tag:theconversation.com,2011:/fr/topics/american-health-care-act-36661/articlesAmerican Health Care Act – The Conversation2018-04-09T10:42:34Ztag:theconversation.com,2011:article/946032018-04-09T10:42:34Z2018-04-09T10:42:34ZWhy the extreme reaction to Obamacare could be the new normal in American politics<figure><img src="https://images.theconversation.com/files/213718/original/file-20180408-5578-1ltph46.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">House Speaker Paul Ryan's attempt to replace the Affordable Care Act in March 2017 was just one of many to undo the health law.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Helth-Care/0197e2b0af014a528f3d40b9eb630e62/5/0">AP Photo/Susan Walsh</a></span></figcaption></figure><p>It has been more than eight years since the <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/j.1541-0072.2012.00446.x">passage of the Affordable Care Act</a>. Many may not remember the tumultuous scenes in Washington, D.C., and around the nation that preceded its passage. <a href="https://www.npr.org/sections/itsallpolitics/2013/08/07/209919206/5-memorable-moments-when-town-hall-meetings-turned-to-rage">Town halls</a> from Iowa to California turned into shouting matches. <a href="https://www.theguardian.com/world/2009/aug/12/healthcare-town-halls-obama">Signs comparing President Barack Obama to Hitler and Stalin</a> were waved at demonstrations. Angry seniors demanded to <a href="https://www.huffingtonpost.com/bob-cesca/get-your-goddamn-governme_b_252326.html">“keep your government hands off my Medicare”</a> in protesting the ACA.</p>
<p>Yet, we have seen few signs of abatement since President Obama signed the bill into law. Indeed, just weeks ago, <a href="https://theconversation.com/republicans-attacking-obamacare-one-more-time-92568">20 states filed a lawsuit seeking to overturn the Affordable Care Act.</a> It seems hardly a week goes by without <a href="https://www.washingtonpost.com/blogs/plum-line/wp/2018/02/20/another-day-another-trump-attack-on-the-affordable-care-act/">President Trump attacking his predecessor’s signature accomplishment</a>.</p>
<p>One of the hotbeds of resistance can be found in a small group of members of Congress, particularly in the House of Representatives. These legislators have shown little interest in letting up their opposition to kill the law. What is driving this persistence?</p>
<p>Our <a href="https://read.dukeupress.edu/jhppl/article/43/2/271/133583/How-Intense-Policy-Demanders-Shape-Postreform">recent article published in the Journal of Health Policy, Politics, and Law</a> shows that the driving force behind the continued repeal effort has been what political scientists call “intense policy demanders.” These are mobilized activists who use their control of important electoral resources to shape the policy agenda. </p>
<p>Our analysis shows that when it comes to the ACA, extremists have defined the politics of repeal and replace in fundamental ways.</p>
<h2>What Republicans have done to make the ACA fail</h2>
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<img alt="" src="https://images.theconversation.com/files/213720/original/file-20180408-5578-1wzx7tj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/213720/original/file-20180408-5578-1wzx7tj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/213720/original/file-20180408-5578-1wzx7tj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/213720/original/file-20180408-5578-1wzx7tj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/213720/original/file-20180408-5578-1wzx7tj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/213720/original/file-20180408-5578-1wzx7tj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/213720/original/file-20180408-5578-1wzx7tj.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">Opposition to the ACA has been fierce from some groups, even though the law is popular with millions.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/caldwell-idahousa-december-6-view-healthcare-166155479?src=XljaEiHYyJiYBiAt8FBoZQ-1-2">txking/Shutterstock.com</a></span>
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<p>Of course, Republican opposition has not emerged from Congress alone. Many <a href="http://onlinelibrary.wiley.com/doi/10.1111/puar.12065/full">Republican-controlled state legislatures and governors</a> have done their fair share to oppose the implementation of the ACA.</p>
<p><a href="https://read.dukeupress.edu/jhppl/article-abstract/40/2/281/13726">Dozens of lawsuits have been filed</a> seeking to overturn parts or the entirety of the health law. <a href="https://read.dukeupress.edu/jhppl/article-abstract/40/2/281/13726">Many states have refused to establish insurance marketplaces or expand their Medicaid program</a>. </p>
<p>Various states have passed <a href="http://onlinelibrary.wiley.com/doi/10.1111/puar.12065/full">have prevented state employees from cooperating with the federal government</a> in any implementation activities. </p>
<p>Most recently, states like <a href="https://www.washingtonpost.com/national/health-science/idaho-tests-the-bounds-of-skirting-affordable-care-act-insurance-rules/2018/02/27/114157da-1266-11e8-9570-29c9830535e5_story.html">Idaho</a> and <a href="http://www.modernhealthcare.com/article/20180405/NEWS/180409944">Iowa</a> are seeking to allow the sale of low-quality insurance products prohibited under the ACA.</p>
<p>Since taking office, the <a href="https://theconversation.com/trump-isnt-letting-obamacare-die-hes-trying-to-kill-it-81373">Trump administration has also taken a slew of actions</a> seeking to damage and undo much of the ACA.</p>
<p>In a <a href="https://theconversation.com/trump-isnt-letting-obamacare-die-hes-trying-to-kill-it-81373">concerted effort</a>, administration officials sought to <a href="https://theconversation.com/trump-isnt-letting-obamacare-die-hes-trying-to-kill-it-81373">raise uncertainty</a> about the future of the health law by making a slew of false and misleading statements about the ACA. </p>
<p>Next, the Trump administration relaxed <a href="https://www.fiercehealthcare.com/practices/trump-administration-let-states-decide-if-health-plans-have-enough-doctors">oversight of provider networks</a> in the insurance marketplaces to undoing the <a href="https://www.cosmopolitan.com/politics/a19601266/cecile-richards-make-trouble-affordable-care-act/">ACA’s contraception coverage requirements</a>. </p>
<p>The withholding of so-called <a href="https://theconversation.com/republicans-attacking-obamacare-one-more-time-92568">cost-sharing subsidies</a> temporarily threw many of the nation’s insurance markets into turmoil. The markets seem to have stabilized by now. However, actions by the Trump administration to allow the purchase of <a href="https://www.usatoday.com/story/opinion/2018/04/04/small-businesses-more-choices-association-health-plans-column/464059002/">association-based</a> and <a href="http://www.philly.com/philly/health/health-cents/short-term-health-plans-will-undermine-the-aca-20180314.html">short-term</a> health plans may lead to more harm for insurance markets. </p>
<h2>Republican opposition in the House</h2>
<p><a href="https://read.dukeupress.edu/jhppl/article/43/2/271/133583/How-Intense-Policy-Demanders-Shape-Postreform">Our research</a> focuses on opposition to the ACA by Republicans in Congress. Unlike opposition in the states and in the courts, this component has gained little scholarly attention so far.</p>
<p>We argue that much of the persistence of Republican resistance can be attributed to intense policy demanders. These ideological extremists include groups like the Koch-funded <a href="https://americansforprosperity.org">Americans for Prosperity</a>, think tanks like the <a href="https://www.heritage.org">Heritage Foundation</a>, and political action committees like <a href="https://www.clubforgrowth.org/about/club-for-growth-action/">Club for Growth Action</a>. They are often intensely focused on a limited set of issues.</p>
<p>Using the resources at their disposal, they support like-minded individuals in return for loyalty commitments. These resources include campaign contributions and endorsements.</p>
<p>The <a href="https://read.dukeupress.edu/jhppl/article/43/2/271/133583/How-Intense-Policy-Demanders-Shape-Postreform">first part of our analysis</a> looks at the introduction of bills seeking to overturn all or part of the ACA. </p>
<p>Our findings show that contributions by businesses are the <a href="https://read.dukeupress.edu/jhppl/article/43/2/271/133583/How-Intense-Policy-Demanders-Shape-Postreform">most important predictor of bill introductions</a> for this part of the repeal effort. This particularly holds for bills seeking major changes to the ACA. The <a href="https://read.dukeupress.edu/jhppl/article/43/2/271/133583/How-Intense-Policy-Demanders-Shape-Postreform">most conservative members</a> of the Republican Party were also the ones seeking to undo the ACA.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/213721/original/file-20180408-5575-omj4x9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/213721/original/file-20180408-5575-omj4x9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=413&fit=crop&dpr=1 600w, https://images.theconversation.com/files/213721/original/file-20180408-5575-omj4x9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=413&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/213721/original/file-20180408-5575-omj4x9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=413&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/213721/original/file-20180408-5575-omj4x9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=519&fit=crop&dpr=1 754w, https://images.theconversation.com/files/213721/original/file-20180408-5575-omj4x9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=519&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/213721/original/file-20180408-5575-omj4x9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=519&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">House Freedom Caucus Chairman Mark Meadows, R-N.C., led efforts to pass the American Health Care Act in March 2017.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Congress-Tax-Overhaul/9abee96b14f3481ea8cd72dfdb4b6fd9/62/0">AP Photo/J. Scott Applewhite</a></span>
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<p>The <a href="https://read.dukeupress.edu/jhppl/article/43/2/271/133583/How-Intense-Policy-Demanders-Shape-Postreform">second part of our research</a> analyzed the first major Republican repeal effort under the Trump administration, the American Health Care Act. We particularly looked at the role of the <a href="http://www.pewresearch.org/fact-tank/2015/10/20/house-freedom-caucus-what-is-it-and-whos-in-it/">Freedom Caucus</a> because it is the group most aligned with these intense policy demanders.</p>
<p>When it was first introduced in March of 2017, the <a href="https://theconversation.com/essential-health-benefits-suddenly-at-center-of-health-care-debate-but-what-are-they-75125">American Health Care Act</a>, proved decidedly too liberal for groups like the Heritage Foundation and Americans for Prosperity. Indeed, they were vocal in their opposition as they referred to it as “<a href="https://www.washingtonpost.com/news/powerpost/wp/2017/03/07/obamacare-lite-rinocare-conservatives-rebel-against-gops-aca-bill/?utm_term=.f75c71a9ee1d">Obamacare Lite</a>.” As a result, membership in the Freedom Caucus <a href="https://read.dukeupress.edu/jhppl/article/43/2/271/133583/How-Intense-Policy-Demanders-Shape-Postreform">proved the overwhelming predictor</a> of initial Republican opposition. </p>
<p>Seeking to salvage their efforts, Republicans were able to negotiate a compromise by the end of April 2017. The so-called MacArthur amendment allowed states to opt out of almost all the requirements of the ACA. Most of the Freedom Caucus, along with <a href="https://read.dukeupress.edu/jhppl/article/43/2/271/133583/How-Intense-Policy-Demanders-Shape-Postreform">virtually all Republicans</a>, eventually voted for the bill.</p>
<p>Although not part of our analysis, the same dynamic of conservative opposition to “Obamacare Lite” also help to explain the inability of Senate leaders to advance their version ACA repeal, the <a href="https://www.budget.senate.gov/imo/media/doc/SENATEHEALTHCARE.pdf">Better Care Reconciliation Act (BCRA)</a>. The key vote on BCRA <a href="https://www.nytimes.com/interactive/2017/07/25/us/politics/senate-votes-repeal-obamacare.html">failed 43-57</a> because it alienated moderates like Sens. Susan Collins, R-Maine, and Lisa Murkowski, R-Ark. But it also failed because of opposition from conservative anti-ACA loyalists like <a href="https://www.lee.senate.gov/public/index.cfm/op-eds?ID=042777CA-538B-496D-AB0B-DA23999D78C8">Mike Lee, R-Utah,</a> and <a href="http://www.slate.com/blogs/the_slatest/2017/06/22/senate_conservatives_react_to_the_health_care_bill.html">Rand Paul, R-Ky.</a>, who believed the bill did not go far enough in rolling back the ACA. </p>
<h2>What we can learn from the Republican opposition to the ACA</h2>
<p>Our analysis of Republican resistance to the ACA in Congress holds lessons that go beyond the controversial health law.</p>
<p>The <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/j.1541-0072.2012.00446.x">Affordable Care Act came with many flaws</a>. These mishaps inhibited its swift and efficient implementation.</p>
<p>Yet its drafters were limited in what they could have done to stave off Republican opposition. No matter what design choices they would have made, the ACA was to trigger an asymmetric mobilization of ideological extreme partisan policy demanders. </p>
<p>Over the past years, we have seen the growing influence of intensely ideological and well-funded outside groups. As a result, the post-enactment partisan battle surrounding the ACA may become the new normal in American politics. </p>
<p>We believe there’s an important lesson here for policymakers. In a polarized world, <a href="https://www.degruyter.com/view/j/for.2017.15.issue-2/for-2017-0020/for-2017-0020.xml?format=INT">policy does not generate political support on its own</a>. Getting policy design decisions right and passing legislation is not enough to see it succeed. Policymakers need to expect persistent opposition and seek to find well-organied political allies beyond the Capitol.</p><img src="https://counter.theconversation.com/content/94603/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors 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>Efforts to undo Obamacare went far beyond grass-roots activities, with new research showing that contributions by businesses were significant. Does this signal a change in the political process?Simon F. Haeder, Assistant Professor of Political Science, West Virginia UniversityPhilip Rocco, Assistant Professor of Political Science, Marquette UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/780182017-06-27T01:06:20Z2017-06-27T01:06:20ZGOP health care bill would make rural America’s distress much worse<figure><img src="https://images.theconversation.com/files/175743/original/file-20170626-3062-1apmidn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Rural hospitals, such as this one in Wedowee, Alabama, are struggling to stay open.
</span> <span class="attribution"><span class="source">AP Photo/Brynn Anderson</span></span></figcaption></figure><p>Much has been made of the <a href="http://www.asanet.org/news-events/speak-sociology/more-rural-revolt-landscapes-distress-and-2016-presidential-election">distress</a> and <a href="http://www.reuters.com/article/us-usa-election-michigan-idUSKBN13621W">discontent</a> in rural areas during the 2016 U.S. presidential election. Few realize, however, this is also felt through unequal health. </p>
<p>Researchers call it the “<a href="https://www.ncbi.nlm.nih.gov/pubmed/18556611">rural</a> <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2901280/">mortality</a> <a href="http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2014.301989">penalty</a>.” While rates of mortality have steadily fallen in the nation’s <a href="http://www.pnas.org/content/113/7/E815.full">urban areas</a>, they have actually climbed for rural Americans. And <a href="http://www.washingtonpost.com/sf/national/2016/04/10/a-new-divide-in-american-death/?utm_term=.314f4a5d0e00">the picture is even bleaker</a> for specific groups, such as rural white women and people of color, who <a href="http://onlinelibrary.wiley.com/doi/10.1111/jrh.12181/full">face persistent disparities in health outcomes</a>. In every category, <a href="https://ruralhealth.und.edu/projects/health-reform-policy-research-center/pdf/2014-rural-urban-chartbook-update.pdf">from suicide to unintentional injury to heart disease</a>, rural residents’ health has been declining since the 1990s. </p>
<p>While some have blamed these <a href="https://theconversation.com/six-charts-that-illustrate-the-divide-between-rural-and-urban-america-72934?sr=6">gaping disparities</a> on “culture” or “lifestyle” factors – such as a supposed <a href="https://www.ncbi.nlm.nih.gov/pubmed/21834356">fatalism</a> or overconsumption of unhealthy products like <a href="http://www.salon.com/2012/08/10/dont_put_mountain_dew_in_a_baby_bottle/">Mountain Dew</a> – the truth is that the biggest culprit is limited access to health care and challenging economic circumstances. </p>
<p>The passage of the Affordable Care Act (ACA) in 2010 <a href="https://medium.com/usda-results/rural-health-day-f6aac8ad7be7">began to change this</a> as more rural Americans gained insurance coverage and the government invested more money into regional health facilities and training.</p>
<p>This progress <a href="https://theconversation.com/rural-america-already-hurting-could-be-most-harmed-by-trumps-promise-to-repeal-obamacare-71453?sr=4">is now at risk</a>, however, as the Republican Congress inches closer to repealing Obamacare and replacing it with a feeble alternative that greatly weakens rural health care access. As researchers who study the mental and physical health of rural Americans, we believe this would have disastrous consequences. </p>
<h2>The travails of rural America</h2>
<p>Even as <a href="https://theconversation.com/where-is-rural-america-and-what-does-it-look-like-72045?sr=1">rural America</a> feeds the country, <a href="http://www.npr.org/sections/thesalt/2017/05/22/529493413/in-some-rural-counties-hunger-is-rising-but-food-donations-arent">hunger is on the rise</a> in rural areas. </p>
<p>Some <a href="https://www.iatp.org/files/258_2_98043.pdf">98 percent of rural residents</a> live in food deserts – defined as counties in which one must drive more than 10 miles to get to the nearest supermarket. This makes it challenging to maintain healthy and nutritious diets, leading to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3481194/">higher rates of obesity in rural areas</a> that greatly increase the risk for diabetes, heart disease and certain cancers.</p>
<p>As rural workers struggle to <a href="https://www.wsj.com/articles/rural-america-struggles-as-young-people-chase-jobs-in-cities-1395890099">sustain employment</a> in a <a href="https://www.washingtonpost.com/news/wonk/wp/2016/05/22/a-very-bad-sign-for-all-but-americas-biggest-cities/?utm_term=.174ccab19701">shifting economy</a>, the increasing poverty is contributing to mental distress and <a href="http://journals.sagepub.com/doi/abs/10.1177/002204260703700302">substance use</a>. On a larger scale, the economic changes that have hit rural areas have resulted in a declining tax base, lower incomes and strained educational institutions. Together, they challenge rural residents’ health not just in the immediate term but cumulatively over their lives. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/175505/original/file-20170625-13475-1udmu6z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/175505/original/file-20170625-13475-1udmu6z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=428&fit=crop&dpr=1 600w, https://images.theconversation.com/files/175505/original/file-20170625-13475-1udmu6z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=428&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/175505/original/file-20170625-13475-1udmu6z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=428&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/175505/original/file-20170625-13475-1udmu6z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=538&fit=crop&dpr=1 754w, https://images.theconversation.com/files/175505/original/file-20170625-13475-1udmu6z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=538&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/175505/original/file-20170625-13475-1udmu6z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=538&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Like many other rural hospitals in the U.S., Evans Memorial in Claxton, Georgia, has struggled to keep its doors open while treating patients who tend to be older, poorer and often uninsured.</span>
<span class="attribution"><span class="source">AP Photo/Russ Bynum</span></span>
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</figure>
<h2>Barriers to accessing health care</h2>
<p>Yet, despite all these medical issues, rural residents have a tough time getting the health care they need.</p>
<p>The nature of rural employment, for example, is characterized by <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1748-0361.2005.tb00058.x/epdf">self-employment, seasonal work and lower-than-average pay</a>. This means rural workers are <a href="https://www.ruralhealthinfo.org/pdf/research_compendium.pdf">less likely to get insurance through their jobs and thus face higher premiums</a> when buying their own policies. </p>
<p>The lack of public transportation in most rural areas is also a major hurdle to seeing a doctor, particularly as residents <a href="https://www.ncbi.nlm.nih.gov/pubmed/16606425">have to travel much farther</a> than those in urban areas to reach health care providers.</p>
<p>Rural residents get most of their services through primary care providers, <a href="http://pediatrics.aappublications.org/content/118/1/e132">who take on the work of other practitioners</a>, like behavioral health clinicians, due to longstanding specialist shortages. When handling <a href="http://www.sciencedirect.com/science/article/pii/S0033318207710265">numerous complaints</a> during a single medical encounter, primary care providers may concentrate on the most acute health concerns of their patients, undermining the ability to diagnose all their conditions and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3609543/">meaningfully discuss their larger health risks</a>, such as exercise, weight and substance use. When providers are rushed or deliver sub-par care, rural residents may wonder if seeking it out is worth the challenge, <a href="https://www.ncbi.nlm.nih.gov/pubmed/27322157">opting to struggle on their own</a>. </p>
<p>These and other constraints make it tougher for rural Americans to get the screenings necessary to spot serious diseases such as <a href="http://www.tandfonline.com/doi/abs/10.1300/J013v42n02_06">cancer</a> early or to maintain adequate followup on conditions like <a href="https://www.ncbi.nlm.nih.gov/pubmed/24183213">hearing loss</a>. Finding the regular medical care necessary to manage chronic conditions, such as diabetes, <a href="https://www.ncbi.nlm.nih.gov/pubmed/27322157">depression</a> or <a href="https://www.hrsa.gov/advisorycommittees/rural/publications/opioidabuse.pdf">opioid disorders</a>, is even more challenging. </p>
<p>Rural health care has at times been <a href="https://www.ncbi.nlm.nih.gov/pubmed/18709749">characterized as patchwork</a>. In part, that’s because the <a href="https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/30/10/36/rural-health-goals-guaranteeing-a-future">costs of sustaining health care infrastructure in rural areas are higher</a> thanks to the large service areas, the inability to negotiate bulk pricing and lack of financial incentives to fill in provider gaps. </p>
<h2>The ACA and the AHCA</h2>
<p>The ACA, intended to turn this around, has in fact led to dramatic gains in insurance coverage among rural Americans. </p>
<p>Broadly speaking, insurance rates in rural areas <a href="http://hrms.urban.org/quicktakes/Substantial-Gains-in-Health-Insurance-Coverage-Occurring-for-Adults-in-Both-Rural-and-Urban-Areas.html">reached almost 86 percent</a> in early 2015, up from an estimated 78 percent in 2013.</p>
<p>In Kentucky – a state with high poverty, a large rural population (42 percent of residents) and a successful <a href="https://theconversation.com/love-it-or-hate-it-obamacare-has-expanded-coverage-for-millions-66472?sr=2">Medicaid expansion</a> initiative – <a href="http://www.cbpp.org/blog/medicaid-at-50-kentuckys-experience-highlights-benefits-of-medicaid-expansion">tens of thousands of newly insured low-income adults</a> began using preventative services after previously being unable to afford it. The state’s uninsured fell by half and, as a result, <a href="http://content.healthaffairs.org/content/35/1/96.abstract">fewer people skipped taking their medications</a> due to financial hardships relative to other states that didn’t expand Medicaid. </p>
<p>The ACA also <a href="http://www.scholarsstrategynetwork.org/brief/how-obamacare-repeal-would-harm-rural-america">strengthened rural health care institutions</a> by investing in upgrades to hospitals and clinics, preventative health programs and support for providers to stay in rural areas. While rural hospitals are often laden with the expense of providing extensive care without payment to indigent patients, rural hospitals in states that expanded Medicaid under the ACA <a href="http://www.cbpp.org/research/health/house-passed-bill-would-devastate-health-care-in-rural-america?utm_source=CBPP+Email+Updates&utm_campaign=d303d5c441-EMAIL_CAMPAIGN_2017_05_16&utm_medium=email&utm_term=0_ee3f6da374-d303d5c441-110964945">finally were able to better balance their books when caring for this vulnerable group</a>. At the same time, the ACA supported innovative models ideal for rural areas that prioritized <a href="https://www.ncbi.nlm.nih.gov/pubmed/18709749">outreach</a>, <a href="http://content.healthaffairs.org/content/29/5/852.abstract">integration of services</a> and <a href="http://nashp.org/wp-content/uploads/2016/09/Rural-Opioid-Primer.pdf">collaboration between safety-net players</a>.</p>
<p>Both the <a href="https://www.washingtonpost.com/graphics/2017/politics/obamacare-senate-bill-compare/">House and Senate</a> bills to repeal and replace Obamacare would <a href="http://www.scholarsstrategynetwork.org/brief/how-obamacare-repeal-would-harm-rural-america">drastically reduce rural Americans’ insurance coverage</a> and significantly threaten the ability of <a href="http://www.npr.org/sections/health-shots/2017/06/22/533680909/republicans-proposed-medicaid-cuts-would-hit-rural-patients-hard">many rural hospitals and clinics to keep their doors open</a>. <a href="http://www.cbpp.org/research/health/house-passed-bill-would-devastate-health-care-in-rural-america">Analysts show</a> that the bill would provide insufficient tax credits to pay for rural premium costs, drastically increase the price of rural premiums and increase uncompensated care in rural hospitals. </p>
<h2>What rural areas need from health care reform</h2>
<p>Previous efforts at health care reform show us that rural areas are uniquely vulnerable. Efforts need to take account not only of coverage and access – as has been the focus of the current debate – but also how reform affects rural health care institutions and the larger social factors shaping overall health.</p>
<p>The particular economic factors affecting rural health care institutions <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3415203/">make rural areas particularly vulnerable to political shifts</a> that disrupt services for existing patients and for those newly insured, creating immense challenges for rural providers. Steps that fail to account for the impact of financial hardship on these institutions not only hurt their bottom line but contribute to <a href="https://www.ncbi.nlm.nih.gov/pubmed/22229021">poor morale and workforce turnover</a> and larger-scale decisions to reduce services, which decrease their ability to address patient needs. </p>
<p>At the same time, commitment to improving the health of rural Americans requires attention to the so-called upstream factors shaping rural health. That means <a href="http://www.prnewswire.com/news-releases/medicaid-plays-a-more-significant-role-in-small-towns-and-rural-communities-than-in-metro-areas-300469734.html">preserving the safety net programs so vital in rural areas</a> with underemployment and low-paying jobs, <a href="http://www.soar-ky.org/about-us">strengthening rural economies</a> and investing in <a href="https://www.brookings.edu/blog/brown-center-chalkboard/2017/01/04/a-better-future-for-rural-communities-starts-at-the-schoolhouse/">high-quality education</a>. </p>
<p>If our leaders are serious about reform that will lessen the rural-urban mortality gap, they should recognize the unique needs of rural America and ensure health care policy reflects how vital access to quality care is to their financial success – not to mention their well-being.</p><img src="https://counter.theconversation.com/content/78018/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors 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>Health outcomes for rural Americans have steadily deteriorated in recent decades even as they’ve improved elsewhere. The GOP plan to replace the Affordable Care Act will worsen the problem.Claire Snell-Rood, Assistant Professor of Public Health, University of California, BerkeleyCathleen Willging, Adjunct Associate Professor of Anthropology, University of New MexicoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/790722017-06-11T20:17:44Z2017-06-11T20:17:44ZHow Obamacare may morph into Medicaid<p>The slow-motion <a href="http://www.cnn.com/2017/06/06/politics/republican-health-care/index.html">consideration by Congress</a> and the president to change the Affordable Care Act is likely to produce surprising results. The insurance market does not go into suspended animation while Washington debates. </p>
<p>In fact, starting this month, insurers face a series of filing deadlines that will determine what comes next for health insurance plans in the ACA marketplace. <a href="http://www.businessinsider.com/anthem-obamacare-exchange-exit-from-ohio-2017-6">Anthem’s plan to exit</a> from the Ohio Obamacare individual insurance exchange is just the next act in a long-running drama of insurers and the ACA. </p>
<p>As a former insurance CEO and a professor of health finance, I see trouble lurking. President Trump predicted the exchanges would collapse. But what he didn’t say is that he’d help make sure that happens. The end result may be many people will rejoin the ranks for of the uninsured.</p>
<h2>Premiums and subsidies on the Obamacare exchanges</h2>
<p>Let’s step back a little to consider how the ACA exchanges actually work. </p>
<p>If the <a href="http://www.kff.org/health-reform/issue-brief/insurer-participation-on-aca-marketplaces-2014-2017/">dwindling number of insurance companies</a> still offering plans under Obamacare want to continue next year, they must file their designs and premiums with their states and the federal government now. Open enrollment for people to sign up for insurance on these exchanges then starts in the fall. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/172997/original/file-20170608-32392-rozjng.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/172997/original/file-20170608-32392-rozjng.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/172997/original/file-20170608-32392-rozjng.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/172997/original/file-20170608-32392-rozjng.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/172997/original/file-20170608-32392-rozjng.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/172997/original/file-20170608-32392-rozjng.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/172997/original/file-20170608-32392-rozjng.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">The 2017 website from which consumers could enroll in health care plans under the Affordable Care Act.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/caldwell-idaho-november-9-2016-healthcare-513017347?src=VaFfwdWZW8V1pQacMRM0YQ-1-8">txking/From www.shutterstock.com</a></span>
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</figure>
<p>These plans must fit into four actuarial categories. The first category, called platinum level, is for plans that cover 90 percent of the estimated full cost of medical expenses; gold plans cover 80 percent; silver plans cover 70 percent; and bronze plans cover 60 percent.</p>
<p>Insurance companies have the option of pulling these plans from the exchanges in September if they wish, based on their actual medical costs incurred and resulting gains or losses in the current year. In other words, if their numbers indicate they cannot make a profit, health insurance providers can leave. This is important, since insurers are making broad guesses regarding projected costs and premiums for consumers when they file so early, with little experience to back their decisions.</p>
<p>This year, they have much less certainty regarding the ground rules and subsidies on the exchanges. If they make the reasonable assumption that the government will <a href="http://www.npr.org/2017/05/04/526923181/gop-health-care-bill-would-cut-about-765-billion-in-taxes-over-10-years">cut back on their subsidies</a>, as Republicans have indicated they will, the premiums they set now must reflect this additional risk in the future, since insurers will still be legally committed to their filings. Judging from early indications, this additional uncertainty will drive up <a href="https://www.bna.com/obamacare-premiums-estimated-n57982086939/">premiums over 20 percent</a>, although the underlying general increases in <a href="http://www.milliman.com/mmi/">health care costs are less than 5 percent</a>.</p>
<p>On top of this, the additional <a href="https://www.nytimes.com/2017/05/22/us/politics/health-care-subsidies-trump.html">cost sharing reduction</a> (CSR) subsidies under the silver plans are literally being held <a href="https://www.wsj.com/articles/trump-threatens-to-withhold-payments-to-insurers-to-press-democrats-on-health-bill-149202984">hostage by the president</a>. A pending court case and President Trump’s statements give credibility to the threat of withholding these payments. </p>
<p>The loss of these would require additional premium <a href="http://www.kff.org/health-reform/issue-brief/the-effects-of-ending-the-affordable-care-acts-cost-sharing-reduction-payments/">increases of 19 percent to offset the reduced government support</a>. </p>
<p>These subsidies are critical to the many people buying silver plans since they reduce the average out-of-pocket cost of copays and deductibles radically from the standard 30 percent (i.e., the part not covered by the silver plans) to only 6 percent for the lowest-income people and somewhat higher for those with greater income. </p>
<h2>The insurers’ dilemma</h2>
<p>As a former CEO of an insurance company, I can say that this would create a huge dilemma for me. Premiums must be sufficient to cover likely costs, or I will lose my job!</p>
<p>But I don’t know what costs will be, and now I can only guess at what subsidies will be available. So, I must file rates that cover the most extreme possibilities.</p>
<p>The resulting high premiums will be excessive for those not receiving subsidies. These folks most likely will just revert to their former uninsured status.</p>
<p>This will leave only those low-income purchasers whose subsidies under the ACA will automatically rise to offset the higher premiums, leaving the net cost to the working poor the same based on the percentage of their income that is deemed “affordable.” </p>
<p>In fact, since enrollees’ incomes haven’t risen, their net payment for silver plans after these subsidies has remained flat for three years. An insurer, then, can raise premiums as much as it needs to, and the net price to most of those low income people still purchasing plans will still look like a great deal.</p>
<p>The problem for government is that its expenditures may not drop even with lower enrollments, since the people now receiving subsidies are likely to continue to buy policies while those without this assistance drop out. </p>
<p>Ironically, due to the resulting much higher premiums, it is likely that the total cost to the government will be even bigger since the subsidies required for low-income people will shoot up. The difference is that choices will be dramatically reduced, and everyone else will be priced out of the market! Far fewer people will actually be insured.</p>
<h2>Net result of delay and uncertainty</h2>
<p>The result of this mess is likely to be a radical change in the exchanges and those who sell insurance through them. Insurers will fall into one of three categories. </p>
<p>First are those like <a href="http://money.cnn.com/2016/04/19/investing/unitedhealthcare-obamacare-exchanges-aca/index.html">United Healthcare</a>, who entered the exchanges late and left early. They bet on failure or loss of government support from the outset. More are joining this camp by completely withdrawing. But this isn’t due to an inevitable failure of Obamacare, as the president maintains. Instead, it’s due to the withdrawal of promised market support and uncertainty fostered by the delays. </p>
<p>Second are those who are uncertain about the future but want to keep their options open. Most of these firms will file plans this month with very high premiums as placeholders but with a significant probability of withdrawal in the fall when it is clearer what will happen in the policy world. If no changes to the ACA occur in a stalemated Congress, this strategy may pay off handsomely due to their higher premiums and continuing subsidies. However, some courageous insurers might file lower premiums to be more competitive and then withdraw if conditions warrant it.</p>
<p>The third set are those insurers who are betting that the CSR subsidies will be canceled, but who think higher premiums will be enough to offset the loss of this income. With the exit of most or all of their competitors, they would pick up market share and do just fine.</p>
<p>In any event, the delay and uncertainty, along with predicted reactions of insurers, will guarantee that only low-income working people who are eligible for subsidies will be covered by exchange plans. </p>
<p>Ironically, these are akin to the folks that Medicaid covers now but at a higher level of income than what would qualify for coverage normally. Thus, the result of the impending meltdown of the exchanges may be effectively an extension of Medicaid-type coverage to a greater number of working poor than we have now. </p>
<p>By destroying the initial thrust of the ACA exchanges to give affordable options to everyone regardless of income or health status, we may effectively wind up just extending our current and revamped Medicaid programs for the poor to those with somewhat higher incomes – an ironic result for those bent on reducing Medicaid. But this would come at the cost of returning the individual markets for everyone else to their former dysfunctional state.</p>
<p>And this all may happen by default while the debate goes on rather than by design. </p>
<p>Is this the way to do health policy?</p><img src="https://counter.theconversation.com/content/79072/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>JB Silvers is affiliated with MetroHealth Medical Center and Case Western Reserve University.</span></em></p>Senate Republicans have been trying to find a way to get enough votes to repeal Obamacare. Here’s how their delay could lead to a result they did not expect – more Medicaid.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/776642017-05-17T00:02:38Z2017-05-17T00:02:38ZIvanka Trump’s deeply political tome<figure><img src="https://images.theconversation.com/files/169591/original/file-20170516-11945-ppaurg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Do the rules of success apply equally to all women?</span> <span class="attribution"><span class="source">Nick Lehr/The Conversation via Wikimedia Commons</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>By and large, critics have taken Ivanka Trump at her word about her new book, “Women Who Work.” </p>
<p><a href="https://www.nytimes.com/2017/04/20/us/politics/ivanka-trump-charity-women-who-work.html?_r=0">She claims</a> she wrote it before her father’s election, “from the perspective of an executive and an entrepreneur.” And though they criticize her for being <a href="https://www.washingtonpost.com/opinions/ivankas-advice-for-working-women-who-already-have-it-pretty-good/2017/05/02/b439b41e-2e82-11e7-8674-437ddb6e813e_story.html?utm_term=.1000d31cd9af">trite</a>, <a href="http://www.vanityfair.com/hollywood/2017/05/samantha-bee-ivanka-trump-women-who-work">derivative</a>, <a href="https://www.usnews.com/opinion/civil-wars/articles/2017-05-02/ivanka-trumps-new-book-is-completely-out-of-touch-with-women-who-work">out of touch</a> and <a href="http://www.freep.com/story/life/2017/05/08/ivanka-trump-women-who-work/101334308/">racially tone-deaf</a>, most readers have accepted the premise that this is a largely apolitical book. </p>
<p>Yet as every scholar of literature knows, each book contains what theorist Fredric Jameson has dubbed a “<a href="https://books.google.com/books/about/The_Political_Unconscious.html?id=9xE6vLE71yUC">political unconscious</a>.” In other words, through the sheer act of narrating, a book reinforces one particular point of view while <a href="https://books.google.com/books?id=dq5ExUAR_KsC&printsec=frontcover&dq=the+novel+and+the+police&hl=en&sa=X&ved=0ahUKEwjdku7L0_LTAhUQ8mMKHTDeDEIQ6AEIJzAA#v=onepage&q=the%20novel%20and%20the%20police&f=false">policing others</a>. </p>
<p>With this in mind, a close read of “Women at Work” reveals deeply political undertones. Throughout her narrative, Trump advances an ideology of individualism framed by unlimited choice, perfect health and no time constraints. While in many ways, it’s aligned with the principles of the Republican Party, most American working women would probably find her advice for tackling life’s challenges difficult to reconcile.</p>
<h2>Time: The great equalizer?</h2>
<p>The works of the major Russian writers I study rarely engage with political themes in overt ways. But in emphasizing everyday life, families and communities, writers from Leo Tolstoy to Ivan Turgenev reject the possibility of drastic societal upheaval. Written during a period of political transition and reform, these works are inadvertently conservative; they seem to rebuff the position of the left-wing revolutionaries who sought to destroy the status quo. </p>
<p>In the case of “Women Who Work,” Ivanka Trump’s underlying assumption – her political perspective – is that 21st-century women live a life driven by personal choice. </p>
<p>“You choose,” she writes at one point. These words are perhaps the motto of her book, which presents women’s lives as a series of choices: career, partner, friends and so on. This much is predictable enough. </p>
<p>As an heiress, Trump is perhaps hesitant to discuss finances. So her discussion of choice is instead framed by allocation of another currency: time.</p>
<p>This, she claims, is the great human equalizer. </p>
<p>“No matter your age, your background, your education, or your successes,” she points out, “we are all granted 168 hours in a week.”</p>
<p>According to Trump, we each have at our disposal a limited amount of time to distribute among daily tasks. Her empowerment of women rests on the premise that all it takes to juggle all work and family responsibilities is creative time management. If used in a proactive – rather than reactive – way, the currency of time allows human entrepreneurship to thrive. </p>
<p>But in truth, time is no great equalizer. Buried in this time calculus is the fact that Ivanka’s management skills are powered by her considerable wealth. On simple quantitative terms, someone who can’t afford a housekeeper or babysitter will surely have less time at their disposal than someone who can. If a college professor is able to work from home after hours, a waitress at a diner cannot. And never mind the waste of time and money that results from things we do not choose – like illnesses. </p>
<h2>When illness is a choice</h2>
<p>Indeed, you would also think, after reading Trump’s book, that 21st-century women don’t simply possess the power to choose how to allocate their time. They also possess perfect health.</p>
<p>Even as a harbinger of our mortality, time is no great equalizer because we have different levels of access to quality health care. Whereas more than half of American adults struggle with one or more <a href="https://www.cdc.gov/chronicdisease/overview/">chronic health conditions</a> in their lifetime, Trump never betrays any vulnerability to illness and never discusses getting sick in “Women Who Work.” In fact, even though we know she’s given birth three times, after reading this book you would think that she’s never set foot in a hospital. </p>
<p>Throughout, Trump explains about how health conditions can be vanquished through mental balance. </p>
<p>“Proactive people are passionate and productive,” she writes, “they focus their energies on the things they can influence and improve: their families, their health, their work.” She spends considerable time noting how stress produces unhealthy eating habits and how she stocks her refrigerator with healthy snacks.</p>
<p>These comments, coupled with Trump’s apparent excellent health, seem to say that illness, too, is a matter of choice. And in this sense, her empowerment of women is founded on the same ideological underpinnings as the new GOP health care plan that just passed in the House of Representatives – a plan that emphasizes choice above all else, including compassion and access. </p>
<p>It’s a vision of life – and health – driven by market principles of efficiency and management (what academics like to call <a href="https://books.google.com/books?id=F5DZvEVt890C&printsec=frontcover&dq=neoliberalism&hl=en&sa=X&ved=0ahUKEwjKu_CqoPXTAhWCi1QKHQYsDakQ6wEIKDAA#v=onepage&q=neoliberalism&f=false">neoliberalism</a>). <a href="https://www.usatoday.com/story/opinion/2017/03/07/health-care-obamacare-replacement-paul-ryan-column/98858696/">In an op-ed he wrote</a> advocating for an earlier incarnation of the bill, House Speaker Paul Ryan spoke shockingly little of health. Instead, he focuses on costs and health insurance markets. </p>
<p>Some Republicans have even stretched their choice doctrine to an absurd degree by suggesting, as Trump indirectly does, that perhaps we also choose our illnesses. As Republican Congressman Mo Brooks <a href="http://www.al.com/news/index.ssf/2017/05/rep_mo_brooks_people_who_live.html">controversially declared</a>, people who “lead good lives” won’t have to deal with preexisting conditions. This idea strikes me as Ivanka Trump’s female empowerment plan played to perfection: a life of self-actualization – to the point of the outright elimination of disease.</p>
<p>Operating with different currencies – but fueled by the same market-driven philosophy of individual management and investment – both the GOP health care plan and “Women Who Work” leave individuals to their own lonely devices, with the towering task of making the impossible possible through sheer force of will. </p>
<p>I’ve never met Ivanka Trump, so I have no clue what preexisting conditions she has. But after reading her book where she effortlessly handles raising three children, working two full-time jobs and going on eight-hour hikes in Patagonia, I strongly believe that she would be the perfect pitchwoman for the health care system advocated by the GOP health care plan. Both betray a shocking lack of empathy for those who lack choices. </p>
<p>By using time as a currency to insist on equality where there is none, Ivanka is not merely tone-deaf, but rather advancing the beloved GOP doctrine of free-market capitalism. With no external time constraints, Ivanka Trump suggests that we can all become happy, healthy and wealthy – just like her.</p><img src="https://counter.theconversation.com/content/77664/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ani Kokobobo 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>‘Women Who Work’ attempts to present itself as an apolitical work. But no narratives ever are – and it’s especially the case for those that anxiously seek to appear that way.Ani Kokobobo, Assistant Professor of Russian Literature, University of KansasLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/771382017-05-05T01:26:24Z2017-05-05T01:26:24ZHow pre-existing conditions became front and center in health care vote<figure><img src="https://images.theconversation.com/files/167948/original/file-20170504-21616-1iddpd7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Rep. Billy Long (R-Mo.) speaks to reporters outside the White House on May 3, 2017 after a meeting with the president on proposed legislation that could limit coverage for preexisting conditions. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/Search?query=fred+upton&ss=10&st=es&entitysearch=P%7CFred+Upton%7CCEE638D367D54A209FC2FB0F2BE2311C&toItem=15&orderBy=Newest&searchMediaType=excludecollections">Susan Walsh/AP</a></span></figcaption></figure><p>Pre-existing conditions became the focus of debate on the American Health Care Act, which was narrowly passed 217-213 by the House of Representatives.</p>
<p>The debate led to bitter disagreement, as Republicans sought to undo a requirement of the Affordable Care Act that insurers be forced to cover pre-existing conditions and at the same premiums as others.</p>
<p>The issue, long contentious, gained further fuel this week through two illustrative videos seen by millions of Americans. On the one hand, a tearful late-night show host <a href="http://time.com/money/4763061/jimmy-kimmel-baby-obamacare/">Jimmy Kimmel</a> described the nightmare of every parent when his son was born with a serious, complex, and costly birth defect. On the other hand, <a href="https://www.commondreams.org/news/2017/05/02/exposing-gop-cruelty-alabama-rep-says-pre-existing-conditions-are-your-fault">Rep. Mo Brooks</a> (R-AL) stated that those Americans “who lead good lives” and have “done the things to keep their bodies healthy” should not have to support Americans with pre-existing conditions.</p>
<p>Why should this be such a contentious issue? As someone who <a href="http://simonfhaeder.wixsite.com/home/academic">studies and teaches</a> health care policy in West Virginia, one of the states with the <a href="http://kff.org/health-reform/issue-brief/pre-existing-conditions-and-medical-underwriting-in-the-individual-insurance-market-prior-to-the-aca/">highest percentage</a> of individuals with pre-existing conditions, let me offer some answers. </p>
<h2>What is a pre-existing condition, anyway?</h2>
<p>Pre-existing conditions are health conditions which were diagnosed or treated by a provider prior to the purchase of insurance. <a href="http://www.ilhealthagents.com/bluecross-blueshield-illinois/pre-existing-condition-exclusions/">Twenty-three states</a> even include cases where individuals did not seek medical attention but when a “prudent” person would have sought care. </p>
<p>Pre-existing conditions apply only to those circumstances where the sale of insurance policies is based on individual risk, as opposed to risk spread across many people, such as in employer-sponsored insurance or Medicare. </p>
<p>Addressing the contentious issue of pre-existing conditions, and most importantly how to distribute the costs associated with them, is a crucial one for all health care systems. The issue has been with us from the very emergence of health insurance, particularly as for-profit insurers sought to minimize their risks and to maximize their profits.</p>
<p>However, while most other industrialized nations have long resolved the issue equitably, the U.S. continues to struggle with it, even after the passage of the ACA. </p>
<p>Before passage of the ACA, pre-existing conditions were subject to a confusing mix of state and federal laws, regulations and enforcement. <a href="http://kff.org/other/state-indicator/individual-market-portability-rules/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Elimination%20Riders%20Permitted%22,%22sort%22:%22desc%22%7D">Almost 20 percent of the states provided</a> no definition of preexisting conditions at all. </p>
<p>Insurers hence had significant leeway in determining what counted as a preexisting condition unless a state <a href="http://www.nytimes.com/2008/06/01/health/01insure.html">specifically banned the practice for certain conditions</a>.</p>
<p>States also differed on how far back health conditions were relevant, ranging from <a href="http://www.ilhealthagents.com/bluecross-blueshield-illinois/pre-existing-condition-exclusions/">six months to indefinitely</a>.</p>
<p>Insurers could elect to deny coverage altogether to individuals with preexisting conditions in most states. In others, insurers charged much higher premiums for those with preexisting conditions.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/167952/original/file-20170504-21616-1lv7f6q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/167952/original/file-20170504-21616-1lv7f6q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/167952/original/file-20170504-21616-1lv7f6q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/167952/original/file-20170504-21616-1lv7f6q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/167952/original/file-20170504-21616-1lv7f6q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/167952/original/file-20170504-21616-1lv7f6q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/167952/original/file-20170504-21616-1lv7f6q.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">Man being treated for sleep apnea, once an excluded preexisting condition.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/539015356?src=9x1Jlo3FOwbjYR5gUcj9Ew-1-3&size=huge_jpg">From www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>Insurers are generally not concerned about preexisting conditions per se, but only about those that are expected to incur significant medical costs in the future. </p>
<p>Basing their decisions on risk models, individual insurers have developed lists of <a href="http://files.kff.org/attachment/Issue-Brief-Pre-existing-Conditions-and-Medical-Underwriting-in-the-Individual-Insurance-Market-Prior-to-the-ACA">declinable conditions</a> (such as substance abuse, acne and sleep apnea), <a href="http://files.kff.org/attachment/Issue-Brief-Pre-existing-Conditions-and-Medical-Underwriting-in-the-Individual-Insurance-Market-Prior-to-the-ACA">medications</a> (such as heparin, Zyrexa and Interferon) or <a href="http://files.kff.org/attachment/Issue-Brief-Pre-existing-Conditions-and-Medical-Underwriting-in-the-Individual-Insurance-Market-Prior-to-the-ACA">occupations</a> (such as miners, pilots and air traffic controllers).</p>
<p>A congressional report found that <a href="http://thehill.com/images/stories/blogs/memo1.pdf">425 medical diagnoses</a> have been used to decline coverage. </p>
<p>Certain reasons for rejection fueled public outrage more than others. For example, immediately prior to the ACA’s passage, being the victim of domestic violence counted as a preexisting condition <a href="http://www.mcclatchydc.com/news/politics-government/article24557818.html">in eight states</a>. </p>
<p>Similarly, many insurers also included <a href="http://www.huffingtonpost.com/2009/10/21/insurance-companies-rape-_n_328708.html">rape</a> as a pre-existing condition, and <a href="https://www.healthinsurance.org/blog/2012/04/28/health-reform-a-huge-victory-for-women/2/">45 states</a> allowed the practice for C-sections.</p>
<h2>How the idea of denying coverage got started</h2>
<p>The issue of pre-existing conditions is not new to the American health care system. At the beginning – in the 1920s and 1930s – emerging health insurers like Blue Cross and Blue Shield were created as nonprofits with special tax treatment. Most plans charged the same rates to all consumers.</p>
<p>As the insurance market became more profitable, for-profit insurers entered the market. Focused on maximizing their profits, these companies sought to attract only the healthiest individuals. They did this by offering lower premiums than their nonprofit competitors to healthy individuals. </p>
<p>Naturally, this entailed excluding individuals with preexisting conditions. In order to avoid being left with only the sickest individuals, all insurers eventually had to move to medical underwriting, at least in the individual market.</p>
<p>Over time, both states and federal government enacted certain, albeit very limited, protections, such as high-risk pools, for individuals with preexisting conditions. </p>
<p>Some states also required insurers to issue policies to all comers. These <a href="http://kff.org/other/state-indicator/individual-market-guaranteed-issue-not-applicable-to-hipaa-eligible-individuals/?currentTimeframe=0&sortModel=%7B%22colId%22%3A%22Location%22%2C%22sort%22%3A%22asc%22%7D">guaranteed issue requirements,</a> however, often did not address costs issues. </p>
<p>As result, while consumers may not have been denied coverage, they were penalized with higher premiums for having these conditions. </p>
<p>Common efforts to limit losses for insurers from those with preexisting conditions included the temporary or permanent <a href="http://kff.org/other/state-indicator/individual-market-portability-rules/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Elimination%20Riders%20Permitted%22,%22sort%22:%22desc%22%7D">restriction of benefits for certain enrollees</a> based on their health condition; the creation of so-called <a href="https://www.ehealthinsurance.com/short-term-health-insurance">bare-bone plans</a> or allowing insurers to charge <a href="http://www.nytimes.com/2008/06/01/health/01insure.html">discriminatory premiums</a>. </p>
<p>However, none of the approaches offered a comprehensive solution.</p>
<p>A study by the <a href="https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0ahUKEwiH0vvAyNTTAhUERCYKHQQFCbsQFggnMAA&url=http%3A%2F%2Fwww.commonwealthfund.org%2F%7E%2Fmedia%2FFiles%2FPublications%2FIssue%2520Brief%2F2009%2FJul%2FFailure%2520t">Commonwealth Fund in 2007</a> found that 36 percent of individuals had been turned down or charged a higher price for a preexisting condition.</p>
<p>An <a href="http://thehill.com/images/stories/blogs/memo1.pdf">investigation by the Committee on Energy and Commerce</a> of the House of Representatives showed that the nation’s four largest for-profit insurers covering close to three million individuals had turned down more than 600,000 individuals between 2007 and 2009. Moreover, during the same period they refused to pay medical treatment for a preexisting condition for more than 200,000 claims.</p>
<p>Those most closely affected were those 16 million Americans (in 2008) who held policies in the individual market and the additional <a href="http://khn.org/news/census-number-of-uninsured-drops/">50 million</a> who were uninsured.</p>
<p>However, transition between insurance is inherently frequent in a <a href="http://www.commonwealthfund.org/publications/blog/2017/mar/premium-surcharge-under-aca-repeal-bill">mobile society</a> like the United States. A significant number of people in any given year lose their jobs. Both instances leave many Americans uncovered for at least part of the year, and potentially seeking insurance in the individual market.</p>
<h2>Obamacare’s call for coverage</h2>
<p>The pre-existing condition issue is one pretty much unique to the American health system.</p>
<p>The ACA sought to solve the issue through a variety of arrangements surrounding the <a href="http://onlinelibrary.wiley.com/doi/10.1111/puar.12065/full">insurance marketplaces</a> including community rating, a minimum amount of benefits (the <a href="https://theconversation.com/essential-health-benefits-suddenly-at-center-of-health-care-debate-but-what-are-they-75125">Essential Health Benefits</a>), the elimination of annual and lifetime benefit limits, and subsidies. </p>
<p>In contrast, the American Health Care Act would allow insurers to charge higher premiums to those individuals. </p>
<p>The AHCA does offer some very limited funding to offset its negative effects. However, policy experts, providers and patient groups have described these as <a href="https://www.forbes.com/sites/brucejapsen/2017/04/27/doctors-hospitals-say-latest-trumpcare-version-a-bigger-disaster/#31e786c91ea4">inadequate</a>. The most recent <a href="http://www.politico.com/story/2017/05/02/health-care-republicans-obamacare-237910">Upton Amendment</a> slightly increased this funding – something that possibly contributed to the law’s passage. But policy experts continue to see the funding as significantly <a href="https://www.vox.com/policy-and-politics/2017/5/3/15538556/republican-health-care-bill-ahca-upton-amendment">too small</a>.</p>
<h2>Are we all in this together, or not?</h2>
<p>Millions of Americans could potentially be affected by the changes under the new legislation. </p>
<p>The point is that pre-existing conditions remain ubiquitous in American society. A <a href="http://kff.org/health-reform/issue-brief/pre-existing-conditions-and-medical-underwriting-in-the-individual-insurance-market-prior-to-the-aca/">Kaiser Family Foundation analysis</a> a few months ago found 52 million Americans under age 65, or 27 percent of the population would not be able to obtain insurance on their own under pre-ACA conditions. </p>
<p>The situation was considerably worse in states like West Virginia, Mississippi, Kentucky and Alabama, where more than one in three residents, according to the analysis, would not be able to.</p>
<p>Making sure that those among us with pre-existing conditions have health care is challenging and unquestionably costly. It also requires a degree of sacrifice, in terms of higher premiums, from those who, at any given point in time, are relatively healthy.</p>
<p>What is required is a degree of solidarity with our neighbors, friends and family members who, often through no fault of their own, have suffered from poor health. Not the least, it is a degree of solidarity with our own future selves as all of us could fall sick at any point in time.</p>
<p>Americans of all political persuasions seem to be willing to make the required sacrifices. Most Americans, including 63 percent of Republicans and 75 percent of Democrats in a <a href="http://kff.org/slideshow/us-public-opinion-on-health-care-reform-2017/">recent poll</a>, support the preexisting condition components of the Affordable Care Act.</p><img src="https://counter.theconversation.com/content/77138/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>How preexisting conditions came to be a condition for passage of the Republicans’ health care law is a complicated tale. Insurers created the cost-saving technique, excluding millions over the years.Simon F. Haeder, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/772152017-05-04T20:34:49Z2017-05-04T20:34:49ZHow did health insurance get so complicated? Here are some answers<figure><img src="https://images.theconversation.com/files/167974/original/file-20170504-5995-1l56ddi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Two swing votes: Rep. Fred Upton (R-Mich.) and Rep. Greg Waldon (R-Ore.), after striking a deal with Pres. Trump on the heath care bill. </span> <span class="attribution"><span class="source">Susan Walsh/AP Photo</span></span></figcaption></figure><p>With the passage of the Republicans’ health care act, the House of Representatives seems to be saying that coming up with a plan to insure Americans really wasn’t all that hard after all. It just took a bit more of a subsidy – US$8 billion to be precise – for really sick people to make Congress comfortable with the alternative to the Affordable Care Act. </p>
<p>But from being a professor of health finance and a former insurance CEO, I know that it is really much more difficult than this to keep all the insurers competing aggressively in the market, all the providers focused on high quality and all the patients choosing wisely among their options for coverage and care.</p>
<p>One of the biggest underlying problems is confusion over what we are buying here and what incentives are necessary to get everyone to behave.</p>
<h2>What are we buying anyway?</h2>
<p>The first confusion is over the very nature of health insurance. The discussion often reveals an assumption that we are just buying a service and paying for it much as we finance a new car. So why should I pay more in financing costs than I actually get? If I want a VW, why should I pay for a BMW? I don’t need maternity services or mental health, but they are part of the standard package of essential benefits that I have to buy. And this drives up my premium.</p>
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<img alt="" src="https://images.theconversation.com/files/167980/original/file-20170504-21620-1bay2zz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/167980/original/file-20170504-21620-1bay2zz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/167980/original/file-20170504-21620-1bay2zz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/167980/original/file-20170504-21620-1bay2zz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/167980/original/file-20170504-21620-1bay2zz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/167980/original/file-20170504-21620-1bay2zz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/167980/original/file-20170504-21620-1bay2zz.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">Want a BMW?</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/kiev-ukraine-14-may-2014-bmw-379233436">Sabuhi Novruzov/www.shutterstock.com</a></span>
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</figure>
<p>But health insurance is not car financing. By its very nature, it is the strangest of products, one that I hope I will not have to use but is there when I need it. I am not buying specific services but access to potential services, the particulars of which are unknowable in advance. This ticket to ride is very valuable, but pricing it is devilishly difficult.</p>
<p>To make this work, I have to share my potential need with a large group of like-minded consumers who also hope they won’t have to use the ticket. But unlike the lottery, where I want to win and get all that money for the $2 ticket I bought, I am unhappy if I “win” with my health insurance and get back more than I paid when I have a serious illness. It is this confusing nature of the product that leads to bad policy and bad purchasing decisions.</p>
<h2>Proposed patch will wear thin</h2>
<p>The <a href="http://www.businessinsider.com/ahca-high-risk-pools-healthcare-vote-obamacare-2017-5">patch</a> proposed by the AHCA is to pull out of the insurance pool more of those who are likely to need services, leaving the rest with a premium that is closer to what they actually are likely to need on a one-to-one basis. </p>
<p>Loosening up the requirements on pricing to let insurers charge more for people with varying conditions moves us even closer to this image. Why shouldn’t the sick pay more since they use more services? The apparent hope is to come closer to the implicit assumption of health care as car financing – I get what I pay for.</p>
<p>Unfortunately for all of us, this is a losing proposition. There will always be more at the margin who would qualify for coverage under the high-risk pools, driving the cost of these beyond any arbitrary funding, be it $8 billion or $800 billion. </p>
<p>Our experience in many states in the past is that these pools are <a href="http://kff.org/health-reform/issue-brief/high-risk-pools-for-uninsurable-individuals/">inevitably underfunded</a>, leaving those who would qualify the butt of a cruel joke – they can’t get conventional health insurance, but the cost of even the high-risk pool is excessive due to underfunding. </p>
<p>This is the real concern over high-risk pools as an alternative to offering coverage to all, regardless of pre-existing conditions. While economists suggest that this <a href="http://thehealthcareblog.com/blog/2012/03/07/what-is-the-cause-of-excess-costs-in-us-health-care-take-two/">excess demand </a>is the patient’s fault (the so-called “moral hazard” of excess demand when something is covered), no one chooses to have a heart condition, diabetes or a birth defect.</p>
<h2>Payment shapes decisions and incentives</h2>
<p>Another problem comes from, again, the misconception of health insurance as the financing of a known product. Besides just paying for services when needed, we also want to create incentives for prevention and high quality and lowest cost settings to provide them when they are needed. </p>
<p>The Affordable Care Act has moved health care far down this path through <a href="http://www.modernhealthcare.com/article/20161111/MAGAZINE/161109907">value-based payment</a>, which rewards providers for higher quality and lower total cost over the whole spectrum of care, not just for a single service.</p>
<p>But while providers have received the message loud and clear and reacted with <a href="http://www.modernhealthcare.com/article/20161111/MAGAZINE/161109907">major advances</a> on quality and cost, we have far to go in creating similar incentives for the patient. This is where the “skin in the game” argument, as a way to make individuals more responsible for their own care, has some credibility. </p>
<p>But AHCA supporters went further. Under their replacement bill, it is OK to penalize people for being sick, even if it is not their “fault,” and regardless of their wealth or income. </p>
<p>The new legislation’s <a href="http://www.businessinsider.com/biggest-drop-in-subsidies-for-cities-under-ahca-trumpcare-2017-3">subsidies depend on age</a>, not income, and entirely remove the cost-sharing reductions that make high-deductible plans on the Obamacare exchanges feasible for the working poor just above the poverty level. </p>
<p>With these changes, clearly health insurance is no longer affordable for those who were the main target of the ACA.</p>
<p>Admittedly, premiums for those other than the near poor are higher under the ACA, even if health care inflation in general has been largely tamed. Those who support the lower-premium, stripped-down plans of the AHCA replacement bill focus on the concerns of those who now must buy more expensive policies that cover everything they might need – but without the subsidies the poor receive. </p>
<p>So if I think I can predict what I will need and want a plan that will finance this like my new car, then I probably don’t need insurance at all. </p>
<p>And, if I do want coverage and can afford to pay for it, the replacement legislation will do just fine. Because I have the money, I can buy a BMW policy, if I choose.</p>
<p>However, if I am poor – or if I care about a stable insurance market – this is a jalopy with recycled tires, a torn leather seat and an engine about to blow.</p><img src="https://counter.theconversation.com/content/77215/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>J.B. Silvers is on the board of MetroHealth Medical Center</span></em></p>Even Pres. Trump said he had no idea that health insurance can be so complicated.
Part of the reason is that it’s not something we really want to buy – and not something we want to buy for others.J.B. Silvers, Professor of Health Finance, Case Western Reserve UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/751842017-03-28T02:39:52Z2017-03-28T02:39:52ZDid medical Darwinism doom the GOP health plan?<figure><img src="https://images.theconversation.com/files/162548/original/image-20170327-18980-dl97nf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">House Speaker Paul Ryan announced March 24 that he was pulling his proposed health care bill from consideration. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Health-Overhaul-Tax-Reform/2a6d4f6c9dec4b91ba6d57ef76165814/1/0">Scott Applewhite/AP</a></span></figcaption></figure><p><em>“We are now contemplating, Heaven save the mark, <a href="https://archive.org/stream/newyorkstatejour4919medi#page/1904/mode/2up/search/Heaven+save+the+mark">a bill that would tax the well for the benefit of the ill</a>.”</em> </p>
<p>Although that quote reads like it could be part of the Republican repeal-and-replace assault against the Affordable Care Act (ACA), it’s actually from a 1949 editorial in The New York State Journal of Medicine denouncing health insurance itself.</p>
<p>Indeed, the attacks on the ACA seem to have revived a survival-of-the-fittest attitude most of us thought had vanished in America long ago. Yet, again and again, there it was in plain sight, as when House Speaker Paul Ryan (R-WI) <a href="https://www.theatlantic.com/health/archive/2017/03/the-biggest-criticism-of-paul-ryans-health-care-pitch/519138/">declared</a>: “The idea of Obamacare is that the people who are healthy <a href="http://wgxa.tv/news/connect-to-congress/watch-house-speaker-paul-ryans-powerpoint-presentation-on-gop-health-care-bill">pay for the people who are sick</a>.” Contemporary language, but the same thinking that sank President <a href="http://www.pbs.org/newshour/updates/november-19-1945-harry-truman-calls-national-health-insurance-program/">Harry Truman’s health care plan</a> almost seven decades ago.</p>
<p>Ryan’s indignation highlighted a fundamental divergence in attitudes that repeatedly turned the health care debate into a clash over the philosophy behind Obamacare-style health insurance. To some, the communal pooling of financial risk of medical expenses seems too often an unacceptable risk to personal responsibility. </p>
<p>As a researcher who has <a href="http://press.uchicago.edu/Misc/Chicago/525872.html">documented</a> this approach to health care, I’ve been startled to see the debate over the AHCA reignite a political philosophy and policy approach that seemed to be have been discredited – and be in sharp decline.</p>
<p>When Truman launched the <a href="http://www.pbs.org/newshour/updates/november-19-1945-harry-truman-calls-national-health-insurance-program/">first comprehensive effort</a> to cover all Americans, most of the population had no health insurance. </p>
<p>Last year, thanks to the ACA, nearly 90 percent did, according to a Gallup-Healthways <a href="http://www.gallup.com/poll/201641/uninsured-rate-holds-low-fourth-quarter.aspx">poll</a>. Yet then and now, many conservatives have downplayed the impact on physical health and focused, instead, on fiscal temptation. </p>
<h2>If you can’t afford to be sick, then don’t be</h2>
<p>Take, for instance, Rep. Jason Chaffetz (R-UT) <a href="http://www.politico.com/story/2017/03/jason-chaffetz-new-gop-health-care-plan-235762">warning low-income Americans</a> on March 7, 2017 that they had “to make a choice” about their spending: “So rather than getting that new iPhone that they just love and want to go spend hundreds of dollars on that, maybe they should invest in their own health care.” (He <a href="http://www.cnn.com/2017/03/07/politics/jason-chaffetz-health-care-iphones/">later walked back</a> his statement.) </p>
<p>In reality, of course, the premiums from the GOP’s late and abandoned American Health Care Act would dwarf any savings from iPhone abstinence. For a 64-year-old making US$26,500 a year, the cost of health insurance would have shot up from $1,700 to $14,600, <a href="http://time.com/money/4700402/republican-obamacare-replacement-cbo-numbers/">according to the Congressional Budget Office</a> (CBO), or more than half that individual’s pre-tax income.</p>
<p>Chaffetz and others seem to sincerely believe that “what keeps the great majority of people well is the fact that they can’t afford to be ill” – although those words come from the 1949 editorialist again, not a Trump administration tweet. The editorial continued:</p>
<p><em>That is a harsh, stern dictum and we readily admit that under it a certain number of cases of early tuberculosis and cancer, for example, may go undetected. Is it not better that a few such should perish rather than that the majority of the population should be encouraged on every occasion to run sniveling to the doctor? That in order to get their money’s worth they should be sick at every available opportunity? They will find out in time that the services they think they get for nothing – but which the whole people of the United States would pay for – are also worth nothing.</em></p>
<p>As it happens, the effect predicted in 1949 on the detection of cancer – less of it – is precisely what has happened with the spread of high-deductible health plans praised by conservatives for encouraging more careful “shopping” by “consumers.” A <a href="https://www.ncbi.nlm.nih.gov/pubmed/27078821">study</a> in Medical Care showed that screening rates for colorectal cancer declined under high-deductible plans until, under Obamacare, the federal government forced those plans to include first-dollar coverage of preventive services. The screening rates for colorectal cancer promptly rose. A recent <a href="http://onlinelibrary.wiley.com/doi/10.1002/cncr.30476/full">study</a> in Cancer found the same results for mammography.</p>
<p>Separately, <a href="http://healthaffairs.org/blog/2015/10/07/trouble-ahead-for-high-deductible-health-plans/">surveys and research</a> on high-deductible plans have found that 20 to 25 percent of people have avoided needed care of all kinds because they can’t afford it.</p>
<p>Nonetheless, the GOP’s conservative wing denounced ACA-mandated “<a href="https://theconversation.com/essential-health-benefits-suddenly-at-center-of-health-care-debate-but-what-are-they-75125">essential health benefits</a>,” echoing the idea that it is a <a href="http://talkingpointsmemo.com/news/boehner-health-care-greatest-threat-to-freedom-i-ve-seen-in-last-19-years">threat to American freedom</a>. Or as that same <a href="https://archive.org/stream/newyorkstatejour4919medi#page/2130/mode/2up/search/darwin">New York medical journal</a> put it:</p>
<p><em>It is time that someone – everyone – should hoist Mr. Charles Darwin from his grave and blow life into his ashes so that they could proclaim again to the world his tough but practical doctrine of survival of the fittest…The Declaration of Independence said that man was entitled to the “pursuit of happiness.” Any man who wishes to pursue happiness had better be able to stand on his own feet. He will not be successful if he feels that he can afford to be ill</em>.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/162555/original/image-20170327-18984-4cwik4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/162555/original/image-20170327-18984-4cwik4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=851&fit=crop&dpr=1 600w, https://images.theconversation.com/files/162555/original/image-20170327-18984-4cwik4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=851&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/162555/original/image-20170327-18984-4cwik4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=851&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/162555/original/image-20170327-18984-4cwik4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1069&fit=crop&dpr=1 754w, https://images.theconversation.com/files/162555/original/image-20170327-18984-4cwik4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1069&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/162555/original/image-20170327-18984-4cwik4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1069&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Charles Darwin.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/charles-darwin-18091882-circa-1870s1980s-252138244?src=ySZVMopUaF3zX0ZFp8CsGQ-1-1">from www.shutterstock.com</a></span>
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</figure>
<h2>The quality of mercy is not strained</h2>
<p>For most physicians, that compassionless condescension lies in the faraway past; for example, the AHCA was overwhelmingly opposed by medical professional groups, including the <a href="https://www.nytimes.com/2017/03/08/health/american-medical-association-opposes-republican-health-plan.html">American Medical Association</a>. </p>
<p>Yet an implacable medical Darwinism retains a firm grip on many conservatives, even on physicians. Then-Oklahoma Sen. Tom Coburn, an obstetrician/gynecologist and prominent Republican, <a href="https://newrepublic.com/article/68779/who-my-neighbor">told a sobbing woman</a> at a 2009 public meeting on the ACA that “government is not the answer” when she said she couldn’t afford care for her brain-injured husband. </p>
<p>Similarly, in 2011, after the ACA passed, then-Rep. Ron Paul (R-TX), also an obstetrician/gynecologist, <a href="http://abcnews.go.com/blogs/politics/2011/09/tea-party-debate-audience-cheered-idea-of-letting-uninsured-patients-die/">was asked what should be done</a> about an uninsured, 30-year-old man in a coma. “What he should do is whatever he wants to do and <a href="http://www.npr.org/sections/thetwo-way/2011/09/13/140434378/ron-paul-its-not-governments-job-to-take-care-of-uninsured">assume responsibility for himself</a>,” Paul responded, adding, “That’s what freedom is all about, taking your own risk.”</p>
<p>Or as conservative scholar Michael Strain <a href="https://www.washingtonpost.com/opinions/end-obamacare-and-people-could-die-thats-okay/2015/01/23/f436df30-a1c4-11e4-903f-9f2faf7cd9fe_story.html?utm_term=.63f80e225e31">put it</a> in a 2015 Washington Post editorial: “In a world of scarce resources, a slightly higher mortality rate is an acceptable price to pay for certain goals – including…less government coercion and more individual liberty.”</p>
<p>Strain is right, of course, that resources are limited. Moreover, <a href="http://www.journals.uchicago.edu/doi/abs/10.1086/260027">it’s long been known</a> that overgenerous health insurance can lead to overuse of medical care services. </p>
<p>However, most Americans, including some <a href="https://www.forbes.com/sites/theapothecary/2017/03/11/how-paul-ryans-obamacare-replacement-would-trap-millions-in-poverty-and-how-to-fix-it/#1668572c4168">prominent conservative intellectuals</a>, don’t see stripping away health insurance from 24 million countrymen – the CBO’s estimate of the AHCA’s 10-year impact – as striking a blow for liberty. In a <a href="https://poll.qu.edu/national/release-detail?ReleaseID=2443">Quinnipiac University poll</a> released just before the scheduled AHCA vote, only 17 percent of respondents approved of the Republican plan and 46 percent said they’d be less likely to vote for someone who supported it.</p>
<p>One day later, GOP leaders withdrew the legislation, sparing Republican representatives a vote “on the record.” Although Vice President Mike Pence has <a href="http://www.inquisitr.com/3706347/trump-vp-mike-pence-dismisses-evolution-believes-darwin-only-had-a-theory/">called evolution an unproven theory</a>, it turns out Republicans really do believe in “survival of the fittest” (at least in a political sense), after all.</p><img src="https://counter.theconversation.com/content/75184/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael L. Millenson 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 U.S. has been arguing about health care for decades. Critics have argued that insurance for all is a sign of weakness or even Communist. Here’s a look at how the thinking has evolved – or not.Michael L. Millenson, Adjunct Associate Professor of Medicine, Feinberg School of Medicine, Northwestern UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/727732017-03-27T02:37:36Z2017-03-27T02:37:36ZWhy threats to get votes for health law are more workplace bullying than political tactics<figure><img src="https://images.theconversation.com/files/162222/original/image-20170323-4938-1wqrbsq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">President Trump arrived at the Capitol with HHS Secretary Tom Price on March 21 to warn representatives that they could lose their jobs if they do not vote in favor of the health care law. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/Search?query=trump+health+care+vote&ss=10&st=kw&entitysearch=&toItem=15&orderBy=Newest&searchMediaType=excludecollections">Scott Applewhite/AP</a></span></figcaption></figure><p>In an effort to pass the <a href="https://www.washingtonpost.com/powerpost/gop-health-care-plan-hangs-in-balance-as-house-leaders-push-for-thursday-floor-vote/2017/03/23/6e8bf05a-0fbd-11e7-9d5a-a83e627dc120_story.html?utm_term=.0ce9db0cb59c">health care law</a>, Donald Trump placed intense political pressure on members of the House, even telling one key lawmaker “I’m going to come after you,” according <a href="https://www.washingtonpost.com/powerpost/trump-arrives-on-capitol-hill-to-sell-house-gop-health-care-package/2017/03/21/e8ede3d2-0e2b-11e7-9b0d-d27c98455440_story.html">to</a> <a href="https://www.nytimes.com/2017/03/21/us/politics/house-republicans-health-care-donald-trump.html">reports</a>. The president has also made <a href="https://www.washingtonpost.com/news/morning-mix/wp/2017/03/16/appeals-court-judges-rebuke-trump-for-personal-attacks-on-judiciary-intimidation/?utm_term=.c41cb3abde33">personal attacks</a> on members of the judiciary. </p>
<p>How do these strong-arm tactics – I would call it bullying and intimidation – affect the workings of Washington? After all, the president, as the leader of the executive branch of our government, is responsible for establishing the organizational culture and monitoring the behavior of his administration. </p>
<p>As a citizen, a taxpayer and a psychologist, I’m concerned that we have a chief executive exhibiting behavior that would be considered bullying in business. By setting the example that bullying is okay at the top, it could become acceptable practice in our government and by extension in our businesses. And research suggests that could not only be detrimental to the health of individuals being bullied, but also harm the country overall. </p>
<p>The toll of workplace bullying is hard to fully quantify, but we do know that it contributes to <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0135225;%20http://www.tandfonline.com/doi/abs/10.1080/02678373.2012.734709">depression, anxiety, suicidal ideation, substance misuse </a> and <a href="http://onlinelibrary.wiley.com/doi/10.1111/1467-9450.00307/full">somatic complaints</a> such as <a href="http://www.tandfonline.com/doi/abs/10.1080/13594320143000816">headaches</a>. And in addition to the personal toll, workplace bullying can have a <a href="https://www.researchgate.net/publication/265183903_WORKPLACE_BULLYING_IN_AUSTRALIA_A_REVIEW_OF_CURRENT_CONCEPTUALISATIONS_AND_EXISTING_RESEARCH">toxic effect on work performance</a> – decreased productivity, excessive absenteeism, higher worker’s compensation claims and early retirement payouts. </p>
<p>I’m part of a team of psychologists who teach a class in Yale University’s School of Management called <a href="http://som.yale.edu/faculty-research-centers/centers-initiatives/interpersonal-and-group-dynamics/interpersonal-and-group-dynamics-facilitator-community">Interpersonal Dynamics</a>. There, future business leaders are challenged to be receptive to learning about their impact on others, taught to experience and appropriately express their emotions and use that information to engage in respectful interpersonal exchanges. These kinds of skills can create organizational climates that not only hold leaders and employees accountable for their behavior but also offer potential targets psychological safety and some control.</p>
<p>And having skills to defuse bullying behavior helps to keep at least some employees happy.</p>
<p>For example, in a 2015 internal study of Google employees, the most frequently identified attribute for a team’s success was <a href="http://www.businessinsider.com/google-explains-top-traits-of-its-best-teams-2015-11">psychological safety</a>.</p>
<h2>You know it’s bullying when it hurts your soul</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/162380/original/image-20170324-12136-gw1cyl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/162380/original/image-20170324-12136-gw1cyl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/162380/original/image-20170324-12136-gw1cyl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/162380/original/image-20170324-12136-gw1cyl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/162380/original/image-20170324-12136-gw1cyl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/162380/original/image-20170324-12136-gw1cyl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/162380/original/image-20170324-12136-gw1cyl.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">.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/two-businesspeople-bullying-sad-colleague-that-446573998?src=FFrLinC1IyzhMDtpbse78Q-1-2">from www.shutterstock.com</a></span>
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<p>Workplace bullying is more than the occasional snide remark; it involves <a href="https://www.researchgate.net/publication/223887351_Measuring_workplace_bullying">repeated, regular, offensive, abusive, intimidating, malicious or insulting behavior</a> and can include the abuse of power or unfair, penal job sanctions. Examples of workplace bullying include threats to one’s status, such as professional humiliation or belittlement, personal attacks like name-calling or intimidation, rumor spreading or <a href="https://www.researchgate.net/publication/230045399_A_Summary_Review_of_Literature_Relating_to_Workplace_Bullying">work-related harassment</a> like unrealistically high job demands or impossible deadlines.</p>
<p>Prevalence rates on workplace bullying vary widely depending on measurement methods and sampling techniques. A 2010 meta-analysis of 86 independent samples with a total number of over 130,000 participants provided an overall estimate of <a href="http://onlinelibrary.wiley.com/doi/10.1348/096317909X481256/full">14.6 percent of current workplace bullying</a>. </p>
<p>This type of behavior is <a href="http://journals.sagepub.com/doi/full/10.1177/0004867416660201">particularly prevalent in large hierarchical organizations</a> with decentralized structures and segregated silos such as governments, large business corporations, the military and law enforcement agencies.</p>
<h2>The leader sets the tone</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/162382/original/image-20170324-12121-1n6po0h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/162382/original/image-20170324-12121-1n6po0h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/162382/original/image-20170324-12121-1n6po0h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/162382/original/image-20170324-12121-1n6po0h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/162382/original/image-20170324-12121-1n6po0h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/162382/original/image-20170324-12121-1n6po0h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/162382/original/image-20170324-12121-1n6po0h.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="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/attractive-businessman-praising-coworker-during-meeting-194288441?src=bevAA0lFrusw6U0zUrbGTg-1-8">from www.shutterstock.com</a></span>
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<p>In most cases, workplace bullying seems to filter from the <a href="https://moh-it.pure.elsevier.com/en/publications/quality-of-leadership-and-workplace-bullying-the-mediating-role-o">top down</a>. If a boss gives a green light to such behavior by personally demeaning and degrading employees, that sets a powerful tone to others that they can do likewise. This in turn <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1467-8551.2009.00664.x/abstract">increases the powerlessness</a>.</p>
<p>Bosses and their organizations don’t always take workplace bullying seriously. Some say “lighten up,” “it’s just teasing,” or “that’s not what’s in his heart.” In such cases, the organization often develops a conspiracy of silence, and the workplace bullying <a href="http://www.crcnetbase.com/doi/abs/10.1201/9780203302262.ch6">remains hidden</a> and <a href="http://journals.sagepub.com/doi/abs/10.1177/00187267035610003">likely continues</a>. </p>
<p>Preliminary research suggests that zero-tolerance policies and <a href="https://www.ncbi.nlm.nih.gov/pubmed/26752457">formal</a> <a href="http://www.sciencedirect.com/science/article/pii/S0956522108000365">reporting</a> <a href="http://journals.sagepub.com/doi/abs/10.1177/216507991005801003">processes</a> may do little to stop workplace bullying. A recent review on the effectiveness of training programs focused on educating employees and on developing skills to handle bullying. It revealed that while we can positively impact people’s knowledge and attitudes about bullying, <a href="https://www.ncbi.nlm.nih.gov/pubmed/27382343">stopping the actual behavior</a> isn’t easy and requires a lot of effort. </p>
<p>Several countries – France, Canada, Sweden, United Kingdom, Australia and Germany – have been at the forefront of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4924877/">tackling workplace bullying</a>. Based on experience from these countries, best practices suggest a comprehensive concerted remedy to this problem is needed. At the core of the solution is the cultivation of an organizational culture that does not tolerate bullying and has transparent, safe procedures for the disclosure of such behavior as well as the sanctioning of its perpetrators.</p>
<h2>A learning opportunity?</h2>
<p>Maybe Trump’s presidency is an opportunity for the American people to recognize bullying and understand its potentially corrosive effects on our public institutions and our culture. This same cause-and-effect relationship also holds for our workplaces and, just like standing up in the public sphere, it is up to us to recognize and call out bullies in our companies.</p>
<p>Similar to what American companies have done in the field of workplace sexual harassment, we can develop and enforce ways to prevent bullying in the workplace and set the right example for our new president and his government.</p><img src="https://counter.theconversation.com/content/72773/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joan Cook receives funding from the National Institute of Mental Health and the Patient Centered Outcomes Research Institute.</span></em></p>President Trump has threatened and criticized federal judges and House representatives. In a typical workplace, this would be called bullying. Here’s why it’s important to stop it.Joan M. Cook, Associate Professor of Psychiatry, Yale UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/751252017-03-24T20:02:48Z2017-03-24T20:02:48ZEssential health benefits suddenly at center of health care debate, but what are they?<figure><img src="https://images.theconversation.com/files/162385/original/image-20170324-12149-cq5bed.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Lisa Schwetschenau, who has multiple sclerosis, shown in a photo in Omaha, Nebraska on March 16. She worries that she could lose some of her essential health benefits under the new proposed health care law.</span> <span class="attribution"><span class="source">Nati Harnik/AP</span></span></figcaption></figure><p>Republicans have <a href="http://www.cnbc.com/2017/03/22/heres-why-the-gop-is-coming-up-short-on-votes-to-repeal-obamacare.html">tirelessly campaigned</a> to repeal and replace the <a href="https://www.medicaid.gov/affordable-care-act">Affordable Care Act (ACA)</a> with a conservative, market-based approach to health care. Almost seven years after its passage, and with the election of a Republican president and Congress, the ACA appeared destined to be repealed and potentially replaced. </p>
<p>The House was scheduled to but did not vote on March 24 on that replacement, the <a href="http://www.speaker.gov/HealthCare">American Health Care Act (AHCA)</a>. In the debate running up to the vote, a major sticking point was a relatively obscure, albeit important, component of the ACA called the <a href="https://www.healthcare.gov/coverage/what-marketplace-plans-cover/">Essential Health Benefit (EHB)</a> provision. </p>
<p>These benefits are those deemed “essential” by the authors of the ACA. They include maternity and newborn care, prescription drugs, emergency services and hospitalization. </p>
<p>As a public policy professor, I have studied the EHB provision, their benefits and drawbacks, and how they fit into the overarching construct of the ACA. While there may be room to improve the EHB provision, I have no doubt that outright eliminating the essential health benefits provisions of the ACA would prove to be disastrous.</p>
<h2>How the benefits came to be - and to be so loathed</h2>
<p>The provision has, together with the individual mandate, long been a bane to conservatives and libertarians. Opponents of the ACA see the EHB as restricting consumer choice and artificially inflating the cost of insurance. </p>
<p>Nonetheless, the elimination of the EHB was initially not included in the Republican efforts to repeal the ACA. Indeed, it was added only when it became clear that the Republican leadership lacked the votes to pass the AHCA because of the <a href="https://www.washingtonpost.com/news/powerpost/wp/2017/03/22/what-the-freedom-caucus-wants-in-the-gop-health-bill-and-why-they-arent-getting-it/?utm_term=.5fb1e06af28f">recalcitrance of their most conservative members</a>. </p>
<p>Prior to the ACA, it was up to each respective state to determine what benefits, called insurance mandates, had to be included in insurance plans. Not surprisingly, states differed widely in terms comprehensiveness required, and no specific benefit was deemed essential in all 50 states and Washington, D.C.</p>
<p>While most states required the <a href="https://lintvwpri.files.wordpress.com/2013/10/mandatesinthestates2011execsumm.pdf">inclusion of such benefits</a> as emergency room services (44 states), far fewer required coverage for well-child visits (32), contraceptives (30), maternity services (25), rehabilitation services (7) or prescription drugs (5).</p>
<h2>Pre-ACA requirements were weak</h2>
<p>Even when essential services requirements were in place before the ACA, they were often fairly weak and allowed insurers to make coverage optional or to cap allowable benefits. This greatly affected what and how much care people had access to. </p>
<p>For example, 62 percent of individuals in the individual market lacked maternity coverage and <a href="https://aspe.hhs.gov/basic-report/essential-health-benefits-individual-market-coverage">34 percent lacked coverage for substance abuse disorder treatment</a>.</p>
<p>Thus, the EHB provisions were included in the ACA, for many reasons. First, the <a href="https://www.medicaid.gov/affordable-care-act">ACA was intended</a> to provide coverage that offers viable protection against some of the most basic health care costs Americans experience. </p>
<p>Also, EHBs were designed to provide marketplace consumers with insurance coverage similar to the coverage of employer-sponsored insurance and Medicaid. It would not be a pared-back, bare-bones policy commonly available prior to the ACA.</p>
<p>Another goal was to empower consumers by helping them to compare different insurance plans in the insurance marketplaces. As all plans are required to provide the same basic services, insurers would be required to compete on a level playing field – and not by artificially reducing premiums by excluding essential services. </p>
<p>However, the inclusion of a minimum set of benefits also had technical reasons that are soundly based in health economics. As insurers are now required to accept all interested consumers, insurers with a more comprehensive benefit design would inevitably attract a disproportionate number of sick, and thus costly, individuals. Health economists refer to this process as <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1541-0072.2012.00446.x/abstract">adverse selection</a>. As a result, premiums for these insurers would significantly increase. In response, insurers could either adjust their benefit design or exit the market.</p>
<p>Finally, the broad set of benefits was meant to attract a large, diverse pool of consumers who would jointly share risk and cost for the services covered under the EHB. By attracting a diverse set on consumers, insurers would not be disproportionately exposed to certain high-cost individuals and the overall insurance market would be stabilized. </p>
<p>By requiring insurers to compete on price and quality – and by not allowing them to utilize benefit design to discourage individuals to sign up for their plans – sicker individuals are more evenly spread among all insurers. </p>
<h2>What would happen without them?</h2>
<p>ACA opponents have argued these requirements restrict consumer choice and artificially inflate the cost of insurance. However, eliminating the EHB provisions would likely entail a variety of negative consequences for individual consumers, insurance market, and the broader health care system. </p>
<p>The difficulty for consumers to understand and navigate the health care and insurance system is <a href="http://content.healthaffairs.org/content/22/4/147.full">well-documented</a>. The EHB guarantee consumers that a <a href="http://www.sciencedirect.com/science/article/pii/S0168851014002607">certain set of basic services</a> are included in their insurance and that they are covered in case of sickness. Without EHBs, insurance plans with different benefit designs and structures would likely proliferate. The amount of information would likely overwhelm most consumers and thus make the comparison of insurance plans virtually impossible. </p>
<p>More generally, the elimination of the EHB requirement could dramatically impact insurance markets across the country. No longer required to provide a certain minimum of benefits, insurers <a href="https://www.nytimes.com/2017/03/23/upshot/late-gop-proposal-could-mean-plans-that-cover-aromatherapy-but-not-chemotherapy.html?_r=0">would successively reduce benefits</a> (a race to the skimpiest plan, if you will) in order to attract only the healthiest consumers. These people are the least likely to use services and thus prefer plans with limited protections and lower premiums. Eventually, most if not all plans would be <a href="https://www.nytimes.com/2017/03/23/upshot/late-gop-proposal-could-mean-plans-that-cover-aromatherapy-but-not-chemotherapy.html?_r=0">priced at the available tax credits</a> offered under the AHCA, because at that point these plans would essentially be free for eligible Americans.</p>
<p>As insurers move toward offering ever skimpier plans, individuals would remain free to purchase additional benefits. However, insurers could charge prohibitively high prices for these optional benefits. Or, they could be hesitant to offer these optional benefits at all, as only individuals who expect to use them would be likely to purchase them. </p>
<p>Similarly, healthy individuals could sign up for the skimpiest available insurance plans in order to fulfill the requirement to remain continuously insured. They would then expand their benefits without incurring a penalty in case they fall sick and have large health costs to cover. Or, as the AHCA premium penalties are set rather low, the healthiest individuals could completely defer obtaining such coverage until a major medical need is incurred. Again, insurers would anticipate this behavior and refuse to offer comprehensive coverage.</p>
<p>Ultimately, eliminating the EHB essentially individualizes risk and cost by shrinking the risk pool down to a single individual, a situation similar to the situation prior to the enactment of the ACA. However, health insurance works best by creating a large, diverse pool of consumers with varying health care costs. The ACA sought to achieve this goal by combining the EHB with requirements for insurers to accept all consumers and for consumers to obtain coverage or pay a fine. If people sign up only when they are sick, it raises costs and makes plans unsustainable for insurers. </p>
<h2>A need to reevaluate, not eliminate</h2>
<p>This situation would potentially be further exacerbated by Republican plans to allow for the <a href="http://khn.org/news/sounds-like-a-good-idea-selling-insurance-across-state-lines/">selling of insurance across state lines</a>. Even if liberal states like California were to maintain similar consumer protections as present in the ACA, it is conceivable, even likely, that more conservative states like Florida would quickly move in the opposite direction. That is, they would allow for the sale of so-called bare-bones plans with few benefits or catastrophic plans – plans that only offer protection in case of significant financial exposure. </p>
<p>Both types of plans would naturally be less expensive compared to the more comprehensive plans, and thus attract the healthiest individuals. This has the potential of triggering a death spiral in the insurance markets of more protective states as their premiums would would skyrocket. </p>
<p>As such, individual consumers would bear significant hardship due to the elimination of the EHB. More limited coverage will inevitably lead to higher out-of-pocket costs for consumers.</p>
<p>The negative effects would likely be compounded for the broader health care system. Hospitals will be subject to increasing uncompensated care costs and will then shift these costs either to other consumers or be forced to close their doors. Also, a lot of the benefits of prevention and early intervention would likely be lost.</p>
<p>The EHBs have undeniably <a href="http://www.heritage.org/health-care-reform/report/obamacare-and-insurance-benefit-mandates-raising-premiums-and-reducing">raised insurance premiums</a>. However, this is hardly surprising because they have done so by reducing out-of-pocket costs and by providing consumers with <a href="https://www.nytimes.com/2016/04/21/upshot/obamacare-seems-to-be-reducing-peoples-medical-debt.html">meaningful protection against the vagaries of sickness</a>. </p>
<p><a href="http://www.sciencedirect.com/science/article/pii/S0168851014002607">In my own work</a>, I have shown the diverse approaches that states have taken to adapt the EHB to their local health insurance markets. Unfortunately, <a href="http://gradworks.umi.com/10/16/10164660.html">I have also shown</a> that states often do not rely on available policy expertise to balance adequate coverage with affordability. </p>
<p>Considering the benefits of EHBs, it would be prudent for all stakeholders to continuously revisit the important question of what services should be included in the EHB and which ones should not.</p><img src="https://counter.theconversation.com/content/75125/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>Essential health benefits under Obamacare are suddenly the center of controversy in the proposed replacement bill. If certain health benefits are so essential, why are they so loathed? Here’s a look.Simon F. Haeder, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/743542017-03-13T00:44:30Z2017-03-13T00:44:30ZCould the individual insurance market collapse in some states? Here’s how that could happen<p>Much of the early analysis of the Republicans’ American Health Care Act (AHCA) has focused on the <a href="https://www.washingtonpost.com/blogs/plum-line/wp/2017/03/07/the-new-republican-health-care-plan-is-awe-inspiringly-awful/?utm_term=.5b2c2c94e2c4">change in subsidies</a> for people purchasing coverage in the individual health insurance market. The plan does away with subsidies and instead offers <a href="https://theconversation.com/house-plan-to-replace-obamacare-has-republican-dna-especially-regarding-mandate-74246">tax credits</a> to help people pay for health insurance. </p>
<p>While the change is important, it may be a moot point if there is no individual health insurance market to subsidize.</p>
<p>That distinct possibility depends on how states and the federal government administer the AHCA, should it become law. The <a href="https://waysandmeans.house.gov/ways-means-republicans-take-historic-action-repeal-obamacare-ensure-americans-access-affordable-care/">House Ways and Means Committee</a> approved the AHCA March 9 and moved forward, despite significant <a href="http://fortune.com/2017/03/08/gop-healthcare-plan-aarp-ama-aha/">resistance from groups</a> such as the American Medical Association, the American Hospital Association and AARP. </p>
<h2>Not truly a repeal</h2>
<p>First, we should recognize that the AHCA does not fully repeal the Affordable Care Act.
It <a href="http://healthaffairs.org/blog/2017/03/07/examining-the-house-republican-aca-repeal-and-replace-legislation/">retains the ACA’s rate regulation</a>: Insurers must offer everyone coverage regardless of illness or preexisting conditions. </p>
<p>It also changes <a href="http://healthaffairs.org/blog/2017/03/07/examining-the-house-republican-aca-repeal-and-replace-legislation/">some of the incentives</a> for consumers to purchase care. </p>
<p>This change is very significant because reducing incentives to purchase coverage may make the individual health insurance market disappear. That is because insurers base premiums on the average cost of claims of the individuals they enroll. If health insurers are required to cover anyone who accepts their premiums, the individuals most likely to sign up will be those with the greatest need for health care.</p>
<p>The individuals least likely to purchase coverage, if they purchase coverage at all, are healthy individuals with low probability of needing health care. This is known as <a href="http://www.naic.org/store/free/ASE-OP.pdf">adverse selection</a>: Individuals select whether and how much health insurance to buy based on their own need for health care.</p>
<p>But when healthy individuals choose not to purchase health insurance, insurers are left with costs greater than their premium income. That forces insurers to increase their premiums, which in turn leads healthier individuals to drop coverage increasing average claims costs.</p>
<p>An adverse selection <a href="https://www.degruyter.com/view/j/fhep.1998.1.1/fhep.1998.1.1.1056/fhep.1998.1.1.1056.xml">death spiral</a> results when insurers can’t raise their premiums enough to cover their costs and they leave the market. </p>
<p>The Affordable Care Act (ACA) contains several measures to address adverse selection. The ACA levied a tax on individuals who did not have health insurance – the individual mandate. </p>
<p>To help individuals pay for insurance that the law mandates, the <a href="https://www.healthcare.gov/glossary/affordable-coverage/">ACA defines</a> what percentage of a family’s income is considered an affordable cost for health insurance. It subsidizes the difference between that amount and the actual premium.</p>
<h2>Insurers have been protected to keep them in the market</h2>
<p>Insurers were initially given several protections against adverse selection. One was a reinsurance program for plans sold in the exchange. Reinsurance defrays some of the insurers expenses of high-cost enrollees.</p>
<p>Another was a <a href="http://kff.org/health-reform/issue-brief/explaining-health-care-reform-risk-adjustment-reinsurance-and-risk-corridors/">risk corridor program</a> that limited insurer losses if their premium income was less than the claims costs of their enrollees. Neither of these programs was sufficiently funded to work as intended, and both of them ended in 2016.</p>
<p>Risk adjustment is another method to address risk selection. It redistributes premium income among insurers in the same market in an attempt to ensure that insurers with fewer health enrollees have sufficient funds to cover their costs. The risk adjustment method used under the ACA has been criticized as not accurately measuring risk.</p>
<p>Although many individual health insurance markets appear to be functioning well, a <a href="https://www.usnews.com/news/articles/2016-08-17/health-insurers-exit-from-obamacare-leaves-little-insurance-choice">number of insurers have withdrawn</a> from the ACA’s individual health insurance market for 2017, citing heavy losses in the marketplaces. They attributed those losses to facing sicker patients in the individual market than they had anticipated.</p>
<p>Healthy consumers chose not to purchase insurance, while people needing care did. <a href="http://www.oregonlive.com/politics/index.ssf/2017/02/aetna_ceo_says_obamacare_in_de.html">Insurers argued</a> that there were not enough incentives or strong enough penalties to keep healthier individuals purchasing coverage.</p>
<h2>Incentives not strong enough to attract healthy people?</h2>
<p>How does the House Republican plan address the danger of insurers of not offering care? </p>
<p>The House Republican plan changes the subsidies available to individuals and replaces the individual mandate with a penalty for those who purchase coverage after being uninsured. The ACA’s penalty for not buying coverage is 3 percent of adjusted gross income in every year a person does not buy coverage. The penalty under the Republicans’ American Health Care Act is a 30 percent higher premium for a year. </p>
<p>For example, a healthy 40-year-old whose income is US$40,000 faces a monthly premium of $400, or $4,800 a year. At her income ACA subsidy would be $1,392, making her net annual premium $3,408. If her premiums rise $50 a month ($600 annually) next year her subsidy would increase and she would still play $3,408 a year. If she chooses not to purchase coverage under the ACA she would pay a tax for being uninsured of $1,500 a year. </p>
<p>Under the House plan, a 40-year-old will be eligible for a $3,000 subsidy. Her net cost for coverage after the subsidy would be $1,800. If her premiums rise $50 a month ($600 annually) next year, her costs would increase to the $2,400. If she chooses not to buy coverage and never needed care she pays nothing: She’s saved $1,800 the first year and $2,400 the next. </p>
<p>If after a period of being uninsured, she becomes sick and needs care, however, her premium penalty is 30 percent of the $5,400 annual premium (assuming premiums don’t increase in the third year) which totals $1,620 for the next year. By waiting to purchase health insurance until she needs care, she has saved money. </p>
<p>If she remained uninsured one year and purchased coverage in the next year she would pay a penalty of $1,440 (30 percent of the premium of $4,800). If she remained uninsured for two years and needs to purchase coverage in the third year, she pays a penalty of $1,620. But now she is ill and needs medical care. The cost of the care she needs is likely to be greater than the premium she is paying, even with the 30 percent penalty. </p>
<p>Choosing to remain uninsured for two years cost this woman $3,000 under current law and a penalty of $1,620 under the House Republican plan. The premium subsidy for this woman is more generous at this premium under the House Republican plan but covers less of the costs as premiums increase. Under both plans an insurer would have to offer her coverage regardless of her health status when she chooses to purchase it. If she waits, her health care costs when she does purchase coverage are likely to exceed her premium. For an insurer, that results in an insurance market with losses that are not sustainable.</p>
<h2>Not enough money for risk pools to keep premiums low for others</h2>
<p>The American Health Care Act <a href="http://www.newsday.com/news/nation/how-is-the-house-republicans-american-health-care-act-different-from-obamacare-1.13223877">does allocate money</a> to the states to create high-risk pools or develop new reinsurance programs to stabilize the individual health insurance markets. That would require states to create and administer the programs that relieve insurers from bearing the full costs of individuals like the person in the above example. </p>
<p>The bill allocates <a href="http://healthaffairs.org/blog/2017/03/07/examining-the-house-republican-aca-repeal-and-replace-legislation/">$15 billion in the first two years</a> for market stabilization efforts and $10 billion annually until 2026. </p>
<p>A number of states had high-risk pools prior to the passage of the ACA, and the ACA funded a national Preexisting Condition Insurance Program (PCIP) prior to its full implementation in 2014. These programs covered between 2 and 12 percent of a state’s individual market, and were costly. Based on that experience, the money allocated in the bill would cover the increased costs of about 2 percent of the current individual insurance market. That may not be enough support to keep premiums low enough to attract sufficient numbers of healthier consumers to the individual health insurance market. </p>
<h2>Depending on states’ actions, market could vanish</h2>
<p>The American Health Care Act allows insurers to <a href="http://healthaffairs.org/blog/2017/03/07/examining-the-house-republican-aca-repeal-and-replace-legislation/">lower premiums for young people</a> and increase premiums for older individuals. Currently, the ACA limits premiums for older enrollees to three times the premium for the youngest. The AHCA would <a href="http://healthaffairs.org/blog/2017/03/07/examining-the-house-republican-aca-repeal-and-replace-legislation/">increase that difference to five times</a>.</p>
<p>The goal of that proposal is to decrease premiums for the younger and healthier to encourage them to buy health insurance coverage. </p>
<p>It will have the effect of increasing older individuals’ premium costs, encouraging the healthier of those individuals to remain uninsured until they are old enough for Medicare.</p>
<p>The total effect of these changes will depend entirely on how they are administered. Ensuring a sustainable individual health insurance market will require states to create and administer market stabilization programs such as high-risk pools or a reinsurance program with sufficient funding to keep premiums affordable.</p>
<p>States historically have taken widely different approaches to insurance regulation and currently have chosen different policies under the ACA. States may not have the resources or the regulatory expertise to maintain a fully funded market stabilization program. Insurers may not find it possible to offer coverage in states that don’t have such a stabilization program. If The American Health Care Act becomes law, it is entirely possible that in some states the market framework will result in no insurers offering coverage in the individual health insurance market. </p>
<p>One of the most high-profile problems with the ACA – insurers pulling out of the states’ individual health insurance marketplaces – may not be addressed under the House Republican bill, and may be compounded.</p><img src="https://counter.theconversation.com/content/74354/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bill Custer 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 House plan for health care has been decried for its effect on the poor, the aged and the sick. Ultimately, though, it could affect everyone, if healthy people don’t sign up.Bill Custer, Director of Center for Health Services Reseach, Associate Professor, Georgia State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/742462017-03-09T04:20:10Z2017-03-09T04:20:10ZHouse plan to replace Obamacare ‘has Republican DNA,’ especially regarding mandate<figure><img src="https://images.theconversation.com/files/160070/original/image-20170308-24182-8dbqmn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">House Majority Whip Steve Scalise of Louisiana, left, joined by Rep. Phil Roe, R-Tenn., holds up a copy of the original Affordable Care Act bill during a news conference on Capitol Hill, Wed., March 8, 2017.
</span> <span class="attribution"><span class="source">J. Scott Applewhite/AP</span></span></figcaption></figure><p>Among Obamacare’s many provisions, none was more galling to Republicans than the individual mandate, which required Americans above a certain income to buy insurance. It was the subject of a lawsuit that went to the <a href="http://www.washingtonpost.com/wp-srv/politics/documents/supreme-court-health-care-decision-text.html">U.S. Supreme Court</a> – and survived. </p>
<p>Republican proposals to reform Obamacare have centered on repealing the mandate and thus the penalty on people who don’t buy comprehensive insurance coverage.</p>
<p>The House bill introduced by GOP leaders on March 6 <a href="http://www.cnn.com/2017/03/06/politics/republicans-public-obamacare-plan/">does just that</a>. The question now is whether the bill contains enough incentives to keep enough healthy people in the pool of people who desire coverage. ACA architects insisted that the mandate was necessary to bring healthy people into those pools.</p>
<p>The GOP plan would try to encourage people to maintain coverage by allowing insurers to impose a <a href="http://healthaffairs.org/blog/2017/03/07/examining-the-house-republican-aca-repeal-and-replace-legislation/">30 percent surcharge</a> for those who do not have continuous coverage. For example, an individual with continuous insurance coverage will pay a standard rate for her age and family size. However, if she had a lapse in coverage of more than 63 days due to a job change or perhaps financial difficulties, insurers could charge her up to 130 percent of the standard rate for her first year of coverage.</p>
<p>Ironically, Republicans argued the penalties for not having insurance were too low to induce the young and healthy to enroll in Obamacare, leading to higher premiums and destabilizing the market. Yet the proposed surcharge is significantly weaker than the current mandate.</p>
<p>For the average person, a one-year, 30 percent increase in premium is less than 2.5 percent of income under Obamacare. Further, the Obamacare penalty is per year without insurance, so a healthy person opting out of coverage for five years would pay a lot more in penalty under Obamacare. </p>
<p>Thus young, healthy people are more likely to forgo coverage until they get sick under the House proposal. In turn, I believe insurers are likely to increase premiums under the House plan as more people who are healthy opt to go without coverage. </p>
<p>There are additional components of the House proposal that could mitigate these concerns – while raising other issues. </p>
<p>Under Obamacare, insurers can charge an older person in the plan <a href="https://www.nytimes.com/interactive/2017/03/06/us/politics/republican-obamacare-replacement.html">only three times </a>as much as the youngest. The Republican plan would allow them to charge <a href="http://www.insurancejournal.com/news/national/2017/03/07/443796.htm">five times as much</a>, which should lower premiums for the young and healthy. </p>
<p>The House proposal also includes age-based tax credits that disproportionately favor the young, and would allow insurers to offer less generous policies that would appeal to healthier individuals. </p>
<p>Moving from a mandate to continuous coverage should exacerbate concerns of adverse selection (young and healthy opting out), all else constant. However, the other components of the plan that are advantageous to the young and healthy will offset this effect to some degree. </p>
<p>On the other hand, if insurers are allowed to sell bare-bones policies that have a minimal actuarial value, the market could segment high and low-risk individuals and destabilize quickly.</p>
<p>While important details remain to be worked out, including the size and distribution of tax credits for purchasing insurance, the House proposal has Republican DNA, emphasizing free markets and individual choice, and benefiting those who are higher income and healthy.</p><img src="https://counter.theconversation.com/content/74246/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Geoffrey Joyce 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 opposed Obamacare’s mandate as much as they decried any part of the bill. How would their replacement idea, pegged to incentives, work?Geoffrey Joyce, Chair & Associate Professor, Department of Pharmaceutical & Health Economics, University of Southern CaliforniaLicensed as Creative Commons – attribution, no derivatives.