for opioid addiction treatment, would be further curtailed by per capita caps.</p>
<p>Moreover, all proposals would either outright eliminate or allow states to waive the crucial <a href="https://theconversation.com/essential-health-benefits-suddenly-at-center-of-health-care-debate-but-what-are-they-75125">Essential Health Benefit provisions</a>. These provisions require insurers to provide coverage for certain specified conditions, such as pregnancy, addiction treatment and emergency room care, that they might otherwise refuse to cover because of their costs. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/179514/original/file-20170724-16930-1meu7y8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/179514/original/file-20170724-16930-1meu7y8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/179514/original/file-20170724-16930-1meu7y8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/179514/original/file-20170724-16930-1meu7y8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/179514/original/file-20170724-16930-1meu7y8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/179514/original/file-20170724-16930-1meu7y8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/179514/original/file-20170724-16930-1meu7y8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Maternity health benefits have been considered essential care under the ACA, as has addiction treatment.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/cropped-shot-doctor-stethoscope-listening-belly-651615208?src=ST2YcfBzCleyODRQYICsjw-1-0">LIghtField Studios/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Under certain proposals, lifetime and annual limits could also affect those covered by employer-provided insurance to lose access to crucial treatment options.</p>
<p>In its most recent iteration, Senate Republicans have added $45 billion over 10 years <a href="http://www.nbcnews.com/storyline/americas-heroin-epidemic/senate-health-care-bill-no-fix-opioid-epidemic-experts-say-n782721">specifically to deal with the opioid crisis</a> to bring on-board crucial moderates like Senators Shelley Moore Capito (Republican-West Virginia) and Robert Portman (Republican-Ohio).</p>
<p>However, as Ohio Gov. John Kasich stated, given the enormous size of the opioid problem, this amounts to “<a href="http://abcnews.go.com/Politics/senate-health-bill-force-choosing-children-seniors-disabled/story?id=48392178">spitting in the ocean</a>.” Medicaid alone spends more than <a href="http://www.urban.org/sites/default/files/publication/91521/2001386-rapid-growth-in-medicaid-spending-on-medications-to-treat-opioid-use-disorder-and-overdose_3.pdf">$1 billion annually</a> solely on medications for addiction treatments. This does not include costs to providers or treatment facilities.</p>
<h2>Moving forward</h2>
<p>Treating addiction is challenging and involves more than access to insurance coverage. However, <a href="https://www.usatoday.com/story/opinion/2017/06/22/gop-health-bill-disaster-substance-abuse-patients-vivek-murthy-column/103023032/">evidence-based treatment</a>, which includes replacement medications and counseling, has shown success in America’s fight against the epidemic ravaging many of its communities.</p>
<p>In my opinion, stemming the opioid epidemic requires a prolonged, multi-pronged approach.</p>
<p>It requires a hard look at how we prescribe painkillers. Health care providers like <a href="https://share.kaiserpermanente.org/article/kaiser-permanente-targets-reduction-of-opioid-prescribing/">Kaiser Permanente</a> have shown that success is possible.</p>
<p>It also requires taking a hard look at the <a href="https://www.bloomberg.com/view/articles/2017-07-11/states-have-good-reason-to-investigate-opioid-makers">role that pharmaceutical companies play</a>.</p>
<p>It requires providing jobs and hope to rural America, which overwhelmingly voted for President Trump and his promises, and which disproportionately suffers from this epidemic.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/179515/original/file-20170724-28519-jmsptg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/179515/original/file-20170724-28519-jmsptg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=409&fit=crop&dpr=1 600w, https://images.theconversation.com/files/179515/original/file-20170724-28519-jmsptg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=409&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/179515/original/file-20170724-28519-jmsptg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=409&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/179515/original/file-20170724-28519-jmsptg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=514&fit=crop&dpr=1 754w, https://images.theconversation.com/files/179515/original/file-20170724-28519-jmsptg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=514&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/179515/original/file-20170724-28519-jmsptg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=514&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Coal miners in Maidsville, West Virginia, ready to descend into the mines in this 1938 photo. The coal industry has been declining for a number of years, however, leading to fewer jobs in mining.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/coal-miners-ready-descend-into-mine-242289910?src=s46GMhDiHarI3hpC85iMuQ-1-1">Everett Historical/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Most definitely, it requires also providing medical treatment to individuals trying to overcome their additions. Unfortunately, so far, none of the GOP proposals have done that. GOP proposals do not include the means to do that.</p>
<p>Trump has long championed the people of West Virginia, but a visit to the Boy Scouts does little to alleviate the suffering in the heart of Appalachia.</p><img src="https://counter.theconversation.com/content/79991/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>West Virginia favored Trump by more than 2:1 in the 2016 election, but Trump’s policies would particularly hurt the state. Its residents depend heavily on Medicaid to treat opioid addiction.Simon F. Haeder, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/788792017-07-17T00:38:49Z2017-07-17T00:38:49ZAs academic hospitals lower mortality rates, should insurers reconsider excluding them?<figure><img src="https://images.theconversation.com/files/177939/original/file-20170712-12241-bctdp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Health care personnel in all hospitals work hard to provide first-rate care, but academic hospitals carry an added responsibility. Some have questioned whether that dilutes clinical care. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/busy-surgeon-doctors-serious-operation-569254738?src=2VAMZeidZgBZkt-QNcCzTA-1-21">gpointstudios/Shutterstock.com</a></span></figcaption></figure><p>A comprehensive new <a href="http://jamanetwork.com/journals/jama/article-abstract/2627971">study has found that major teaching hospitals</a> in the United States outperformed non-teaching hospitals in the most important of all health care outcomes: reducing mortality rates.</p>
<p>Using a traditional measure of surgical quality, the study analyzed mortality rates for 21 million Medicare patients who were hospitalized with one of the 15 most common medical diagnoses or who underwent one of the six most common surgical procedures.</p>
<p>It found that the 30-day mortality rate for such patients was 1.5 percent lower in absolute terms (8.1 percent in teaching hospitals vs. 9.6 percent in non-teaching hospitals), or nearly 15 percent lower percentage-wise.</p>
<p>There would be 58,000 fewer deaths per year among those patients if non-teaching hospitals achieved the same mortality rate as teaching hospitals, according to Dr. Laura Burke, lead author of the study, published in the Journal of the American Medical Association in late May.</p>
<p>This finding was not surprising for those of us who practice at major teaching hospitals and who are especially concerned about the decision of some insurance plans to offer “narrow networks” that exclude teaching hospitals, <a href="https://www.nytimes.com/2017/06/05/upshot/teaching-hospitals-cost-more-but-could-save-your-life.html">which can be more expensive</a>. </p>
<p>The study cuts through one of the central clouds of confusion plaguing health care: how to measure health care outcomes. This is difficult because it is often subjective. As dean of a major medical school, I know very well the challenges of delivering high-quality care while also preparing the next generation of doctors. </p>
<h2>Well-being hard to measure</h2>
<p>We live in a world of metrics, particularly in business. <a href="http://www.druckerinstitute.com/2013/07/measurement-myopia/">Peter Drucker</a>, an icon in the development of modern business principles, is credited with coining the phrase, “If you can’t measure it, you can’t manage it.” Or improve it. </p>
<p>This has led to the proliferation of measurements of quality and cost. It has helped create an entire industry – from Consumer Reports magazine to TripAdvisor to Yelp – that is very useful for those buying a washing machine or planning a vacation.</p>
<p>This approach is not as helpful in health care, because so much important information cannot be measured. It’s hard to quantify the things that make a patient have a better experience. Did the new medicine make you feel better? Are you able to resume the lifestyle you seek after surgery?</p>
<p>For this reason, although modern health care is awash in metrics, many of these outcomes, while measurable, are not particularly relevant. In so many ways, the metrics used to assess quality in health care today are reminiscent of a much older proclamation, “It’s hard to see the forest for the trees.”</p>
<h2>Using the gold standard</h2>
<p>The brilliance of the recent study is that the metric measured was mortality: How many patients from each group were still alive at 30 days after their hospital discharge? Mortality is a gold standard for objectivity – “the body count,” as it is often referred to in clinical trials. Just as important, <a href="http://health.usnews.com/health-care/articles/2017-05-23/at-major-teaching-hospitals-lower-death-rates">the study accounted for the fact</a> that teaching hospitals often treat a sicker mix of patients.</p>
<p>Given that academic medical centers often treat patients who are sicker, some people may have been surprised by the results. Non-teaching hospitals, after all, have clinical care as their single mission. Major teaching hospitals, on the other hand, also perform research to develop new therapies and to educate trainees in many medical fields. Therefore, the clinical care mission of academic hospitals is diluted by these other missions, their thinking goes. </p>
<p>In addition, we know that care at academic medical centers can be more <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690120/">fragmented</a>. This is the result of a larger treatment team that includes trainees. The larger the team, the harder communication can sometimes be. And, the role of the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690120/">attending physician</a> can sometimes be weakened as a result. These are issues that academic centers have long worked on.</p>
<p>That mindset misses a key point. Yes, physicians and leaders in major teaching hospitals have a different approach to health care. Their focus is not solely on the care they can deliver today but also on how they can make it better tomorrow. How can outcomes be improved? A crude but effective formula for measuring health care outcomes is: Value = Quality/Cost. </p>
<h2>Complex cases, complex care</h2>
<p>Major teaching hospitals, with faculty who focus on this formula, are not only thinking about how to provide care but how to improve health care value every day. For instance, in medicine, many guidelines exist for the treatment of different diseases. These guidelines are based on high-quality clinical studies. New and expensive technologies and drugs are likely to be used differently in major teaching hospitals given their mission to provide the best care today and to develop even better care in the future. </p>
<p>This blend of practicality with philosophy – of research, care and training – is a distinct difference between these two different types of hospitals. That approach has helped medical schools and teaching hospitals pioneer some of the <a href="https://members.aamc.org/eweb/upload/Academic%20Medicine%20Where%20Patients%20Turn%20for%20Hope.pdf">greatest advancements, including </a> the first polio vaccine, the first successful pancreas transplant, the first human genome treatment for cystic fibrosis and the first successful surgery on a fetus in utero.</p>
<p>That success is an important reason why about <a href="https://www.aamc.org/download/472884/data/nationalinstitutesofhealth.pdf">half of the NIH’s extramural grants</a> support research conducted at medical schools and teaching hospitals. </p>
<p>Here at the University of Michigan, physicians and researchers have collaborated to develop new and better treatments to reduce mortality rates for a range of deadly conditions including skin cancer and congenital heart failure. Cutting-edge use of <a href="https://medicine.umich.edu/dept/otolaryngology/3d-airway-printed-splint">3-D printers</a>, for example, helped a pediatric surgeon and biomedical engineer pioneer a new technique to treat infants whose collapsed windpipes were nearly sure to be fatal. A splint, made from a bio-absorbable polymer, allows such infants to breathe on their own and eventually develop a normal trachea. </p>
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<figcaption><span class="caption">A splint developed at the University of Michigan medical school allows infants to breathe.</span></figcaption>
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<h2>Where will you get best care?</h2>
<p>For consumers, does this mean they should seek out care at teaching hospitals? Of course, as the leader of a premier academic medical center, I know there are some advantages. The combination of researchers and practitioners, cutting-edge facilities and a commitment to both care and knowledge help produce first-rate care. But the real takeaway from this study is that it validates for consumers that the standard of care will not be lower at a teaching hospital than a non-teaching hospital. </p>
<p>Even as those of us at teaching hospitals trumpet the positive results and lower mortality rates pinpointed by this new study, we should acknowledge that all measurements serve some purpose. Metrics do not predict the future, but to the degree that past performance informs the future, they do have value.</p>
<p>However, they do not tell the whole story. We do – and will continue to – live in Peter Drucker’s world of statistics and metrics. But that should not blind us to the larger fact that so many medical outcomes have a very real subjective component, too.</p><img src="https://counter.theconversation.com/content/78879/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marschall Runge does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Many academic medical centers are facing increasing financial pressure as insurers create so-called narrow networks, but a recent study of mortality data may lead insurers to reconsider.Marschall Runge, Dean, School of Medicine, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/810132017-07-14T02:41:37Z2017-07-14T02:41:37ZWhy health savings accounts are a bust for the poor but a boost for the privileged<figure><img src="https://images.theconversation.com/files/178181/original/file-20170713-9618-8l6p7j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">North Carolina NAACP President Rev. William Barber, accompanied by Rep. Sheila Jackson Lee, Texas, left, as activists, many with the clergy, are taken into custody by U.S. Capitol Police on Capitol Hill in Washington, July 13, 2017, after protesting against the Republican health care bill.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/Search?query=health+care+bill&ss=10&st=kw&entitysearch=&toItem=15&orderBy=Newest&searchMediaType=excludecollections">AP Photo/J. Scott Applewhite</a></span></figcaption></figure><p>When Senate Majority Leader Mitch McConnell released his <a href="https://www.nytimes.com/2017/07/13/us/politics/senate-republican-health-care-bill.html">new version of the Republican health care bill</a> July 13, he relied on a favorite Republican device to solve the nation’s health care woes – Health Savings Accounts.</p>
<p><a href="https://www.ahip.org/wp-content/uploads/2017/02/2016_HSASurvey_Draft_2.14.17.pdf">Health Savings Accounts</a> (HSAs) were established by the same legislation that created the Medicare Part D prescription drug benefit in 2003. <a href="https://www.ahip.org/wp-content/uploads/2017/02/2016_HSASurvey_Draft_2.14.17.pdf">HSAs</a> allow individuals to make tax-deductible contributions, withdraw money tax-free to pay for qualified medical expenses and avoid taxes on the money invested in the account.</p>
<p><a href="https://www.ahip.org/wp-content/uploads/2017/02/2016_HSASurvey_Draft_2.14.17.pdf">Enrollment in HSAs</a> has skyrocketed to nearly 20 million people, but there’s a catch. Very few, if any, of those 20 million people are poor. The HSAs allow individuals to use tax-protected funds for medical purposes for years to come. Some have even called them the <a href="https://www.wageworks.com/blog/2016/july/07/health-savings-accounts-the-new-401k#sthash.eA4uob07.dpbs">“new 401(k)‘s</a>.”</p>
<p>While these savings accounts can be good for people of a certain income level, I have concerns that they will overlook the needs of the poor, who not only stand to gain very little from the tax advantages but who also are unlikely to have thousands of dollars to contribute to such plans.</p>
<h2>Tax savings and a dose of financial responsibility</h2>
<p>Currently, individuals are allowed to make <a href="https://www.ahip.org/wp-content/uploads/2017/02/2016_HSASurvey_Draft_2.14.17.pdf">annual contributions</a> of US$3,400, while families are allowed to contribute up to $6,750. Unlike so-called health Flexible Spending Accounts, or FSAs, left-over assets in the account carry over from year to year. In 2015, the average balance was just over $1,800.</p>
<p>Individuals are able to establish HSAs only when they obtain coverage through so-called High-Deductible Health Plans (HDHPs), which are currently defined as plans with a deductible of at least $1,300 for single people, or at least $2,600 for family coverage. The maximum out-of-pocket cost for individuals and families are $6,450 and $12,900, respectively.</p>
<p>This means that individuals with these plans are responsible for a significant amount of costs before their insurance benefits kick in. There are no data that show how many people of lower income could afford to fund these plans.</p>
<p>What we do know is that there are about <a href="https://www.ebri.org/publications/ib/index.cfm?fa=ibDisp&content_id=3397">20-22 million policyholders</a> with <a href="https://www.ebri.org/publications/ib/index.cfm?fa=ibDisp&content_id=3397">$28 billion in assets</a>. </p>
<p>In larger employers, <a href="https://www.mercer.com/content/dam/mercer/attachments/private/gl-2017-health-national-survey-infographic-series-mercer.pdf">53 percent of employers offer HSAs, and about a quarter of employees are covered</a>. About <a href="http://www.kff.org/health-reform/poll-finding/survey-of-non-group-health-insurance-enrollees-wave-3/">half of individuals</a> obtaining insurance in the individual market do so via a high-deductible plan. This number is expected to <a href="http://healthaffairs.org/blog/2015/10/07/trouble-ahead-for-high-deductible-health-plans/">continue to grow in the future</a>.</p>
<h2>Why are conservatives enamored of HSAs?</h2>
<p>When it comes to conservative ideology, HSA checks off a number of boxes. </p>
<p>For one, they are supposed to empower the individual to take charge of their own health care decisions. With <a href="https://www.jstor.org/stable/1813785?seq=1#page_scan_tab_contents">more “skin in the game,” individuals will be incentivized to make better, more prudent choices</a> when it comes to their health care. This should not only reduce premiums for individuals and families, but equally important, rein in the growth of U.S. healthcare expenditures.</p>
<p>Lower premiums, in turn, would then allow more Americans to obtain insurance coverage. They would also ease the tremendous burden on American companies seeking to provide health insurance to their employees.</p>
<p>HSAs also reduce the tax burden of Americans, albeit mostly for the wealthier part of society. Moreover, the funds in HSAs will provide investment capital to America’s economy and lead to further economic growth.</p>
<h2>Disadvantages of HSAs?</h2>
<p>A handful of studies have been able to provide some insights into potential benefits and problems of HSAs and HDHPs. Most of the studies confirm the general findings of the famous <a href="https://www.rand.org/content/dam/rand/pubs/reports/2006/R3055.pdf">RAND Health Insurance Experiment</a>: Higher deductibles lead to a reduction in the quantity of medical care consumed. The experiment also showed that, on average, this reduction was not detrimental to individuals’ health status.</p>
<p>However, there was one significant exception: Low-income individuals with chronic conditions saw a significant drop in health status.</p>
<p>More recent studies have shown that HDHPs and HSAs lead to spending about <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2910568/">5-7 percent less</a> on medical care per enrollee. Most of these reductions come from <a href="http://www.ajmc.com/journals/issue/2013/2013-1-vol19-n12/medication-utilization-and-adherence-in-a-health-savings-accounteligible-plan/P-1">reducing the amount of care consumed</a> – <a href="http://www.nber.org/papers/w21632?utm_campaign=ntw&utm_medium=email&utm_source=ntw">not from shopping for cheaper providers</a>. There is also evidence that individuals <a href="http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_152.pdf">delay care</a>, <a href="http://www2.deloitte.com/content/dam/Deloitte/us/Documents/life-sciences-health-care/us-lchs-dig-deep-hidden-costs-112414.pdf">do not comply with doctors’ treatment plans</a> and <a href="http://content.healthaffairs.org/content/31/12/2641.full.pdf+html">are unaware of free preventive services</a>.</p>
<p>None of these findings is surprising.</p>
<p>We know that <a href="http://www.bankrate.com/banking/savings/survey-how-americans-contend-with-unexpected-expenses">many Americans do not have enough savings to account for an emergency</a>, medical or otherwise. The wealthiest Americans disproportionately benefit from these insurance arrangements. Indeed, <a href="https://www.cbpp.org/blog/trump-house-gop-health-savings-account-proposals-would-mostly-help-wealthy-not-uninsured">families making in excess of $100,000 make up 70 percent of HSA contributions</a>. </p>
<p>CNN Money called HSAs “<a href="http://money.cnn.com/2017/05/05/pf/hsa-health-savings-account/index.html">the best tax-free investment account you’ll be able to find</a>.”</p>
<p>We know that American health care consumers are notoriously <a href="http://www.kff.org/health-reform/poll-finding/assessing-americans-familiarity-with-health-insurance-terms-and-concepts/">bad at understanding the U.S. insurance and health care system</a>. They also have <a href="http://www.annualreviews.org/doi/abs/10.1146/annurev-publhealth-082313-115826">problems understanding provider quality</a>. Shopping around, already challenging in the health care field – in case of an emergency or when there is only a limited number of providers – is hardly possible in these conditions.</p>
<h2>The recent Senate bill</h2>
<p>The most recent revision of the Senate’s Better Care Reconciliation Act makes four significant changes to HSAs and HDHPs.</p>
<p>First, it almost doubles the amount individuals are allowed to contribute, to $6,550 and $13,100 for individuals and families, respectively.</p>
<p>Second, it further increases these limits for Americans 55 and older in order to allow them to prepare for retirement.</p>
<p>Third, it also reduces the penalty individuals incur for withdrawing funds from their HSAs for nonqualified expenditures.</p>
<p>Fourth, and this is a significant departure from federal policy since the 1940s, it allows individuals and families to use money in HSAs to pay for insurance premiums. Previously, only individuals with employer-provided insurance were subject to preferential tax treatment.</p>
<h2>The rich can get richer?</h2>
<p><a href="http://www.washingtonexaminer.com/new-senate-republican-healthcare-plan-leaves-taxes-on-the-wealthy-in-place-lets-people-buy-less-expensive-plans/article/2628509">Under criticism from advocates and even members of his own party</a>, Senate Majority Leader Mitch McConnell’s (R-KY) most recently released Senate repeal-and-replace effort maintained many of the Affordable Care Act’s taxes. However, well-to-do Americans may have obtained an even better replacement in the form of Health Savings Accounts. We should also not forget that these taxes could be subject to repeal during the upcoming efforts at tax reform or the budget process.</p>
<p>We know very little about the long-term effects of high-deductible plans. However, <a href="http://content.healthaffairs.org/content/31/12/2641.full.pdf+html">scholarly findings</a> on delayed care, reduced preventive care and avoidance of medical care are cause for concern with potentially significant detrimental effects for the American health care system and Americans.</p>
<p>We also know that these arrangements further <a href="https://www.cbpp.org/research/gao-study-confirms-health-savings-accounts-primarily-benefit-high-income-individuals">segregate the risk pool and divide Americans based on their income and health status</a>. Richer and healthier individuals will seek out these plans to shelter their assets. Poorer and sicker Americans will not be able to reap these benefits.</p>
<p>More than 50 years ago, Nobel Prize-winning economist Kenneth Arrow prominently <a href="https://web.stanford.edu/%7Ejay/health_class/Readings/Lecture01/arrow.pdf">pointed out</a> that the health care field is filled with striking market failures. While HSAs and HDHP may sound like a good solution, they are unlikely, I would argue, to be viable and equitable solutions to what ails the American health care system.</p><img src="https://counter.theconversation.com/content/81013/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The latest Senate health care bill is still a hodgepodge of efforts to repeal Obamacare, critics say. One of their concerns is the focus on HSAs.Simon F. Haeder, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/809432017-07-13T00:02:11Z2017-07-13T00:02:11ZThe 5 faulty beliefs that have led to Republican dysfunction on health care<figure><img src="https://images.theconversation.com/files/177961/original/file-20170712-13319-sfkcc2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Senate Majority Leader Mitch McConnell, shown here in June, 2017, is the architect of the new version of the Senate health care bill released today. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Congress-Health-Overhaul-Analysis/715f0700728a4a83b98fceb853661af7/23/0">AP Photo/J. Scott Applewhite</a></span></figcaption></figure><p>After failure of Republicans to reform health care, an outside observer might think that Congress is just dysfunctional, lurching from one extreme to another in search of something that works for health care reform. </p>
<p>The latest development has been the inability of Republicans to even agree on their own proposal and, worse yet, what should come next if it fails. Should they repeal the Affordable Care Act and worry about a replacement later or just try to “fix” the ACA now?</p>
<p>But the problem is much deeper than just a policy fix. As a former health insurance CEO and professor of health finance, it seems clear to me that Republicans are making five key implicit assumptions that are inherently problematic:</p>
<h2>1. If it’s your own money, you’ll be more careful in how you’ll spend it.</h2>
<p>This foundational belief rests on general experience in markets for most goods, and it has led to Republican support for Health Savings Accounts (HSAs), in which people set aside their own money to pay for their health care costs. </p>
<p>Landmark research showed that this approach could work – but under special conditions. The <a href="https://www.rand.org/health/projects/hie.html">RAND Health Insurance Experiment</a> is the basis for current HSAs. It demonstrated that people could save money – with no worsening of their health – if the cost sharing (deductibles and co-pays) was completely prefunded in individual HSAs. The only major exceptions were for kids and some chronic conditions. </p>
<p>But current proposals have extended this logic to populations, such as those with low incomes and few assets, where these findings are not applicable. Furthermore, HSAs generally are not fully funded to the levels used in the RAND research.</p>
<p>Yet, the Better Care Reconciliation Act, as the current Senate bill is officially called, adds a substantial boost to HSAs, and most state-level Medicaid proposals include a modestly funded health savings account. The problem with this Republican approach is that poor people don’t have any money to begin with and typically can’t afford to buy insurance or pay deductibles. </p>
<p>Furthermore, even those with more money aren’t very good at using their HSA money to shop for care, due to opaque prices for services and lack of information about treatment requirements. </p>
<h2>2. Many or most poor people (Medicaid recipients) can work and should contribute to pay for insurance.</h2>
<p>While the Medicaid expansion enrollees are working already (by definition, they have income above the poverty line), their <a href="http://ccf.georgetown.edu/wp-content/uploads/2013/09/GW-Continuity-Report-9-10-13.pdf">job prospects and history are marginal</a>. The 30,000 Medicaid recipients in the health insurance plan that I ran as CEO, for example, had about nine months of Medicaid eligibility before they got a job and lost coverage. </p>
<p>But the myth persists that Medicaid is loaded with moochers who simply do not choose to work and won’t pay for coverage anyway. </p>
<p>The fact is that very few fall in this category. <a href="http://healthaffairs.org/blog/2017/06/07/state-medicaid-lessons-for-federal-health-reform/">Work requirements and required premiums</a> may be simply a way to reduce Medicaid rolls using a faulty assumption. </p>
<h2>3. Government restrictions are holding back insurers from competition that would drive costs lower.</h2>
<p>Both the Senate and House alternatives cut restrictions and taxes on insurers. Most important of these are the broadening of the range of premiums allowed and the elimination or weakening of required <a href="https://theconversation.com/essential-health-benefits-suddenly-at-center-of-health-care-debate-but-what-are-they-75125">essential health benefits</a>, such as preventive care and maternity coverage. Undoubtedly, these changes will allow premiums to drop – but primarily for the healthy population that needs insurance less while others pay more.</p>
<p><a href="http://www.commonwealthfund.org/publications/blog/2017/apr/selling-health-insurance-across-state-lines">Cross-state competition</a> among insurers is a big Republican talking point. The rules of Congress exclude consideration for this particular legislation, however.</p>
<p>What’s more, it is wishful thinking that, with less regulation, there would be a flood of out-of-state insurers entering new markets and driving health care costs down. Insurers are able to compete on premiums by obtaining favorable contracts with providers. New entrants simply won’t get rates comparable to those already in a market.</p>
<p>In any event, the fact is that it is recent government-induced uncertainty that is <a href="http://www.modernhealthcare.com/article/20170510/NEWS/170519999">driving insurers out of the market</a> and forcing huge increases in premiums filed for 2018 offerings. </p>
<p>It is more than ironic that Senate Majority Leader Mitch McConnell suggested that they may need to “<a href="http://khn.org/morning-breakout/mcconnell-concedes-bill-might-not-pass-but-reaffirms-need-to-shore-up-individual-markets/">shore up the individual market</a>” when the Congress has been the main reason for the instability.</p>
<h2>4. Physicians should be the only ones making care decisions (with the consent of their patients) since they know best.</h2>
<p>Health and Human Services Secretary Tom Price, an orthopedic surgeon, was a vocal advocate of this view – before he accepted the Cabinet job.</p>
<p>Recently, however, from my observations, he seems to have discovered that payment incentives and organizational innovation actually do improve quality, satisfaction and cost. </p>
<p>Perhaps acknowledging this, the Senate plan sought to extend these payment incentives and other ACA innovations through a new “Medicaid Flexibility Program” under its <a href="http://healthaffairs.org/blog/2017/06/24/medicaid-round-two-the-senates-draft-better-care-reconciliation-act-of-2017/">block grant options</a> to the states. </p>
<p>Unfortunately, however, the total amount of <a href="https://www.nytimes.com/interactive/2017/06/26/us/cbo-score-of-senate-health-care-bill.html">funds available to state Medicaid programs</a> would have been cut dramatically. On the principle, however, the Republicans seem to have conceded that health care is a team sport requiring action regarding incentives, organization and knowledge, much like the Democrats, albeit with less funding.</p>
<h2>5. Government should help people – but not too much.</h2>
<p>The original flat premium subsidies proposed by the House are both inadequate and regressive – hurting those with lower incomes. They would have covered almost all of the premium for young people but perhaps half for older enrollees. Also, they would go to everyone regardless of income, unlike Obamacare subsidies, which were based on a defined percent of the purchaser’s income. </p>
<p>The Senate partially corrects this bad arithmetic – and economics – by allowing subsidies to vary somewhat by income. Unfortunately, the base level is far lower than under the ACA. Subsidies are cut substantially for the poor while giving the wealthy tax relief.</p>
<h2>What next?</h2>
<p>So the bottom line is that the <a href="https://www.nytimes.com/2017/07/18/us/politics/republicans-obamacare-repeal-now-replace-later.html?emc=edit_th_20170719&nl=todaysheadlines&nlid=47546052">implosion of the Obamacare exchanges</a> that Republicans have predicted may become a self-fulfilling prophecy under continued threats to sabotage it by administrative action or inaction.</p>
<p>Unfortunately, even with the demise of the Senate bill, it is likely that the grand experiment of Obamacare – advancing the social objective of a fully insured population using a competitive but regulated marketplace – will fade away as insurers run away from <a href="https://www.nytimes.com/2017/01/17/opinion/the-gops-health-care-death-spiral.html">unpredictable markets</a>. </p>
<p>We may come full circle. We could end up with a dysfunctional individual market and a much smaller Medicaid population with many more uninsured people. Once again, Republicans and Democrats continue to debate specifics – rather than deal with differences in beliefs – in an evidence-free brawl.</p><img src="https://counter.theconversation.com/content/80943/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>J.B. Silvers does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Republicans have had a hard time dismantling the Affordable Care Act, despite their promises. That could be because they are operating under certain beliefs about health care that are not accurate.J.B. Silvers, Professor of Health Finance, Weatherhead School of Management & School of Medicine, Case Western Reserve UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/795522017-06-30T21:10:25Z2017-06-30T21:10:25ZWhy poverty is not a personal choice, but a reflection of society<figure><img src="https://images.theconversation.com/files/175906/original/file-20170627-24798-1qj4yt9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A homeless camp in Los Angeles, where homelessness has risen 23 percent in the past year, in May 2017.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Los-Angeles-Homeless/71e100cbdbac40c29e56c13445e65e08/22/0">AP Photo/Richard Vogel</a></span></figcaption></figure><p>As the Senate <a href="http://www.politico.com/story/2017/06/28/donald-trump-obamacare-repeal-240044">prepares to modify</a> its version of the health care bill, now is a good time to back up and examine why we as a nation are so divided about providing health care, especially to the poor. </p>
<p>I believe one reason the United States is cutting spending on health insurance and safety nets that protect poor and marginalized people is because of American culture, which overemphasizes individual responsibility. Our culture does this to the point that it ignores the effect of root causes shaped by society and beyond the control of the individual. How laypeople define and attribute poverty may not be that much different from the way U.S. policymakers in the Senate see poverty. </p>
<p>As someone who studies <a href="http://poverty.umich.edu/experts/">poverty solutions</a> and social and health inequalities, I am convinced by the academic literature that the biggest reason for poverty is how a society is structured. Without structural changes, it may be very <a href="https://theconversation.com/why-is-it-so-hard-to-close-the-racial-health-gap-in-the-us-69012">difficult</a> if not impossible to eliminate disparities and poverty.</p>
<h2>Social structure</h2>
<p>About <a href="https://www2.census.gov/programs-surveys/demo/visualizations/p60/256/figure4.pdf">13.5 percent</a> of Americans are living in poverty. Many of these people do not have insurance, and efforts to help them gain insurance, be it through Medicaid or private insurance, have been stymied. Medicaid provides insurance for the disabled, people in nursing homes and the poor. </p>
<p>Four states recently asked the Centers for Medicare and Medicaid Services for permission to require Medicaid recipients in their states who are not disabled or elderly to work.</p>
<p>This request is reflective of the fact that many Americans believe that poverty is, by and large, the result of <a href="https://www.washingtonpost.com/posteverything/wp/2017/03/08/laziness-isnt-why-people-are-poor-and-iphones-arent-why-they-lack-health-care/?utm_term=.58f8fed8454f">laziness</a>, immorality and irresponsibility. </p>
<p>In fact, poverty and other social miseries are in large part due to <a href="https://www.britannica.com/topic/social-structure">social structure</a>, which is how society functions at a macro level. Some societal issues, such as racism, sexism and segregation, constantly cause disparities in education, employment and income for marginalized groups. The majority group naturally has a head start, relative to groups that deal with a wide range of societal barriers on a daily basis. This is what I mean by structural causes of poverty and inequality. </p>
<h2>Poverty: Not just a state of mind</h2>
<p>We have all heard that the poor and minorities need only make better choices – work hard, stay in school, get married, do not have children before they can afford them. If they did all this, they wouldn’t be poor. </p>
<p>Just a few weeks ago, Housing Secretary Ben Carson called poverty “<a href="http://www.npr.org/2017/05/25/530068988/ben-carson-says-poverty-is-a-state-of-mind">a state of mind</a>.” At the same time, his budget to help low-income households could be cut by more than <a href="http://www.npr.org/2017/05/25/530068988/ben-carson-says-poverty-is-a-state-of-mind">US$6 billion</a> next year.</p>
<p>This is an example of a simplistic view toward the complex social phenomenon. It is minimizing the impact of a societal issue caused by <a href="http://www.oxfordscholarship.com/view/10.1093/acprof:oso/9780195385878.001.0001/acprof-9780195385878-chapter-7">structure</a> – macro‐level labor market and societal conditions – on individuals’ behavior. Such claims also ignore a large body of sociological science. </p>
<h2>American independence</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/175909/original/file-20170627-16411-1p5ebf7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/175909/original/file-20170627-16411-1p5ebf7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/175909/original/file-20170627-16411-1p5ebf7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/175909/original/file-20170627-16411-1p5ebf7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/175909/original/file-20170627-16411-1p5ebf7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/175909/original/file-20170627-16411-1p5ebf7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/175909/original/file-20170627-16411-1p5ebf7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Americans value their independence, rather than interdependence, more than many cultures.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/portrait-young-enthusiastic-patriotic-lady-651400231?src=rVvFH7_ZNmoBEXrIVu9gnA-2-3">Dmytro Zinkevych/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Americans have one of the most independent cultures on Earth. A majority of Americans define people in terms of internal attributes such as <a href="http://onlinelibrary.wiley.com/doi/10.1080/00049530701447368/abstract">choices</a>, abilities, values, preferences, decisions and traits. </p>
<p>This is very different from <a href="http://onlinelibrary.wiley.com/doi/10.1080/00049530701447368/abstract">interdependent</a> <a href="http://psycnet.apa.org/index.cfm?fa=buy.optionToBuy&id=1991-23978-001">cultures</a>, such as eastern Asian countries where people are seen mainly in terms of their environment, context and relationships with others. </p>
<p>A direct consequence of independent mindsets and cognitive models is that one may ignore all the historical and environmental conditions, such as slavery, segregation and discrimination against women, that contribute to certain outcomes. When we ignore the historical context, it is easier to instead attribute an unfavorable outcome, such as poverty, to the person. </p>
<h2>Views shaped by politics</h2>
<p>Many Americans view poverty as an individual phenomenon and say that it’s primarily <a href="http://www.theamericanconservative.com/dreher/poverty-the-fault-of-the-poor/">their own fault</a> that people are poor. The <a href="http://news.harvard.edu/gazette/story/2008/10/wilson-perceives-social-structure-and-culture-as-key-causes-of-poverty/">alternative</a> view is that poverty is a structural phenomenon. From this viewpoint, people are in poverty because they find themselves in holes in the economic system that deliver them inadequate income. </p>
<p>The fact is that people move <a href="http://wagner.nyu.edu/files/faculty/publications/In%20and%20Out%20of%20Poverty%20-%20Morduch%20and%20Siwicki%20-%20June%202017.pdf">in and out</a> of poverty. <a href="http://www.nber.org/papers/w1199">Research</a> has shown that 45 percent of poverty spells last no more than a year, 70 percent last no more than three years and only 12 percent stretch beyond a decade.</p>
<p>The Panel Study of Income Dynamics (<a href="https://psidonline.isr.umich.edu/">PSID</a>), a 50-year longitudinal study of 18,000 Americans, has shown that around four in 10 adults experience an entire year of poverty from the ages of 25 to 60. The last Survey of Income and Program Participation (<a href="https://www.census.gov/sipp/">SIPP</a>), a longitudinal survey conducted by the U.S. Census, had about one-third of Americans in episodic poverty at some point in a three-year period, but just <a href="http://www.demos.org/blog/7/28/14/two-theories-poverty">3.5 percent</a> in episodic poverty for all three years. </p>
<h2>Why calling the poor ‘lazy’ is victim blaming</h2>
<p>If one believes that poverty is related to historical and environmental events and not just to an individual, we should be careful about blaming the poor for their fates. </p>
<p><a href="https://crcvc.ca/docs/victim_blaming.pdf">Victim blaming</a> occurs when the victim of a crime or any wrongful act is held entirely or partially responsible for the harm that befell them. It is a common psychological and societal phenomenon. Victimology has shown that humans have a tendency to perceive victims <a href="http://journals.sagepub.com/doi/10.1177/0886260511403752">at least partially responsible</a>. This is true even in rape cases, where there is a considerable tendency to <a href="https://www.ncbi.nlm.nih.gov/pubmed/20587449">blame victims</a> and is true particularly if the victim and perpetrator know each other.</p>
<p>I believe all our lives could be improved if we considered the structural influences as root causes of social problems such as poverty and inequality. Perhaps then, we could more easily agree on solutions.</p><img src="https://counter.theconversation.com/content/79552/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Shervin Assari does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Americans, an independent group, tend to believe that people can “pull themselves up by their boot straps.” Yet bigger forces are at play in a person’s ability to gain education, a good job and money.Shervin Assari, Research Investigator of Psychiatry, Public Health, and Poverty Solutions, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/798192017-06-29T23:50:27Z2017-06-29T23:50:27ZHow bills to replace Obamacare would especially harm women<figure><img src="https://images.theconversation.com/files/176287/original/file-20170629-21076-nfnuql.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A woman speaks up at a town hall gathering with Sen. Lindsey Graham (R-South Carolina) in March 2017.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Health-Overhaul-Town-Hall-Graham/bf0a5459ad374d22b1db0ff66600343d/36/0">Mark Crammer/AP</a></span></figcaption></figure><p>As members of Congress are heading back to their districts over Fourth of July break, the future of the Affordable Care Act (ACA), America’s health care system and millions of Americans continues to hang in the balance.</p>
<p>While the House and Senate version of a proposed ACA repeal differ in the details, their broad outlines essentially boil down to three major items.</p>
<p>Both essentially roll back the Medicaid expansion enacted in the ACA that has benefited more than 10 million Americans.</p>
<p>Both significantly reduce funding for the entire Medicaid program that currently benefits 75 million Americans. </p>
<p>And both significantly roll back insurance market regulations that have benefited all Americans wherever they get their insurance. </p>
<p>If these bills become law, more than 20 million Americans would lose coverage over the next 10 years, according to <a href="https://www.cbo.gov/publication/52849">estimates from the nonpartisan Congressional Budget Office</a>. All but the richest Americans will be worse off.</p>
<p>However, one of the most detrimentally affected demographics is actually America’s largest demographic group: America’s women, who would see reductions in coverage, benefits and access.</p>
<p>Much of my <a href="http://simonfhaeder.wixsite.com/home/academic">academic work over the past seven years</a> has focused on the Affordable Care Act. However, as a son, husband and father, whose wife has been previously denied insurance, my concerns are also deeply personal. Policies that are bad for women are bad for all of America.</p>
<h2>Obtaining coverage</h2>
<p>Obtaining insurance coverage has long been challenging for women, as their rates of employer-sponsored insurance have <a href="http://www.kff.org/womens-health-policy/fact-sheet/medicaids-role-for-women/">traditionally trailed those of men significantly</a>.</p>
<p>Not surprisingly, the most dramatic and significant change for women under the ACA, or Obamacare, occurred through the expansion of coverage. Overall the uninsured rate among women fell from <a href="http://files.kff.org/attachment/Issue-Brief-Ten-Ways-That-the-House-American-Health-Care-Act-Could-Affect-Women">17 to 11 percent by 2015</a>. Particularly dramatic were the changes for <a href="http://files.kff.org/attachment/Issue-Brief-Ten-Ways-That-the-House-American-Health-Care-Act-Could-Affect-Women">women of color and those of low socioeconomic standing.</a></p>
<p>One major vehicle for the increase was the expansion of the Medicaid program. Today, <a href="http://files.kff.org/attachment/Issue-Brief-Ten-Ways-That-the-House-American-Health-Care-Act-Could-Affect-Women">20 percent of American women</a> receive coverage through the program. The program serves as the <a href="https://theconversation.com/not-just-for-the-poor-the-crucial-role-of-medicaid-in-americas-health-care-system-78582">crucial backbone for America’s health care system</a>.</p>
<p>In addition, <a href="http://www.kff.org/womens-health-policy/fact-sheet/womens-health-insurance-coverage-fact-sheet/">close to nine million women</a> obtained health insurance coverage in the individual market reformed under the ACA.</p>
<p>Finally, the ACA allowed more than <a href="https://nwlc.org/resources/women-and-health-care-law-united-states/">3.1 million young adults</a> to remain on their parents’ health insurance until age 26.</p>
<h2>Lowering costs</h2>
<p>The availability of insurance coverage is only a first step. Individuals must be able to afford that coverage. While far from perfect, the ACA provided significant funding for women in this regard.</p>
<p>For those women obtaining coverage through Medicaid, <a href="http://files.kff.org/attachment/Fact-Sheet-Medicaids-Role-for-Women">premium and out-of-pocket costs were strictly limited or nonexistent</a>.</p>
<p>Those women who obtained coverage on the <a href="http://jhppl.dukejournals.org/content/early/2015/01/22/03616878-2882219.abstract">ACA’s insurance marketplaces</a> and whose income fell below 400 percent of poverty were eligible for insurance premium subsidies. </p>
<p>For those falling below 250 percent of poverty, <a href="http://onlinelibrary.wiley.com/doi/10.1111/puar.12065/abstract">subsidies to pay for out-of-pocket costs were also available</a>, in addition to premium subsidies. Even for those above the cutoff, the ACA strictly limited annual out-of-pocket costs.</p>
<p>The ACA also sought greater gender equity. As a result, it banned the prevalent practice of gender rating, the practice of charging women higher premiums solely based on their gender. Indeed, in most states it was even common to <a href="https://www.nwlc.org/sites/default/files/pdfs/nwlc_2012_turningtofairness_report.pdf">charge a male smoker less than a female nonsmoker</a> before passage of the ACA.</p>
<p>Finally, the ACA also facilitates access to services by eliminating out-of-pocket costs for preventive services including mammograms and colonoscopies, well-woman visits, vaccinations, domestic and interpersonal violence screening and counseling.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/176285/original/file-20170629-26970-95zbj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/176285/original/file-20170629-26970-95zbj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/176285/original/file-20170629-26970-95zbj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/176285/original/file-20170629-26970-95zbj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/176285/original/file-20170629-26970-95zbj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/176285/original/file-20170629-26970-95zbj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/176285/original/file-20170629-26970-95zbj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The Affordable Care Act pays for preventive services, including mammogram screenings for women.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/happy-woman-looking-doctor-while-undergoing-607144922?src=DoSYX2GufwuY9FDK9l-9qg-1-7">Tyler Olson/www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>The preventive services provisions have proven crucial for all women in America. Annually, <a href="https://obamacarefacts.com/obamacare-womens-health-services/">six million women</a> receive mammograms through Medicare free of charge. <a href="https://obamacarefacts.com/obamacare-womens-health-services/">Forty-seven million privately insured women</a> are also eligible for the free service.</p>
<p>An <a href="https://nwlc.org/resources/women-and-health-care-law-united-states/">estimated 27 million nonelderly women received preventive services without a co-payment in 2011 and 2012</a>. An additional <a href="https://nwlc.org/resources/women-and-health-care-law-united-states/">38 million women with Medicare</a> received preventive services at no additional cost in 2011.</p>
<h2>Benefits and services</h2>
<p>Some of the most crucial advances from the ACA for women came in the form of insurance market reforms. </p>
<p>For the first time, women could no longer be denied coverage for <a href="https://theconversation.com/how-pre-existing-conditions-became-front-and-center-in-health-care-vote-77138">preexisting conditions</a> such as a C-section, being a survivor of breast or cervical cancer, or having received medical treatment for domestic or sexual violence.</p>
<p>Insurers were also required to provide comprehensive coverage to women because insurance plans have to include the so-called <a href="https://theconversation.com/essential-health-benefits-suddenly-at-center-of-health-care-debate-but-what-are-they-75125">Essential Health Benefits</a>. These minimum required benefits include such crucial components of health care as prescription drugs, inpatient care, mental health and substance abuse services, and pediatric oral and vision care. </p>
<p>For those women eligible for Medicaid, <a href="http://files.kff.org/attachment/Fact-Sheet-Medicaids-Role-for-Women">they now gained access to a comprehensive set of health benefits</a>. </p>
<p>Finally, the ACA eliminated annual and lifetime benefit limits for everyone. </p>
<h2>Helping pregnant women and mothers</h2>
<p>While beneficial for all women, the ACA has been particularly helpful for <a href="http://www.healthpolicyjrnl.com/article/S0168-8510(14)00260-7/abstract">mothers and pregnant women</a>. In addition to providing coverage and reducing costs, the ACA also guaranteed mothers and pregnant women access to crucial benefits.</p>
<p>Under the <a href="http://www.healthpolicyjrnl.com/article/S0168-8510(14)00260-7/abstract">Essential Health Benefit provisions</a>, insurers had to provide coverage for pregnancy, maternity and newborn care. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/176286/original/file-20170629-16069-z58qsp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/176286/original/file-20170629-16069-z58qsp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/176286/original/file-20170629-16069-z58qsp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/176286/original/file-20170629-16069-z58qsp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/176286/original/file-20170629-16069-z58qsp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/176286/original/file-20170629-16069-z58qsp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/176286/original/file-20170629-16069-z58qsp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Maternity benefits are costly, but the Affordable Care Act brought their costs down.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pregnant-woman-doctor-hospital-388590370?src=LnkQko4fQ1kVFzHh_2vIpQ-1-11">Africa Studio/www.shutterstock.com</a></span>
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<p>With the premium cost of maternity care estimated at <a href="https://www.americanprogress.org/issues/healthcare/news/2017/06/20/434670/senate-health-care-bill-drive-coverage-costs-maternity-care-mental-health-substance-use-disorder-treatment/">more than US$17,000</a>, these guarantees were undeniably important. Not surprisingly, previously only <a href="https://nwlc.org/resources/women-and-health-care-law-united-states/">12 percent of individual market plans</a> included maternity benefits.</p>
<p>Moreover, women are able to access these services because preventive and prenatal services are now covered free of charge.</p>
<p>Insurers are now required to provide new mothers with equipment to extract breast milk and the support services to do so. In addition, employers are now required to provide the time and appropriate space for working women to extract the milk.</p>
<p>Finally, the ACA also supports women in planning their families. One important component was the elimination of out-of-pocket costs for contraception reducing the number of women who had to shoulder that burden from <a href="http://files.kff.org/attachment/Issue-Brief-Ten-Ways-That-the-House-American-Health-Care-Act-Could-Affect-Women">more than 20 percent to 3 percent</a>.</p>
<h2>Changes under the Republican proposals</h2>
<p>Famously excluding both women and Democrats from their secret deliberations, it is perhaps not surprising that the Senate repeal and replace proposal is particularly damaging to women’s health. While all Americans will be affected by the change, the damage for America’s women is particularly striking, as the <a href="https://www.cbo.gov/publication/52849">just-released CBO score</a> confirmed.</p>
<p>Rolling back coverage expansions will force millions of women into uninsurance. Eliminating financial support will reduce access to insurance coverage and services. </p>
<p>And undoing insurance market reforms will eliminate crucial benefits from women’s health plans and prevent them from purchasing adequate insurance coverage that fulfills their health needs. </p>
<p>Cuts to Planned Parenthood will reduce access to crucial reproductive and health services that have nothing to do with abortions.</p>
<p>Because of congressional restrictions, neither the Senate nor the House bill can fully undo the ACA. Yet the detrimental effect of a Republican bill’s passage on Americans is now well-established. </p>
<p>Moreover, we should not forget that <a href="https://theconversation.com/how-trump-and-tom-price-can-kill-obamacare-without-the-senate-76489">further regulatory actions</a> and the <a href="https://theconversation.com/beyond-the-cbo-score-how-trump-budget-and-the-ahca-are-dismantling-americas-safety-net-78308">Trump administration’s budget</a> are bound to further reduce coverage and eliminate benefits for male and female Americans alike.</p>
<p>Without the crucial protections of the ACA, America’s women – our mothers, grandmothers, wives, daughters, sisters, neighbors and friends – will be worse off. So will the rest of America.</p><img src="https://counter.theconversation.com/content/79819/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Almost nine million women gained insurance coverage from the Affordable Care Act. Here’s why women could be set back by Republican bills to undo the ACA.Simon F. Haeder, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/801752017-06-29T00:43:13Z2017-06-29T00:43:13ZRepublican health care bills defy the party’s own ideology<figure><img src="https://images.theconversation.com/files/175914/original/file-20170627-24813-1dsbdu5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Senate Majority Leader Mitch McConnell, who announced June 27 that a vote on the Senate health care bill has been delayed until after the July 4 recess.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Congress-Health-Overhaul/36b1273fd7f24263858fdab35af5dacd/14/0">Carolyn Kaster/AP</a></span></figcaption></figure><p>The Senate’s health care proposal made it clear that Republicans, despite their rhetoric, are not interested in market-based reform. Instead, they prefer pro-business, pro-privileged reform. </p>
<p>With Senate Republicans <a href="http://www.politico.com/story/2017/06/27/republicans-key-repeal-vote-delay-240010">planning to rewrite</a> their bill, it’s hard to predict the details of the final proposal. Nonetheless, gauging the House and Senate bills, one can guess that the broad outlines of the final package will be similar. </p>
<p>Because Senate Republicans proposed <a href="https://www.nytimes.com/2017/06/22/us/politics/senate-health-care-bill.html">reducing Medicaid coverage and health care exchange subsidies</a> for low-income individuals, reaction to their bill from consumers, patient advocates and pundits has been <a href="http://www.businessinsider.com/what-doctors-think-of-republican-healthcare-plan-2017-5">overwhelmingly negative</a>. But missing from the national discussion is how the GOP’s legislation also fails to do what party leaders promised their voters. </p>
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<p>Republicans have repeatedly assured their base that repealing the Affordable Care Act (ACA) will solve health care cost problems by returning the system to a <a href="http://www.heritage.org/health-care-reform/report/competitive-markets-health-care-the-next-revolution">land of competitive markets</a>. But out-of-control medical costs have been an issue at least since the 1950s. Moreover, the health care system was not based on market forces even before the ACA’s passage. </p>
<h2>Breaks for the rich, rollbacks for the poor</h2>
<p>To pay for expanded coverage, the ACA raised taxes on drug and insurance companies while imposing an excise tax on the sale of medical devices. It also <a href="http://www.foxbusiness.com/features/2017/06/22/senate-health-bill-gives-huge-tax-cuts-to-businesses-high-income-households.html">levied a special investment tax</a> and an income surcharge on individuals earning over US$200,000 a year. </p>
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<img alt="" src="https://images.theconversation.com/files/175917/original/file-20170627-7455-s7wpmj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/175917/original/file-20170627-7455-s7wpmj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=416&fit=crop&dpr=1 600w, https://images.theconversation.com/files/175917/original/file-20170627-7455-s7wpmj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=416&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/175917/original/file-20170627-7455-s7wpmj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=416&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/175917/original/file-20170627-7455-s7wpmj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=522&fit=crop&dpr=1 754w, https://images.theconversation.com/files/175917/original/file-20170627-7455-s7wpmj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=522&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/175917/original/file-20170627-7455-s7wpmj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=522&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Taxes on drug companies, such as AstraZeneca, helped pay for expanded health insurance coverage under the Affordable Care Act.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/521453077?src=2FR_QUCwjR_H025maLluWg-1-0&size=huge_jpg">From www.shutterstock.com</a></span>
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<p>The Senate’s proposal seeks to <a href="http://www.politifact.com/truth-o-meter/article/2017/jun/22/senate-health-care-bill-whats-it/">rescind these taxes</a>, granting financial relief to both corporations and the rich. </p>
<p>The result is that the aged and those at the lower end of the earning scale stand to lose benefits. For example, the GOP bill would <a href="http://www.politifact.com/truth-o-meter/article/2017/jun/22/senate-health-care-bill-whats-it/">roll back Medicaid coverage</a> and decrease the income threshold necessary to qualify for subsidies on the ACA’s state exchanges – from 400 percent of the <a href="https://www.nytimes.com/2017/06/22/us/politics/senate-health-care-bill.html">federal poverty line</a> to 350 percent.</p>
<p>Both the House and Senate proposals would change the formula for <a href="https://www.nytimes.com/2017/06/22/us/politics/senate-health-care-bill.html">how subsidies are calculated</a>, with an overall effect of reducing them. </p>
<p>The Senate bill would also <a href="http://www.politifact.com/truth-o-meter/article/2017/jun/22/senate-health-care-bill-whats-it/">eliminate the individual mandate</a> to purchase insurance and continue requiring that insurers accept applicants with preexisting conditions. </p>
<p>To prevent the state exchanges from being left with only the sickest policyholders and even more rapidly rising premium prices, a proposal introduced on June 26 institutes a waiting period. Anyone who allowed their insurance to <a href="http://www.cnbc.com/2017/06/26/us-senate-republicans-to-issue-revised-health-care-bill-senate-aide.html">lapse for more than 63 days</a> would have to wait six months for their new policy’s coverage to kick in.</p>
<h2>The Republicans’ political problem</h2>
<p>The House and Senate bills obliterate the idea – for which their party purportedly stands – of competitive markets lowering prices and enhancing consumer welfare. That’s both a political and a policy problem for Republicans.</p>
<p>In the U.S. health care system, neither public officials nor market forces order <a href="https://www.amazon.com/Ensuring-Americas-Health-Creation-Corporate/dp/1107622875/ref=mt_paperback?_encoding=UTF8&me=">pricing and delivery</a>. Instead, a messy mixture of government and private-sector power has evolved over decades. This framework has driven up costs so high that the average family now pays over $18,000 a year for insurance. </p>
<p>A key component of this unwieldy public-private system is the insurance industry’s dominance over health care. </p>
<p>Many people assume that insurance companies play a natural function in the financing and organization of health services. Yet <a href="https://www.amazon.com/Ensuring-Americas-Health-Creation-Corporate/dp/1107622875/ref=mt_paperback?_encoding=UTF8&me=">insurers did not gain</a> their central position through competitive market processes that sought efficiency. As I wrote in a previous <a href="https://theconversation.com/why-insurance-companies-control-your-medical-care-62540">article for The Conversation</a>, in the early part of the 20th century, the American Medical Association (AMA) swept away a bevy of elegant and cost-effective health care arrangements, which they branded “commercial” and “unethical.” </p>
<p>To replace these health care programs, AMA leaders designed the insurance company model at the end of the 1930s. The insurance company model pushed up costs because it <a href="https://theconversation.com/why-insurance-companies-control-your-medical-care-62540">incentivized doctors</a> to run up a bill that they then sent off to a faraway, faceless corporation.</p>
<p>One reason the insurance company model took hold is that <a href="https://theconversation.com/why-insurance-companies-control-your-medical-care-62540">federal tax policy rewarded companies</a> for providing employees with fringe benefits, including medical insurance. This tax subsidy spread insurance coverage to more people, helped along by the fact that escalating prices were largely hidden from consumers who usually split premium costs with their employer. </p>
<p>As the insurance company model expanded, rapidly mounting medical costs compelled insurers to extend their influence over health care. Over the course of many decades, insurers evolved beyond simply financing health services to also supervising physicians and regulating medical care – all in the name of cost containment. The insurance company model grew. And both the 1965 Medicare program and the 2010 ACA incorporated its logic.</p>
<p>Despite this history, the Republicans’ legislation neglects structural changes, somehow imagining that 2009, the year before the ACA passed, represented halycon days for the U.S. health care system.</p>
<p>True, it’s helpful that Republicans propose reducing ACA requirements so that consumers are permitted to purchase good, but not necessarily gold-plated, coverage. Consumers would instead be able to choose lower-priced policies with smaller deductibles in lieu of high-cost policies with more generous benefits – for example, mental health and drug rehabilitation coverages – that are nonetheless difficult to tap into because of high annual deductibles. But this policy change is weak medicine to remedy our ailing system. Do Republicans really believe that changing mandatory benefits guidelines will be the one tweak that finally gets our country’s health care costs under control?</p>
<p>At bottom, Republican proposals have left vulnerable populations either without coverage or with reduced benefits, but still trapped inside a high-cost system. </p>
<p>This is a key weakness before the Republican base and before conservative ideologues. For many low-income individuals, no amount of bootstrapping or hard work ethic will get them adequate health insurance because coverage is simply too expensive. And that flies in the face of the Republican political narrative.</p>
<h2>Does this make economic sense?</h2>
<p>Republicans may be too timid or lack the votes to advance structural reform. And they may feel it necessary to prop up insurance companies struggling with the costs of insuring high-risk patients. That’s a fair calculation.</p>
<p>But are they ready to create a health care system that aids every group except the working poor? The wealthy will have their health care and their tax cuts. The middle classes will continue to enjoy expensive, generous insurance that’s indirectly funded through the tax code. And insurance companies will accept whatever assistance the government provides – from tax cuts to coverage penalty periods – to continue increasing their authority over the medical system. </p>
<p>That’s an arrangement that leaves out the very groups that are most desperate for health care reform: lower-income families and the working poor.</p><img src="https://counter.theconversation.com/content/80175/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christy Ford Chapin receives funding from Johns Hopkins University, the University of Maryland College Park, the Harvard Business School, and the Library of Congress.</span></em></p>The health care bill proposed by Senate Republicans was little better than the House version, which begs an important question: Who’s driving health care law – a free market or insurance companies?Christy Ford Chapin, Visiting scholar at Johns Hopkins University and Assistant Professor of History, University of Maryland, Baltimore CountyLicensed as Creative Commons – attribution, no derivatives.