tag:theconversation.com,2011:/id/topics/ahca-37040/articlesAHCA – The Conversation2017-09-20T03:14:08Ztag:theconversation.com,2011:article/843172017-09-20T03:14:08Z2017-09-20T03:14:08ZHow the latest effort to repeal Obamacare would affect millions<figure><img src="https://images.theconversation.com/files/186610/original/file-20170919-16985-113283u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">From left, Sen. Dean Heller, R-Nev., Sen. Bill Cassidy, R-La., Sen. Ron Johnson, R-Wis., and Sen. Lindsey Graham, R-S.C., hold a press conference on Capitol Hill in Washington, Wednesday, Sept. 13, 2017. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Congress-Health-Overhaul/62e533c109554ce28adbfb4e275e46a6/1/0">AP Photo/Andrew Harnik</a></span></figcaption></figure><p>At the end of July, the nation held its collective breath as Senate Majority Leader Mitch McConnell (R-Ky.) looked poised to achieve his most formidable parliamentary accomplishment: the <a href="https://www.nytimes.com/2017/07/27/us/politics/senate-health-care-vote.html?mcubz=0&_r=0">repeal and replacement of the Affordable Care Act</a>.</p>
<p>But Republican hopes were dashed by one of their own, Sen. John McCain (R-Ariz.), who <a href="https://www.washingtonpost.com/powerpost/the-night-john-mccain-killed-the-gops-health-care-fight/2017/07/28/f5acce58-7361-11e7-8f39-eeb7d3a2d304_story.html?utm_term=.00c807d2ce92">cast the deciding vote</a> that appeared to decisively derail the multi-year effort. </p>
<p>McCain called to return to “regular order,” to work through committees, to bring in and listen to experts, to be open and transparent, and perhaps most importantly, to at least listen to both parties.</p>
<p>And indeed, Senators Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) went to work, bringing together demands from Republicans like <a href="https://www.axios.com/murray-makes-big-concession-in-bipartisan-health-talks-2486922713.html">more flexibility for states to waive certain provisions of the ACA</a>, and demands from Democrats to provide cost-sharing subsidies, for example, to <a href="http://thehill.com/policy/healthcare/350643-senate-health-panel-aims-for-deal-on-stabilizing-markets-early-next-week">stabilize health care markets</a>. The bipartisanship appeared to be spreading as <a href="https://www.hatch.senate.gov/public/index.cfm/releases?ID=071428C9-0FD3-4C76-B3E1-734F93B46CF4">Orrin Hatch (R-Utah) and Ron Wyden (D-Ore.)</a> appeared to have reached an agreement on the future of the Children’s Health Insurance Program.</p>
<p>Now Republican hopes of repealing the ACA have been rekindled with the <a href="http://files.kff.org/attachment/Summary-of-Graham-Cassidy-Heller-Johnson-Amendment">Graham-Cassidy-Heller-Johnson Amendment</a> led by Senators Lindsey Graham (R-S.C.) and Bill Cassidy (R-La). </p>
<p>Like all health care legislation, the bill is complex, but the broad outlines of it are rather clear: It would undo much of the reforms implemented through the ACA and then go a step further.</p>
<h2>What’s in the bill?</h2>
<p>Senate Republicans are rushed once more as they want to achieve health care reform by September 30, the deadline to pass the bill through the <a href="http://www.politifact.com/truth-o-meter/article/2017/jun/22/senate-health-care-bills-two-front-war-policy-and-/">reconciliation process</a> which requires only a simple majority. Indeed, due to their haste, the Congressional Budget Office <a href="https://www.cbo.gov/publication/53116">will not be able to provide any estimates of the bill’s effects on the deficit, health insurance coverage or premiums</a>.</p>
<p>Graham-Cassidy seeks to undo many of the reforms initiated by the ACA. For one, by 2020 it would eliminate the ACA’s Medicaid expansion, which has provided coverage <a href="http://www.kff.org/health-reform/state-indicator/medicaid-expansion-enrollment/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">for 12 million Americans</a> for <a href="http://jhppl.dukejournals.org/content/40/2/281.short">states that chose to expand their program</a>. However, it would prevent new states from expanding their program by 2017. It would also eliminate the insurance marketplace subsidies to assist individuals purchase coverage and with out-of-pocket costs. </p>
<p>To soften states’ financial losses, Graham-Cassidy partially replaces funding for both components with a temporary block grant to states that would run out in 2026. Yet even with the block grant, states would see their funding reduced by a combined <a href="https://www.cbpp.org/research/health/cassidy-graham-plans-damaging-cuts-to-health-care-funding-would-grow-dramatically-in">US$239 billion over six years</a>, according to an analysis by the left-leaning Center on Budget and Policy Priorities. </p>
<p>Graham-Cassidy also significantly alters the regulatory reforms implemented via the ACA. The much-maligned individual and employer mandates would be repealed retroactively. The individual mandate requires that all people of a certain income buy insurance or face a penalty. The employer mandate requires that all employers of a certain size provide insurance to their employees.</p>
<p>While individuals still could not be turned down based on their health status, states could also obtain waivers to weaken or wholly eliminate <a href="https://theconversation.com/how-pre-existing-conditions-became-front-and-center-in-health-care-vote-77138">preexisting condition protections</a>. For example, the Center for American Progress has estimated that individuals could face insurer premium <a href="https://www.americanprogress.org/issues/healthcare/news/2017/09/18/439091/graham-cassidy-aca-repeal-bill-cause-huge-premium-increases-people-pre-existing-conditions/">surcharges of $140,000 for metastatic cancer, $17,000 for being pregnant and $26,000 for rheumatoid arthritis</a>.</p>
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<span class="caption">In one analysis, states could choose to not cover well visits to doctors.</span>
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<p>Similarly, states would be able to waive the ACA’s <a href="https://theconversation.com/essential-health-benefits-suddenly-at-center-of-health-care-debate-but-what-are-they-75125">Essential Health Benefit</a> provisions that required insurers to cover cost for expenditures like ambulance transport, prescription drugs and inpatient services. This would affect all individuals in the respective states because lifetime and annual limits apply only to the Essential Health Benefits. States could also waive the requirement to cover preventive services like immunizations and well-child visits.</p>
<p>Yet like most of the previous efforts to repeal the ACA over the past several months, Graham-Cassidy goes well beyond addressing changes brought about by the ACA. Most severely, the bill moves to dramatically slash and transform the Medicaid program. It would do so by establishing severe per capita caps: that is, it would provide a set amount of money for each enrolled individual compared to an open-ended federal match. These caps, which would affect children, seniors and individuals with disabilities, would also begin in 2020. They would be adjusted by inflation, but not the much larger medical inflation. They would thus result in further reductions over time. The resulting cuts would amount to $175 billion by 2026. </p>
<p>It would also allow states to establish work requirements for the program, defund Planned Parenthood and further expand <a href="https://theconversation.com/why-health-savings-accounts-are-a-bust-for-the-poor-but-a-boost-for-the-privileged-81013">Health Savings Accounts</a>, among other things.</p>
<p>However, unlike most of its <a href="http://files.kff.org/attachment/Summary-of-the-Better-Care-Reconciliation-Act-Updated-072017">predecessors</a>, Graham-Cassidy provides political protections for its supporters because the full extent and severity of its cuts would not fully emerge until 2027, at least two elections away for most senators. The Center on Budget and Policy Priorities has estimated that the effect in 2027 alone, the cliff year, would amount to <a href="https://www.cbpp.org/research/health/cassidy-graham-plans-damaging-cuts-to-health-care-funding-would-grow-dramatically-in">$300 billion</a>. California alone would lose $58 billion, while the state of West Virginia would lose $2 billion. The Center on Budget and Policy Priorities also expects that <a href="https://www.cbpp.org/research/health/cassidy-graham-plans-damaging-cuts-to-health-care-funding-would-grow-dramatically-in">more than 32 million</a> Americans would lose their insurance.</p>
<h2>A step backward … and not addressing the real issues</h2>
<p>In my reading, Graham-Cassidy, just like all its predecessors, does little to fix the problems of the American health care system.</p>
<p>Our system is generally of low quality. Medical errors kill more than <a href="http://www.bmj.com/content/353/bmj.i2139">250,000 Americans each year, making it the third leading cause of death</a>. Prescription errors alone are responsible for more than <a href="https://www.forbes.com/sites/leahbinder/2013/09/03/the-shocking-truth-about-medication-errors/#6e7c907510ab">7,000 deaths</a>. Virtually the entire developed world, and many less-developed countries, are ahead of us with regard to <a href="https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html">infant mortality</a>. The list goes on.</p>
<p>Despite these obvious shortcomings, our health care system is also, by far, the most expensive system in the world. We spend more than <a href="http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective">17 percent of our GDP, or well over $9,000 per person</a>, on health care. This compares to <a href="http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective">10 percent and $3,700 for Japan</a>, <a href="http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective">11 percent and $4,900 for Germany</a>, and <a href="http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective">9 percent and $3,300 for the United Kingdom</a>.</p>
<p>And yet, even after the coverage expansions of the Affordable Care Act, and <a href="http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective">after spending more money from the public’s purses than all but two countries</a>, our uninsurance rates just <a href="http://www.dailynews.com/2017/09/16/healthcare-uninsured-rate-in-us-falls-to-record-low-of-8-8/">inched below 10 percent, and more than 28 million Americans are without insurance</a>.</p>
<p>Indeed, we do not even cover all children in this country, although the rate of insurance from children reached a <a href="http://www.kff.org/other/state-indicator/children-0-18/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">historic high of 95 percent</a>.</p>
<p>With low quality, high costs and lack of universal coverage, much needs to be improved about the American health care system. Unfortunately, Graham-Cassidy as currently written does nothing to improve quality, and it does nothing to reduce the underlying drivers of excessive costs. Indeed, it reverses the significant progress achieved under the ACA in offering coverage to all Americans.</p>
<p>Large-scale changes to the American health care system cannot and should not be quickly patched together without input from the Congressional Budget Office, policy experts, the public and the other party. Many lives and one-sixth of our economy hang in the balance. The American public deserves better.</p><img src="https://counter.theconversation.com/content/84317/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A Senate vote in July seemed to signal the end of efforts to kill the Affordable Care Act. With a Sept. 30 deadline looming, though, a new bill has real possibilities. Here’s why that could be bad.Simon F. Haeder, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/813072017-09-13T02:33:48Z2017-09-13T02:33:48ZWant to fix America’s health care? First, focus on food<figure><img src="https://images.theconversation.com/files/180401/original/file-20170731-22175-67v3q2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Poor diet hurts our health and our wallets.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/closeup-home-made-tasty-burger-on-440673169?src=5ZiZh-oDCb7zYkmg0ZoiOQ-1-26">Lukas Goja/Shutterstock.com</a></span></figcaption></figure><p>The national debate on health care is moving into a new, hopefully bipartisan phase. </p>
<p>The fundamental underlying challenge is <a href="http://www.politico.com/magazine/story/2017/05/24/the-health-care-debate-is-about-money-215189">cost</a> – the massive and ever-rising price of care which drives nearly all disputes, from access to benefit levels to Medicaid expansion. </p>
<p>So far, policymakers have tried to reduce costs by tinkering with how care is delivered. But focusing on care delivery to save money is like trying to reduce the costs of house fires by focusing on firefighters and fire stations. </p>
<p>A more natural question should be: What drives poor health in the U.S., and what can be done about it?</p>
<p>We know the answer. Food is <a href="http://doi.org/10.1001/jama.2013.13805">the number one cause</a> of poor health in America. As a cardiologist and public health scientist, I have studied nutrition science and policy for 20 years. Poor diet is not just about individual choice, but about the systems that make eating poorly the default for most Americans.</p>
<p>If we want to cut down on disease and achieve meaningful health care reform, we should make it a top nonpartisan priority to address our nation’s nutrition crisis.</p>
<h1>Food and health</h1>
<p>Our dietary habits are the leading driver of death and disability, causing an estimated <a href="http://doi.org/10.1001/jama.2013.13805">700,000 deaths each year</a>. Heart disease, stroke, obesity, Type 2 diabetes, cancers, immune function, brain health – all are influenced by <a href="https://doi.org/10.1161/CIRCULATIONAHA.115.018585">what we eat</a>. </p>
<p>For example, our recent research estimated that poor diet causes <a href="https://doi.org/10.1001/jama.2017.0947">nearly half</a> of all U.S. deaths due to heart disease, stroke and diabetes. There are almost 1,000 deaths from these causes alone, every day. </p>
<p>By combining national data on demographics, eating habits and disease rates with empirical evidence on how specific foods are linked to health, we found that most of problems are caused by too few healthy foods like fruits and vegetables and too much salt, processed meats, red meats and sugary drinks. </p>
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<p>To put this in perspective, about twice as many Americans are estimated to die each year <a href="https://doi.org/10.1001/jama.2017.0947">from eating hot dogs and other processed meats (~58,000 deaths/year)</a> than <a href="http://www.iihs.org/iihs/topics/t/general-statistics/fatalityfacts/state-by-state-overview">from car accidents (~35,000 deaths/year)</a>. </p>
<p>Poor eating also contributes to U.S. disparities. People with lower incomes and who are otherwise disadvantaged often have the <a href="https://doi.org/10.1001/jama.2016.7491">worst diets</a>. This causes a vicious cycle of poor health, lost productivity, increased health costs and poverty.</p>
<h1>What a poor diet costs</h1>
<p>It’s hard to fathom how much our country actually spends on health care: currently <a href="https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/highlights.pdf">US$3.2 trillion per year</a>, or nearly 1 in 5 dollars in the entire U.S. economy. That’s almost $1,000 each month for every man, woman and child in the country, exceeding most people’s budgets for food, gas, housing or other common necessities. </p>
<p>Diet-related conditions account for <a href="https://doi.org/10.1161/CIR.0000000000000350">vast health expenditures</a>. Each year, cardiovascular diseases alone result in about $200 billion in direct health care spending and another $125 billion in lost productivity and other indirect costs. </p>
<p>At the same time, health care costs cripple the productivity and profits of American businesses. From small to large companies, crushing health care expenditures are a <a href="https://www.forbes.com/sites/castlight/2014/12/29/how-rising-healthcare-costs-make-american-businesses-less-competitive/">major obstacle to growth and success</a>. Warren Buffet recently called rising medical costs the “<a href="https://www.nytimes.com/2017/05/08/business/dealbook/09dealbook-sorkin-warren-buffett.html">tapeworm of American economic competitiveness</a>.” Our food system is feeding the tapeworm.</p>
<p>Yet, remarkably, nutrition is virtually ignored by our health care system and in the health care debates – both now and a decade ago when Obamacare was passed. Traveling around the country, I find that dietary habits are not included in the electronic medical record, and doctors receive <a href="http://dx.doi.org/10.1155/2015/357627">scant training</a> on healthy eating and other lifestyle priorities. Reimbursement standards and quality metrics rarely cover nutrition. </p>
<p>Meanwhile, total federal spending for nutrition research across all agencies is only about <a href="https://www.ers.usda.gov/amber-waves/2015/june/federal-support-for-nutrition-research-trends-upward-as-usda-share-declines">$1.5 billion per year</a>. Compare that with more than $60 billion spent per year for industry research on drugs, biotechnology and medical devices. </p>
<p>With the top cause of poor health largely ignored, is it any mystery that obesity, diabetes and related conditions are at epidemic levels, while health care costs and premiums skyrocket?</p>
<h1>Moving forward</h1>
<p><a href="https://doi.org/10.1161/CIRCULATIONAHA.115.018585">Advances</a> in nutrition science highlight the most important dietary targets, including foods that should be encouraged or avoided. Policy science provides a road map for successfully addressing our country’s nutrition crisis. </p>
<p><a href="https://doi.org/10.1371/journal.pmed.1002311">For example</a>, according to our calculations, a national program to subsidize the cost of fruits and vegetables by 10 percent could save 150,000 lives over 15 years, while a national 10 percent soda tax could save 30,000 lives. </p>
<p>Similarly, a government-led initiative to <a href="https://doi.org/10.1056/NEJMoa0907355">reduce salt</a> in packaged foods by about three grams per day could prevent tens of thousands of cardiovascular deaths each year, while saving between $10 to $24 billion in health care costs annually. </p>
<p>Companies across the country have been rethinking their approach to employee health, providing a range of financial and other benefits for healthier lifestyles. <a href="https://www.jhrewardslife.com/rewards-article-introducing-the-john-hancock-vitality-healthyfood-program.html">Life insurance</a> has also realized the return on the investment, rewarding clients for healthier living with fitness tracking devices, lower premiums and healthy food benefits which pay back up to $600 each year for nutritious grocery purchases. Every dollar spent on <a href="https://www.acoem.org/uploadedFiles/Knowledge_Centers/Health_and_Productivity/Healthy_Workforce_Now/Investingin_ReducesEmployerCosts.pdf">wellness programs</a> generates about $3.27 in lower medical costs and $2.73 in less absenteeism. </p>
<p>Similar <a href="http://www.nutrisavings.com/">technology-based incentive platforms</a> could be offered to Americans on Medicare, Medicaid and SNAP (formerly known as Food Stamps) – together reaching one in three adults nationally. In 2012, Ohio Senator Rob Portman proposed a Medicare <a href="https://www.portman.senate.gov/public/index.cfm/wellness-rewards">“Better Health Rewards”</a> program to reward seniors for not smoking and for achieving lower weight, blood pressure, glucose and cholesterol. This program should be reintroduced, with updated technology platforms and financial incentives for healthier eating and physical activity.</p>
<p>Several other key strategies should be added, together forming a core for modern healthcare reform. Incorporating such sensible initiatives for better eating will actually improve well-being while lowering costs, allowing expanded coverage for all. </p>
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<p>By any measure, fixing our nation’s nutrition crisis should be a nonpartisan priority. Policy leaders should learn from past successes such as tobacco reduction and <a href="http://circ.ahajournals.org/content/circulationaha/133/2/187/F10.large.jpg">car safety</a>. Through modest steps, we can achieve real reform that makes healthier eating the new normal, improves health and actually reduces costs.</p><img src="https://counter.theconversation.com/content/81307/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dariush Mozaffarian reports honoraria or consulting from Astra Zeneca, Acasti Pharma, GOED, DSM, Haas Avocado Board, Nutrition Impact, Pollock Communications, and Boston Heart Diagnostics; scientific advisory board, Omada Health and Elysium Health; chapter royalties from UpToDate; and research funding from the National Institutes of Health and the Gates Foundation.</span></em></p>Poor diet kills hundreds of thousands per year. If we want to achieve meaningful health care reform, we need to address our nation’s nutrition crisis.Dariush Mozaffarian, Professor of Nutrition, Tufts UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/818002017-08-04T01:58:33Z2017-08-04T01:58:33ZWhat does choice mean when it comes to health care?<figure><img src="https://images.theconversation.com/files/180948/original/file-20170803-29097-xc6w41.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">For many, the heart of the health care debate is the ability of patients to choose their own health care, including whether to buy insurance and which doctor to see. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-patient-665808985?src=Pdsi6uHSlIvHgSRUUk28lA-2-79">Alpa Prod/Shutterstock.com</a></span></figcaption></figure><p>President Trump <a href="http://www.newyorker.com/news/john-cassidy/trumps-health-care-threats-are-nothing-but-spite-and-fury">continues to threaten</a> millions of Americans who now have health insurance with loss of coverage by <a href="https://theconversation.com/trump-isnt-letting-obamacare-die-hes-trying-to-kill-it-81373">undermining the Affordable Care Act</a>, commonly known as “Obamacare.” His goal has been to repeal the ACA, or to have it repealed by a version of congressional bills. </p>
<p>A <a href="https://www.washingtonpost.com/powerpost/the-night-john-mccain-killed-the-gops-health-care-fight/2017/07/28/f5acce58-7361-11e7-8f39-eeb7d3a2d304_story.html?utm_term=.974c84f7b967">July 28 vote killed the Senate bill</a> temporarily, but the threat to those with coverage through the ACA is not over.</p>
<p>As we await the next proposals and rounds of debates, now is a good time to reflect on what the <a href="https://www.forbes.com/sites/theapothecary/2017/01/20/obamacares-individual-mandate-is-really-inefficient/#5ef651ef3ecb">Republicans most detested about Obamacare</a> – the individual mandate, which they argued took away personal choice. The mandate was an essential part of the law, however, by guaranteeing insurers that they would have a large enough pool of healthy people to offset the costs of insuring large numbers of unhealthy people.</p>
<p>As a philosopher of health policy, I think it could be instructional to assess their recent proposals through their lens of “choice.” </p>
<h2>Universal access and choice</h2>
<p>The public debate on proposed health care laws has focused largely on the number of uninsured, which would be lower if we moved to universal coverage. Many experts, advocates and nonprofit research groups, such as Kaiser Family Foundation, use the proportion of people who are covered as a quick way to test whether people have real access to health care. We got partway there with the ACA, with the percentage of <a href="http://www.kff.org/other/state-indicator/total-population/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">uninsured dropping to 9 percent</a> in 2015. </p>
<p>After Trump was elected, Republicans tried to come up with bills, however, that focused not on reducing the number of uninsured but on ensuring that people had a choice about whether to buy insurance. They fought the mandate from the law’s beginnings, filing a lawsuit that reached the U.S. Supreme Court. Chief Justice John Roberts, a George W. Bush appointee, wrote the <a href="http://www.nytimes.com/2012/06/29/us/supreme-court-lets-health-law-largely-stand.html">majority opinion that the mandate did not violate</a> the commerce clause of the Constitution.</p>
<p>If we take them at their word, the system the Republicans aim to replace the ACA with should be focused more on the choices people have, not the number of people who gain insurance. </p>
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<img alt="" src="https://images.theconversation.com/files/180944/original/file-20170803-4947-fxl5km.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/180944/original/file-20170803-4947-fxl5km.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=470&fit=crop&dpr=1 600w, https://images.theconversation.com/files/180944/original/file-20170803-4947-fxl5km.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=470&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/180944/original/file-20170803-4947-fxl5km.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=470&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/180944/original/file-20170803-4947-fxl5km.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=590&fit=crop&dpr=1 754w, https://images.theconversation.com/files/180944/original/file-20170803-4947-fxl5km.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=590&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/180944/original/file-20170803-4947-fxl5km.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=590&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">President Trump and House Speaker Paul Ryan celebrated at the White House on May 5, when the House of Representatives passed Ryan’s version of a health care bill.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Trump-Health-Care-Key-Moments/826c4035d73941b294a6089984bb81a9/1/0">AP Photo/Evan Vucci</a></span>
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<p>The public should take seriously, at least for the sake of argument, the words of<a href="http://www.newsweek.com/resistance-resists-too-often-paul-ryan-health-care-trump-trumpcare-629479"> Paul Ryan</a>, when he said that no one should have to do something they do not want to do. <a href="https://www.usatoday.com/story/opinion/2017/03/13/paul-ryan-cbo-health-care-editorials-debates/99143928/">“Our plan is not about forcing people to buy expensive, one-size-fits-all coverage</a>. It is about giving people more choices and better access to a plan they want and can afford,” Ryan said in a statement issued in March 2017. </p>
<p>Their intent is to replace the goal of universal coverage with an alternative which some have called <a href="https://www.nytimes.com/2016/12/15/us/politics/paul-ryan-affordable-care-act-repeal.html?_r=0">“universal access.”</a> Universal access aims to give people the “choice” of having coverage or foregoing that coverage for other priorities they may have.</p>
<h2>What would a real choice require?</h2>
<p>To have a real choice, people would have to be able to buy insurance plans that meet their possible health needs, both for prevention and treatment. They could compare that choice with the choice to forego coverage. </p>
<p>This means they are not in the position of having only a forced choice. If they have a real choice, they no longer are choosing between a plan they can afford, whose reduced cost reflects the fact that it fails to provide access to preventive or treatment services they want and need, and one they cannot afford at all, though it provides access to the preventive and treatment needs they come to have. </p>
<p>Millions in the U.S. faced such a forced “choice” when they bought in the individual health insurance that preceded the ACA marketplaces.</p>
<p>Such a choice is not a real choice. It is forced because the outcome is determined by limited resources and the lack of freedom that the situation creates.</p>
<h2>Paying for real choice</h2>
<p>Of course, since some goods we want, like cars, come in different brands with different prices, we may not see buying a Chevy instead of a Mercedes as a loss of freedom. If we only want a way to get from A to B, we might not care that the Mercedes provides a better ride and is more prestigious.</p>
<p>But, in buying access to health care, we all want the best care. We all, correctly, think that we are valuable in the ways that health care systems should respect even if we have other preferences and priorities regarding cars. In short, people generally accept ability to pay as a principle for car purchases, but not as a principle for buying access to needed health care.</p>
<p>Accordingly, the Republican effort to avoid coercion and take choice seriously would cost more than their plans allow. </p>
<p>The plans they have offered significantly reduce subsidies to the poor and throw people out of Medicaid, resulting in an <a href="http://healthaffairs.org/blog/2017/06/26/cbo-projects-that-22-million-would-lose-coverage-under-senate-bill/">estimated 22 million people losing insurance</a> coverage. The result is a forced choice, not a real choice, especially for people who want some coverage and perhaps need it but have limited resources that would have qualified them for Medicare or subsidies.</p>
<h2>What happens when some people ‘choose’ to forego coverage?</h2>
<p>The Republican approach does not seem to take into account that even a real choice to forego coverage imposes harms on third parties. It does so by raising the cost and thus limiting the availability of insurance to other people. </p>
<p>Since the Republican plans purport to care about the choices for everyone, these consequences – the harms they impose – are ethical reasons to oppose them on their own terms. Young, healthy people should not be able to “choose” to forego coverage when older, sicker people face only forced choices.</p>
<p>Many people want coverage. What happens to the costs of insurance if the system allows people, who save money by foregoing coverage while they are young and healthier than the average older, sicker person, to receive needed emergency care when they need it? </p>
<p>Consider “free riders,” who may be anyone who foregoes buying insurance coverage but later can get needed health care. The cost of a system that allows people to join it when they have not shared in the cost of providing that care is greater than the cost of a system that excludes such “free riders.” </p>
<p>So allowing those who free ride not to die in the streets when they need care, which is what the existing system of emergency medical care (EMTALA) intends and which Republican plans do not challenge, means that free riding imposes higher costs on those who buy insurance coverage. This is a harm to those who have a real choice to buy coverage. This harm to others involves a cost that goes beyond the unfairness of allowing those who do not contribute their fair share to enjoy the benefit of health care when they need it.</p>
<p>Creating this incentive to free ride is part of what creating “choice” – as envisioned by Republicans – involves. </p>
<h2>Skimpy plans</h2>
<p>Similarly, the <a href="http://thehill.com/policy/healthcare/340570-cruz-plan-could-be-key-to-unlocking-healthcare-votes">Cruz amendment</a>, proposed by Sen. Ted Cruz (R-Texas), to the recent Senate bill would have allowed insurers to market less expensive plans that skimp on needed health care as long as the insurer also markets less skimpy plans at higher prices.</p>
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<img alt="" src="https://images.theconversation.com/files/180945/original/file-20170803-17289-ofxbpa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/180945/original/file-20170803-17289-ofxbpa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/180945/original/file-20170803-17289-ofxbpa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/180945/original/file-20170803-17289-ofxbpa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/180945/original/file-20170803-17289-ofxbpa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/180945/original/file-20170803-17289-ofxbpa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/180945/original/file-20170803-17289-ofxbpa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Sen. Ted Cruz (R-Texas).</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/sioux-center-iowa-january-5-2016-358800029?src=GaOBgP2LzPVylfb9248ecg-1-0">Rich Koele/Shutterstock.com</a></span>
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<p>But the increasing stratification that this amendment produces means greater costs to those who buy less skimpy insurance, harming them. (At the same time, those people facing a forced choice of the skimpy insurance or less skimpy but unaffordable insurance are said to simply “choose” it.)</p>
<p>In sum, the “choice” underlying the congressional plans not only is not really paid for, but exercising that “choice” would harm others in a way that undercuts any appeal it has. Universal access is worse than universal coverage because of the “choice” it creates. </p>
<p><em>Brendan Saloner, assistant professor at the Bloomberg School of Public Health at Johns Hopkins University and a former student of Prof. Daniels, contributed to research for this article.</em></p><img src="https://counter.theconversation.com/content/81800/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Norman Daniels does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The Republican position on health care has been based upon a belief in individual choice. Here’s how their own versions of health care bills eroded choice, however, and how they also did harm.Norman Daniels, Professor of Population Ethics and Professor of Ethics and Population Health, Harvard UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/810132017-07-14T02:41:37Z2017-07-14T02:41:37ZWhy health savings accounts are a bust for the poor but a boost for the privileged<figure><img src="https://images.theconversation.com/files/178181/original/file-20170713-9618-8l6p7j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">North Carolina NAACP President Rev. William Barber, accompanied by Rep. Sheila Jackson Lee, Texas, left, as activists, many with the clergy, are taken into custody by U.S. Capitol Police on Capitol Hill in Washington, July 13, 2017, after protesting against the Republican health care bill.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/Search?query=health+care+bill&ss=10&st=kw&entitysearch=&toItem=15&orderBy=Newest&searchMediaType=excludecollections">AP Photo/J. Scott Applewhite</a></span></figcaption></figure><p>When Senate Majority Leader Mitch McConnell released his <a href="https://www.nytimes.com/2017/07/13/us/politics/senate-republican-health-care-bill.html">new version of the Republican health care bill</a> July 13, he relied on a favorite Republican device to solve the nation’s health care woes – Health Savings Accounts.</p>
<p><a href="https://www.ahip.org/wp-content/uploads/2017/02/2016_HSASurvey_Draft_2.14.17.pdf">Health Savings Accounts</a> (HSAs) were established by the same legislation that created the Medicare Part D prescription drug benefit in 2003. <a href="https://www.ahip.org/wp-content/uploads/2017/02/2016_HSASurvey_Draft_2.14.17.pdf">HSAs</a> allow individuals to make tax-deductible contributions, withdraw money tax-free to pay for qualified medical expenses and avoid taxes on the money invested in the account.</p>
<p><a href="https://www.ahip.org/wp-content/uploads/2017/02/2016_HSASurvey_Draft_2.14.17.pdf">Enrollment in HSAs</a> has skyrocketed to nearly 20 million people, but there’s a catch. Very few, if any, of those 20 million people are poor. The HSAs allow individuals to use tax-protected funds for medical purposes for years to come. Some have even called them the <a href="https://www.wageworks.com/blog/2016/july/07/health-savings-accounts-the-new-401k#sthash.eA4uob07.dpbs">“new 401(k)‘s</a>.”</p>
<p>While these savings accounts can be good for people of a certain income level, I have concerns that they will overlook the needs of the poor, who not only stand to gain very little from the tax advantages but who also are unlikely to have thousands of dollars to contribute to such plans.</p>
<h2>Tax savings and a dose of financial responsibility</h2>
<p>Currently, individuals are allowed to make <a href="https://www.ahip.org/wp-content/uploads/2017/02/2016_HSASurvey_Draft_2.14.17.pdf">annual contributions</a> of US$3,400, while families are allowed to contribute up to $6,750. Unlike so-called health Flexible Spending Accounts, or FSAs, left-over assets in the account carry over from year to year. In 2015, the average balance was just over $1,800.</p>
<p>Individuals are able to establish HSAs only when they obtain coverage through so-called High-Deductible Health Plans (HDHPs), which are currently defined as plans with a deductible of at least $1,300 for single people, or at least $2,600 for family coverage. The maximum out-of-pocket cost for individuals and families are $6,450 and $12,900, respectively.</p>
<p>This means that individuals with these plans are responsible for a significant amount of costs before their insurance benefits kick in. There are no data that show how many people of lower income could afford to fund these plans.</p>
<p>What we do know is that there are about <a href="https://www.ebri.org/publications/ib/index.cfm?fa=ibDisp&content_id=3397">20-22 million policyholders</a> with <a href="https://www.ebri.org/publications/ib/index.cfm?fa=ibDisp&content_id=3397">$28 billion in assets</a>. </p>
<p>In larger employers, <a href="https://www.mercer.com/content/dam/mercer/attachments/private/gl-2017-health-national-survey-infographic-series-mercer.pdf">53 percent of employers offer HSAs, and about a quarter of employees are covered</a>. About <a href="http://www.kff.org/health-reform/poll-finding/survey-of-non-group-health-insurance-enrollees-wave-3/">half of individuals</a> obtaining insurance in the individual market do so via a high-deductible plan. This number is expected to <a href="http://healthaffairs.org/blog/2015/10/07/trouble-ahead-for-high-deductible-health-plans/">continue to grow in the future</a>.</p>
<h2>Why are conservatives enamored of HSAs?</h2>
<p>When it comes to conservative ideology, HSA checks off a number of boxes. </p>
<p>For one, they are supposed to empower the individual to take charge of their own health care decisions. With <a href="https://www.jstor.org/stable/1813785?seq=1#page_scan_tab_contents">more “skin in the game,” individuals will be incentivized to make better, more prudent choices</a> when it comes to their health care. This should not only reduce premiums for individuals and families, but equally important, rein in the growth of U.S. healthcare expenditures.</p>
<p>Lower premiums, in turn, would then allow more Americans to obtain insurance coverage. They would also ease the tremendous burden on American companies seeking to provide health insurance to their employees.</p>
<p>HSAs also reduce the tax burden of Americans, albeit mostly for the wealthier part of society. Moreover, the funds in HSAs will provide investment capital to America’s economy and lead to further economic growth.</p>
<h2>Disadvantages of HSAs?</h2>
<p>A handful of studies have been able to provide some insights into potential benefits and problems of HSAs and HDHPs. Most of the studies confirm the general findings of the famous <a href="https://www.rand.org/content/dam/rand/pubs/reports/2006/R3055.pdf">RAND Health Insurance Experiment</a>: Higher deductibles lead to a reduction in the quantity of medical care consumed. The experiment also showed that, on average, this reduction was not detrimental to individuals’ health status.</p>
<p>However, there was one significant exception: Low-income individuals with chronic conditions saw a significant drop in health status.</p>
<p>More recent studies have shown that HDHPs and HSAs lead to spending about <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2910568/">5-7 percent less</a> on medical care per enrollee. Most of these reductions come from <a href="http://www.ajmc.com/journals/issue/2013/2013-1-vol19-n12/medication-utilization-and-adherence-in-a-health-savings-accounteligible-plan/P-1">reducing the amount of care consumed</a> – <a href="http://www.nber.org/papers/w21632?utm_campaign=ntw&utm_medium=email&utm_source=ntw">not from shopping for cheaper providers</a>. There is also evidence that individuals <a href="http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_152.pdf">delay care</a>, <a href="http://www2.deloitte.com/content/dam/Deloitte/us/Documents/life-sciences-health-care/us-lchs-dig-deep-hidden-costs-112414.pdf">do not comply with doctors’ treatment plans</a> and <a href="http://content.healthaffairs.org/content/31/12/2641.full.pdf+html">are unaware of free preventive services</a>.</p>
<p>None of these findings is surprising.</p>
<p>We know that <a href="http://www.bankrate.com/banking/savings/survey-how-americans-contend-with-unexpected-expenses">many Americans do not have enough savings to account for an emergency</a>, medical or otherwise. The wealthiest Americans disproportionately benefit from these insurance arrangements. Indeed, <a href="https://www.cbpp.org/blog/trump-house-gop-health-savings-account-proposals-would-mostly-help-wealthy-not-uninsured">families making in excess of $100,000 make up 70 percent of HSA contributions</a>. </p>
<p>CNN Money called HSAs “<a href="http://money.cnn.com/2017/05/05/pf/hsa-health-savings-account/index.html">the best tax-free investment account you’ll be able to find</a>.”</p>
<p>We know that American health care consumers are notoriously <a href="http://www.kff.org/health-reform/poll-finding/assessing-americans-familiarity-with-health-insurance-terms-and-concepts/">bad at understanding the U.S. insurance and health care system</a>. They also have <a href="http://www.annualreviews.org/doi/abs/10.1146/annurev-publhealth-082313-115826">problems understanding provider quality</a>. Shopping around, already challenging in the health care field – in case of an emergency or when there is only a limited number of providers – is hardly possible in these conditions.</p>
<h2>The recent Senate bill</h2>
<p>The most recent revision of the Senate’s Better Care Reconciliation Act makes four significant changes to HSAs and HDHPs.</p>
<p>First, it almost doubles the amount individuals are allowed to contribute, to $6,550 and $13,100 for individuals and families, respectively.</p>
<p>Second, it further increases these limits for Americans 55 and older in order to allow them to prepare for retirement.</p>
<p>Third, it also reduces the penalty individuals incur for withdrawing funds from their HSAs for nonqualified expenditures.</p>
<p>Fourth, and this is a significant departure from federal policy since the 1940s, it allows individuals and families to use money in HSAs to pay for insurance premiums. Previously, only individuals with employer-provided insurance were subject to preferential tax treatment.</p>
<h2>The rich can get richer?</h2>
<p><a href="http://www.washingtonexaminer.com/new-senate-republican-healthcare-plan-leaves-taxes-on-the-wealthy-in-place-lets-people-buy-less-expensive-plans/article/2628509">Under criticism from advocates and even members of his own party</a>, Senate Majority Leader Mitch McConnell’s (R-KY) most recently released Senate repeal-and-replace effort maintained many of the Affordable Care Act’s taxes. However, well-to-do Americans may have obtained an even better replacement in the form of Health Savings Accounts. We should also not forget that these taxes could be subject to repeal during the upcoming efforts at tax reform or the budget process.</p>
<p>We know very little about the long-term effects of high-deductible plans. However, <a href="http://content.healthaffairs.org/content/31/12/2641.full.pdf+html">scholarly findings</a> on delayed care, reduced preventive care and avoidance of medical care are cause for concern with potentially significant detrimental effects for the American health care system and Americans.</p>
<p>We also know that these arrangements further <a href="https://www.cbpp.org/research/gao-study-confirms-health-savings-accounts-primarily-benefit-high-income-individuals">segregate the risk pool and divide Americans based on their income and health status</a>. Richer and healthier individuals will seek out these plans to shelter their assets. Poorer and sicker Americans will not be able to reap these benefits.</p>
<p>More than 50 years ago, Nobel Prize-winning economist Kenneth Arrow prominently <a href="https://web.stanford.edu/%7Ejay/health_class/Readings/Lecture01/arrow.pdf">pointed out</a> that the health care field is filled with striking market failures. While HSAs and HDHP may sound like a good solution, they are unlikely, I would argue, to be viable and equitable solutions to what ails the American health care system.</p><img src="https://counter.theconversation.com/content/81013/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The latest Senate health care bill is still a hodgepodge of efforts to repeal Obamacare, critics say. One of their concerns is the focus on HSAs.Simon F. Haeder, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/809432017-07-13T00:02:11Z2017-07-13T00:02:11ZThe 5 faulty beliefs that have led to Republican dysfunction on health care<figure><img src="https://images.theconversation.com/files/177961/original/file-20170712-13319-sfkcc2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Senate Majority Leader Mitch McConnell, shown here in June, 2017, is the architect of the new version of the Senate health care bill released today. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Congress-Health-Overhaul-Analysis/715f0700728a4a83b98fceb853661af7/23/0">AP Photo/J. Scott Applewhite</a></span></figcaption></figure><p>After failure of Republicans to reform health care, an outside observer might think that Congress is just dysfunctional, lurching from one extreme to another in search of something that works for health care reform. </p>
<p>The latest development has been the inability of Republicans to even agree on their own proposal and, worse yet, what should come next if it fails. Should they repeal the Affordable Care Act and worry about a replacement later or just try to “fix” the ACA now?</p>
<p>But the problem is much deeper than just a policy fix. As a former health insurance CEO and professor of health finance, it seems clear to me that Republicans are making five key implicit assumptions that are inherently problematic:</p>
<h2>1. If it’s your own money, you’ll be more careful in how you’ll spend it.</h2>
<p>This foundational belief rests on general experience in markets for most goods, and it has led to Republican support for Health Savings Accounts (HSAs), in which people set aside their own money to pay for their health care costs. </p>
<p>Landmark research showed that this approach could work – but under special conditions. The <a href="https://www.rand.org/health/projects/hie.html">RAND Health Insurance Experiment</a> is the basis for current HSAs. It demonstrated that people could save money – with no worsening of their health – if the cost sharing (deductibles and co-pays) was completely prefunded in individual HSAs. The only major exceptions were for kids and some chronic conditions. </p>
<p>But current proposals have extended this logic to populations, such as those with low incomes and few assets, where these findings are not applicable. Furthermore, HSAs generally are not fully funded to the levels used in the RAND research.</p>
<p>Yet, the Better Care Reconciliation Act, as the current Senate bill is officially called, adds a substantial boost to HSAs, and most state-level Medicaid proposals include a modestly funded health savings account. The problem with this Republican approach is that poor people don’t have any money to begin with and typically can’t afford to buy insurance or pay deductibles. </p>
<p>Furthermore, even those with more money aren’t very good at using their HSA money to shop for care, due to opaque prices for services and lack of information about treatment requirements. </p>
<h2>2. Many or most poor people (Medicaid recipients) can work and should contribute to pay for insurance.</h2>
<p>While the Medicaid expansion enrollees are working already (by definition, they have income above the poverty line), their <a href="http://ccf.georgetown.edu/wp-content/uploads/2013/09/GW-Continuity-Report-9-10-13.pdf">job prospects and history are marginal</a>. The 30,000 Medicaid recipients in the health insurance plan that I ran as CEO, for example, had about nine months of Medicaid eligibility before they got a job and lost coverage. </p>
<p>But the myth persists that Medicaid is loaded with moochers who simply do not choose to work and won’t pay for coverage anyway. </p>
<p>The fact is that very few fall in this category. <a href="http://healthaffairs.org/blog/2017/06/07/state-medicaid-lessons-for-federal-health-reform/">Work requirements and required premiums</a> may be simply a way to reduce Medicaid rolls using a faulty assumption. </p>
<h2>3. Government restrictions are holding back insurers from competition that would drive costs lower.</h2>
<p>Both the Senate and House alternatives cut restrictions and taxes on insurers. Most important of these are the broadening of the range of premiums allowed and the elimination or weakening of required <a href="https://theconversation.com/essential-health-benefits-suddenly-at-center-of-health-care-debate-but-what-are-they-75125">essential health benefits</a>, such as preventive care and maternity coverage. Undoubtedly, these changes will allow premiums to drop – but primarily for the healthy population that needs insurance less while others pay more.</p>
<p><a href="http://www.commonwealthfund.org/publications/blog/2017/apr/selling-health-insurance-across-state-lines">Cross-state competition</a> among insurers is a big Republican talking point. The rules of Congress exclude consideration for this particular legislation, however.</p>
<p>What’s more, it is wishful thinking that, with less regulation, there would be a flood of out-of-state insurers entering new markets and driving health care costs down. Insurers are able to compete on premiums by obtaining favorable contracts with providers. New entrants simply won’t get rates comparable to those already in a market.</p>
<p>In any event, the fact is that it is recent government-induced uncertainty that is <a href="http://www.modernhealthcare.com/article/20170510/NEWS/170519999">driving insurers out of the market</a> and forcing huge increases in premiums filed for 2018 offerings. </p>
<p>It is more than ironic that Senate Majority Leader Mitch McConnell suggested that they may need to “<a href="http://khn.org/morning-breakout/mcconnell-concedes-bill-might-not-pass-but-reaffirms-need-to-shore-up-individual-markets/">shore up the individual market</a>” when the Congress has been the main reason for the instability.</p>
<h2>4. Physicians should be the only ones making care decisions (with the consent of their patients) since they know best.</h2>
<p>Health and Human Services Secretary Tom Price, an orthopedic surgeon, was a vocal advocate of this view – before he accepted the Cabinet job.</p>
<p>Recently, however, from my observations, he seems to have discovered that payment incentives and organizational innovation actually do improve quality, satisfaction and cost. </p>
<p>Perhaps acknowledging this, the Senate plan sought to extend these payment incentives and other ACA innovations through a new “Medicaid Flexibility Program” under its <a href="http://healthaffairs.org/blog/2017/06/24/medicaid-round-two-the-senates-draft-better-care-reconciliation-act-of-2017/">block grant options</a> to the states. </p>
<p>Unfortunately, however, the total amount of <a href="https://www.nytimes.com/interactive/2017/06/26/us/cbo-score-of-senate-health-care-bill.html">funds available to state Medicaid programs</a> would have been cut dramatically. On the principle, however, the Republicans seem to have conceded that health care is a team sport requiring action regarding incentives, organization and knowledge, much like the Democrats, albeit with less funding.</p>
<h2>5. Government should help people – but not too much.</h2>
<p>The original flat premium subsidies proposed by the House are both inadequate and regressive – hurting those with lower incomes. They would have covered almost all of the premium for young people but perhaps half for older enrollees. Also, they would go to everyone regardless of income, unlike Obamacare subsidies, which were based on a defined percent of the purchaser’s income. </p>
<p>The Senate partially corrects this bad arithmetic – and economics – by allowing subsidies to vary somewhat by income. Unfortunately, the base level is far lower than under the ACA. Subsidies are cut substantially for the poor while giving the wealthy tax relief.</p>
<h2>What next?</h2>
<p>So the bottom line is that the <a href="https://www.nytimes.com/2017/07/18/us/politics/republicans-obamacare-repeal-now-replace-later.html?emc=edit_th_20170719&nl=todaysheadlines&nlid=47546052">implosion of the Obamacare exchanges</a> that Republicans have predicted may become a self-fulfilling prophecy under continued threats to sabotage it by administrative action or inaction.</p>
<p>Unfortunately, even with the demise of the Senate bill, it is likely that the grand experiment of Obamacare – advancing the social objective of a fully insured population using a competitive but regulated marketplace – will fade away as insurers run away from <a href="https://www.nytimes.com/2017/01/17/opinion/the-gops-health-care-death-spiral.html">unpredictable markets</a>. </p>
<p>We may come full circle. We could end up with a dysfunctional individual market and a much smaller Medicaid population with many more uninsured people. Once again, Republicans and Democrats continue to debate specifics – rather than deal with differences in beliefs – in an evidence-free brawl.</p><img src="https://counter.theconversation.com/content/80943/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>J.B. Silvers does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Republicans have had a hard time dismantling the Affordable Care Act, despite their promises. That could be because they are operating under certain beliefs about health care that are not accurate.J.B. Silvers, Professor of Health Finance, Weatherhead School of Management & School of Medicine, Case Western Reserve UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/789712017-06-29T23:50:33Z2017-06-29T23:50:33ZWhy market competition has not brought down health care costs<figure><img src="https://images.theconversation.com/files/176312/original/file-20170629-11567-1rf25h9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Decreased regulation has failed to reduce the growing administrative burden of health care. </span> <span class="attribution"><span class="source">Valeri Potapova/Shutterstock.com</span></span></figcaption></figure><p>It is easier than ever to buy stuff. You can purchase almost anything on Amazon <a href="https://www.amazon.com/gp/help/customer/display.html?nodeId=468480">with a click</a>, and it is only slightly harder to find a place to stay in a foreign city on Airbnb. </p>
<p>So why can’t we pay for health care the same way? </p>
<p><a href="http://www.pnhp.org/sites/default/files/docs/2012/Dollars%20and%20Sense.pdf">My research into the economics of health care</a> suggests we should be able to do just that, but only if we say goodbye to our current system of private insurance – and the heavy administrative burden that goes along with it. <a href="https://theconversation.com/republican-health-care-bills-defy-the-partys-own-ideology-80175">Republican efforts</a> to repeal the <a href="https://theconversation.com/us/topics/affordable-care-act-13354">Affordable Care Act</a> (ACA) would take us in the wrong direction. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/176314/original/file-20170629-5317-1vbuf4y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/176314/original/file-20170629-5317-1vbuf4y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/176314/original/file-20170629-5317-1vbuf4y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/176314/original/file-20170629-5317-1vbuf4y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/176314/original/file-20170629-5317-1vbuf4y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/176314/original/file-20170629-5317-1vbuf4y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/176314/original/file-20170629-5317-1vbuf4y.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">Senate Majority Leader Mitch McConnell, middle, on June 27 announced he was delaying a vote on the Republican health care bill.</span>
<span class="attribution"><span class="source">AP Photo/Andrew Harnik</span></span>
</figcaption>
</figure>
<h2>What makes health care so complicated</h2>
<p>In a way, the reason buying health care is different than shopping for a garden gnome or short-term apartment seems obvious. Picking the right doctor, for example, involves a lot more <a href="https://web.stanford.edu/%7Ejay/health_class/Readings/Lecture01/arrow.pdf">anxiety and uncertainty</a> and concerns matters of life and death. </p>
<p>But that’s not really the reason we can’t purchase health care the same way we <a href="http://www.cnn.com/2017/03/07/politics/jason-chaffetz-health-care-iphones/">buy an iPhone</a>. In 1969, this would almost be true (for a rotary phone anyway). Back then, the bill for a birth in a New Jersey hospital <a href="http://www.latimes.com/business/la-fi-healthcare-watch-bills-20150323-story.html">looked a lot like the receipt</a> you’d get for buying pretty much anything else: customer name, amount and a box to be checked for payment by check, charge or money order. </p>
<p>Today, paying for even the simplest office visit <a href="https://www.uta.edu/faculty/story/2311/Misc/2013,2,26,MedicalCostsDemandAndGreed.pdf">can become a nightmare</a>, requiring insurance preauthorization, reimbursements adjusted for in-network or out-of-network copays and deductibles and the physician “tier” (or how your prospective doctor is evaluated for cost and quality by the insurance company). </p>
<p>Prescriptions require even more authorizations, while follow-up care necessitates coordinated review – and it goes without saying that many forms will have to be completed. And this doesn’t end when you arrive at the doctor’s office. A large chunk of any visit is spent with a beleaguered nurse, or even the physician, filling out a required checklist of insurance-mandated questions.</p>
<p>The growing complexity of health care finance explains why it’s becoming more and more expensive even though there has been <a href="http://www.nejm.org/doi/full/10.1056/NEJMp0910064#t=article">little or no improvement in quality</a>. Since 1971, the share of our national income spent on health care <a href="https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsProjected.html">has doubled</a>.</p>
<p>We can blame a significant part of the soaring cost of health care on the ever-increasing burden of administrative complexity, whose cost <a href="https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html">has climbed at a pace of more than 10 percent a year</a> since 1971 and now consumes over 4 percent of GDP, up from less than 1 percent back then. </p>
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<h2>Lemons and cherries</h2>
<p>So if the rising cost of administration is a primary force driving health care inflation, why don’t we do something about it? </p>
<p>That’s because administrative complexity and waste are no accident but rather are baked into our private health insurance system and made worse by continuing attempts to use competitive market processes to achieve social ends other than maximizing profit. </p>
<p>Paying a doctor was relatively simple in the 1960s. <a href="https://books.google.com/books/about/The_Blues.html?id=LGE7OAAACAAJ">Most people had the same insurance policy</a>, issued by Blue Cross and Blue Shield, which back then was a private company but operated like a non-profit under strict regulation.</p>
<p>But in hopes of controlling steadily rising costs, policymakers encouraged insurers besides Blue Cross to enter health insurance markets, beginning with the <a href="https://healthcare.uslegal.com/managed-care-and-hmos/the-hmo-act-of-1973/">HMO Act of 1973</a>. The proliferation of for-profit companies with competing plans raised billing costs for health care providers, which now had to submit claims to a multitude of different insurers, each with its own codes, forms and regulations. </p>
<p>Not only that, but insurers quickly <a href="https://meps.ahrq.gov/data_files/publications/st497/stat497.pdf">discovered the dirty secret of health care finance</a>: Sick people are expensive and make up most costs, while healthy people are profitable. </p>
<p>In other words, the vital lesson for an insurer looking to make money is to identify the few sick people and get them to go away (“<a href="http://frugalfamilydoctor.blogspot.com/2013/06/cherry-picking-and-lemon-dropping.html">lemon dropping</a>”) and find the healthy majority and do things that attract them to your plan (“<a href="https://clearhealthcosts.com/blog/2016/11/doctors-point-view-payments-cherry-picking-lemon-dropping/">cherry picking</a>”). </p>
<p>Insurers are happy to offer discounts on <a href="http://www.aetna.com/employer/commMaterials/documents/Roadmap_to_Wellness/fitness-reimbursement-member-postenroll-flyer-hcr.PDF">fitness club memberships</a> to attract healthy people, for example. But they punish the sick with <a href="http://www.kff.org/health-costs/press-release/average-annual-workplace-family-health-premiums-rise-modest-3-to-18142-in-2016-more-workers-enroll-in-high-deductible-plans-with-savings-option-over-past-two-years/">higher copays and deductibles</a>, as well as increasingly restrictive and intrusive regulations on preauthorization.</p>
<p><a href="http://www.nber.org/papers/w6107">Economists call it adverse selection</a>. Regular people call it paperwork hell. Whatever the name, it’s the purpose of increasingly complicated insurance plans and reimbursement forms.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/176315/original/file-20170629-2996-1mhmzw3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/176315/original/file-20170629-2996-1mhmzw3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/176315/original/file-20170629-2996-1mhmzw3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/176315/original/file-20170629-2996-1mhmzw3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/176315/original/file-20170629-2996-1mhmzw3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/176315/original/file-20170629-2996-1mhmzw3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/176315/original/file-20170629-2996-1mhmzw3.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">Insurers use ‘lemon dropping’ and ‘cherry picking’ to control costs.</span>
<span class="attribution"><span class="source">uoucheg/Shutterstock.com</span></span>
</figcaption>
</figure>
<h2>A failure to fix</h2>
<p>The public and government authorities figured this out quickly, but too often the cures have been as bad as the disease. </p>
<p>We could, and I believe should, have abandoned the use of for-profit private insurance to adopt a <a href="http://www.pnhp.org/facts/what-is-single-payer">simple single-payer system</a>, in which a government agency would provide coverage to everyone in the U.S. Instead, in forging the ACA and in every other health reform enacted in the past 40 years, <a href="http://www.nytimes.com/2010/03/21/health/policy/21health.html?mcubz=0">policymakers decided to work with private insurance</a> while trying to fix some of its evils. </p>
<p>We <a href="https://archive.hhs.gov/news/press/1999pres/990412.html">adopted the “Patient’s Bill of Rights”</a> around the turn of the century and created processes to allow patients and providers to appeal medical decisions made by insurers. State health commissioners now have considerable power to supervise insurers, while the ACA <a href="https://www.healthcare.gov/glossary/essential-health-benefits/">mandates certain essential benefits</a> be provided in all insurance plans.</p>
<p>Yet each of these efforts to protect the sick from abuses inherent in the for-profit insurance system only added to the administrative burden, and the costs, on the entire industry. </p>
<p>Some perceived the problem as a lack of market competition so <a href="http://content.healthaffairs.org/content/16/1/142.abstract">governments freed hospitals</a> and other health care providers from regulations on prices and restrictions on mergers, advertising and other practices. Far from reducing administrative complexity or lowering prices, research has shown that <a href="http://www.sciencedirect.com/science/article/pii/S0148296301003095">deregulation made both problems worse</a> by allowing the formation of networks of hospitals and providers who use advertising and other business and financial practices to control markets and stifle competition.</p>
<p>Simply put, each attempt to fix a <a href="http://www.sciencedirect.com/science/article/pii/S0148296301003095">problem</a> has led to more administration because we have kept intact the system of private health insurance – and for-profit medicine – that is <a href="https://www.bostonglobe.com/opinion/2012/06/21/years-later-weld-deregulation-hospital-rates-looms-large-root-today-cost-crisis-weld-action-root-health-care-cost-crisis/x8RD0if5Mhgoooq5A4ZYmK/story.html">at the root of at the dual problems of rising health care costs</a> and <a href="http://www.fiercehealthcare.com/finance/place-blame-for-high-hospital-prices-squarely-deregulation">growing complexity</a>. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/176313/original/file-20170629-11661-398jad.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/176313/original/file-20170629-11661-398jad.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=412&fit=crop&dpr=1 600w, https://images.theconversation.com/files/176313/original/file-20170629-11661-398jad.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=412&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/176313/original/file-20170629-11661-398jad.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=412&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/176313/original/file-20170629-11661-398jad.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=517&fit=crop&dpr=1 754w, https://images.theconversation.com/files/176313/original/file-20170629-11661-398jad.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=517&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/176313/original/file-20170629-11661-398jad.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=517&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A growing share of Americans support switching to a single-payer health care system.</span>
<span class="attribution"><span class="source">AP Photo/Rich Pedroncelli</span></span>
</figcaption>
</figure>
<h2>It’s time to take a step back</h2>
<p>Clearly, our experiment in market-driven health care has gone awry. </p>
<p>Before we introduced competition and deregulation into health care, things were relatively simple, with <a>most revenue going to providers</a>. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3024588/">We could save a lot of money</a> if we went backwards and adopted a single-payer system like Canada’s, where insurers do not engage in systematic preauthorization or utilization review and hospitals and pharmaceutical companies do not form monopolies to profit at the expense of the public. </p>
<p>Largely by reducing administrative costs within the insurance industry and to providers, a single-payer program could save enough money to <a href="http://www.pnhp.org/sites/default/files/Funding%20HR%20676_Friedman_7.31.13_proofed.pdf">provide health care to all Americans</a>.</p>
<p>Compared with Canada’s single payer system, American doctors and hospitals <a href="http://www.nejm.org/doi/full/10.1056/NEJMsa022033#t=article">have nearly twice as many administrative staff workers</a>. </p>
<p>So whether the ACA remains in force or it’s replaced by something else, I believe we won’t be able to control health costs – and make health care affordable for all Americans – until we revamp the system with <a href="http://time.com/money/4733018/what-is-single-payer-healthcare-system/">something like single payer</a>.</p><img src="https://counter.theconversation.com/content/78971/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gerald Friedman belongs to the Massachusetts Society of Professors (a National Education Association affiliate) and Democratic Socialists of America. He has done some consulting work for the Vermont State Employees and has written reports on single-payer plans for several states, including Maryland, Pennsylvania and New York. </span></em></p>GOP lawmakers say their bills to replace the Affordable Care Act would do a better job than the ACA of controlling rising health care costs, but 40 years of deregulation show it just won’t work.Gerald Friedman, Professor of Economics, UMass AmherstLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/798192017-06-29T23:50:27Z2017-06-29T23:50:27ZHow bills to replace Obamacare would especially harm women<figure><img src="https://images.theconversation.com/files/176287/original/file-20170629-21076-nfnuql.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A woman speaks up at a town hall gathering with Sen. Lindsey Graham (R-South Carolina) in March 2017.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Health-Overhaul-Town-Hall-Graham/bf0a5459ad374d22b1db0ff66600343d/36/0">Mark Crammer/AP</a></span></figcaption></figure><p>As members of Congress are heading back to their districts over Fourth of July break, the future of the Affordable Care Act (ACA), America’s health care system and millions of Americans continues to hang in the balance.</p>
<p>While the House and Senate version of a proposed ACA repeal differ in the details, their broad outlines essentially boil down to three major items.</p>
<p>Both essentially roll back the Medicaid expansion enacted in the ACA that has benefited more than 10 million Americans.</p>
<p>Both significantly reduce funding for the entire Medicaid program that currently benefits 75 million Americans. </p>
<p>And both significantly roll back insurance market regulations that have benefited all Americans wherever they get their insurance. </p>
<p>If these bills become law, more than 20 million Americans would lose coverage over the next 10 years, according to <a href="https://www.cbo.gov/publication/52849">estimates from the nonpartisan Congressional Budget Office</a>. All but the richest Americans will be worse off.</p>
<p>However, one of the most detrimentally affected demographics is actually America’s largest demographic group: America’s women, who would see reductions in coverage, benefits and access.</p>
<p>Much of my <a href="http://simonfhaeder.wixsite.com/home/academic">academic work over the past seven years</a> has focused on the Affordable Care Act. However, as a son, husband and father, whose wife has been previously denied insurance, my concerns are also deeply personal. Policies that are bad for women are bad for all of America.</p>
<h2>Obtaining coverage</h2>
<p>Obtaining insurance coverage has long been challenging for women, as their rates of employer-sponsored insurance have <a href="http://www.kff.org/womens-health-policy/fact-sheet/medicaids-role-for-women/">traditionally trailed those of men significantly</a>.</p>
<p>Not surprisingly, the most dramatic and significant change for women under the ACA, or Obamacare, occurred through the expansion of coverage. Overall the uninsured rate among women fell from <a href="http://files.kff.org/attachment/Issue-Brief-Ten-Ways-That-the-House-American-Health-Care-Act-Could-Affect-Women">17 to 11 percent by 2015</a>. Particularly dramatic were the changes for <a href="http://files.kff.org/attachment/Issue-Brief-Ten-Ways-That-the-House-American-Health-Care-Act-Could-Affect-Women">women of color and those of low socioeconomic standing.</a></p>
<p>One major vehicle for the increase was the expansion of the Medicaid program. Today, <a href="http://files.kff.org/attachment/Issue-Brief-Ten-Ways-That-the-House-American-Health-Care-Act-Could-Affect-Women">20 percent of American women</a> receive coverage through the program. The program serves as the <a href="https://theconversation.com/not-just-for-the-poor-the-crucial-role-of-medicaid-in-americas-health-care-system-78582">crucial backbone for America’s health care system</a>.</p>
<p>In addition, <a href="http://www.kff.org/womens-health-policy/fact-sheet/womens-health-insurance-coverage-fact-sheet/">close to nine million women</a> obtained health insurance coverage in the individual market reformed under the ACA.</p>
<p>Finally, the ACA allowed more than <a href="https://nwlc.org/resources/women-and-health-care-law-united-states/">3.1 million young adults</a> to remain on their parents’ health insurance until age 26.</p>
<h2>Lowering costs</h2>
<p>The availability of insurance coverage is only a first step. Individuals must be able to afford that coverage. While far from perfect, the ACA provided significant funding for women in this regard.</p>
<p>For those women obtaining coverage through Medicaid, <a href="http://files.kff.org/attachment/Fact-Sheet-Medicaids-Role-for-Women">premium and out-of-pocket costs were strictly limited or nonexistent</a>.</p>
<p>Those women who obtained coverage on the <a href="http://jhppl.dukejournals.org/content/early/2015/01/22/03616878-2882219.abstract">ACA’s insurance marketplaces</a> and whose income fell below 400 percent of poverty were eligible for insurance premium subsidies. </p>
<p>For those falling below 250 percent of poverty, <a href="http://onlinelibrary.wiley.com/doi/10.1111/puar.12065/abstract">subsidies to pay for out-of-pocket costs were also available</a>, in addition to premium subsidies. Even for those above the cutoff, the ACA strictly limited annual out-of-pocket costs.</p>
<p>The ACA also sought greater gender equity. As a result, it banned the prevalent practice of gender rating, the practice of charging women higher premiums solely based on their gender. Indeed, in most states it was even common to <a href="https://www.nwlc.org/sites/default/files/pdfs/nwlc_2012_turningtofairness_report.pdf">charge a male smoker less than a female nonsmoker</a> before passage of the ACA.</p>
<p>Finally, the ACA also facilitates access to services by eliminating out-of-pocket costs for preventive services including mammograms and colonoscopies, well-woman visits, vaccinations, domestic and interpersonal violence screening and counseling.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/176285/original/file-20170629-26970-95zbj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/176285/original/file-20170629-26970-95zbj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/176285/original/file-20170629-26970-95zbj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/176285/original/file-20170629-26970-95zbj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/176285/original/file-20170629-26970-95zbj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/176285/original/file-20170629-26970-95zbj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/176285/original/file-20170629-26970-95zbj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The Affordable Care Act pays for preventive services, including mammogram screenings for women.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/happy-woman-looking-doctor-while-undergoing-607144922?src=DoSYX2GufwuY9FDK9l-9qg-1-7">Tyler Olson/www.shutterstock.com</a></span>
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<p>The preventive services provisions have proven crucial for all women in America. Annually, <a href="https://obamacarefacts.com/obamacare-womens-health-services/">six million women</a> receive mammograms through Medicare free of charge. <a href="https://obamacarefacts.com/obamacare-womens-health-services/">Forty-seven million privately insured women</a> are also eligible for the free service.</p>
<p>An <a href="https://nwlc.org/resources/women-and-health-care-law-united-states/">estimated 27 million nonelderly women received preventive services without a co-payment in 2011 and 2012</a>. An additional <a href="https://nwlc.org/resources/women-and-health-care-law-united-states/">38 million women with Medicare</a> received preventive services at no additional cost in 2011.</p>
<h2>Benefits and services</h2>
<p>Some of the most crucial advances from the ACA for women came in the form of insurance market reforms. </p>
<p>For the first time, women could no longer be denied coverage for <a href="https://theconversation.com/how-pre-existing-conditions-became-front-and-center-in-health-care-vote-77138">preexisting conditions</a> such as a C-section, being a survivor of breast or cervical cancer, or having received medical treatment for domestic or sexual violence.</p>
<p>Insurers were also required to provide comprehensive coverage to women because insurance plans have to include the so-called <a href="https://theconversation.com/essential-health-benefits-suddenly-at-center-of-health-care-debate-but-what-are-they-75125">Essential Health Benefits</a>. These minimum required benefits include such crucial components of health care as prescription drugs, inpatient care, mental health and substance abuse services, and pediatric oral and vision care. </p>
<p>For those women eligible for Medicaid, <a href="http://files.kff.org/attachment/Fact-Sheet-Medicaids-Role-for-Women">they now gained access to a comprehensive set of health benefits</a>. </p>
<p>Finally, the ACA eliminated annual and lifetime benefit limits for everyone. </p>
<h2>Helping pregnant women and mothers</h2>
<p>While beneficial for all women, the ACA has been particularly helpful for <a href="http://www.healthpolicyjrnl.com/article/S0168-8510(14)00260-7/abstract">mothers and pregnant women</a>. In addition to providing coverage and reducing costs, the ACA also guaranteed mothers and pregnant women access to crucial benefits.</p>
<p>Under the <a href="http://www.healthpolicyjrnl.com/article/S0168-8510(14)00260-7/abstract">Essential Health Benefit provisions</a>, insurers had to provide coverage for pregnancy, maternity and newborn care. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/176286/original/file-20170629-16069-z58qsp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/176286/original/file-20170629-16069-z58qsp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/176286/original/file-20170629-16069-z58qsp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/176286/original/file-20170629-16069-z58qsp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/176286/original/file-20170629-16069-z58qsp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/176286/original/file-20170629-16069-z58qsp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/176286/original/file-20170629-16069-z58qsp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Maternity benefits are costly, but the Affordable Care Act brought their costs down.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pregnant-woman-doctor-hospital-388590370?src=LnkQko4fQ1kVFzHh_2vIpQ-1-11">Africa Studio/www.shutterstock.com</a></span>
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<p>With the premium cost of maternity care estimated at <a href="https://www.americanprogress.org/issues/healthcare/news/2017/06/20/434670/senate-health-care-bill-drive-coverage-costs-maternity-care-mental-health-substance-use-disorder-treatment/">more than US$17,000</a>, these guarantees were undeniably important. Not surprisingly, previously only <a href="https://nwlc.org/resources/women-and-health-care-law-united-states/">12 percent of individual market plans</a> included maternity benefits.</p>
<p>Moreover, women are able to access these services because preventive and prenatal services are now covered free of charge.</p>
<p>Insurers are now required to provide new mothers with equipment to extract breast milk and the support services to do so. In addition, employers are now required to provide the time and appropriate space for working women to extract the milk.</p>
<p>Finally, the ACA also supports women in planning their families. One important component was the elimination of out-of-pocket costs for contraception reducing the number of women who had to shoulder that burden from <a href="http://files.kff.org/attachment/Issue-Brief-Ten-Ways-That-the-House-American-Health-Care-Act-Could-Affect-Women">more than 20 percent to 3 percent</a>.</p>
<h2>Changes under the Republican proposals</h2>
<p>Famously excluding both women and Democrats from their secret deliberations, it is perhaps not surprising that the Senate repeal and replace proposal is particularly damaging to women’s health. While all Americans will be affected by the change, the damage for America’s women is particularly striking, as the <a href="https://www.cbo.gov/publication/52849">just-released CBO score</a> confirmed.</p>
<p>Rolling back coverage expansions will force millions of women into uninsurance. Eliminating financial support will reduce access to insurance coverage and services. </p>
<p>And undoing insurance market reforms will eliminate crucial benefits from women’s health plans and prevent them from purchasing adequate insurance coverage that fulfills their health needs. </p>
<p>Cuts to Planned Parenthood will reduce access to crucial reproductive and health services that have nothing to do with abortions.</p>
<p>Because of congressional restrictions, neither the Senate nor the House bill can fully undo the ACA. Yet the detrimental effect of a Republican bill’s passage on Americans is now well-established. </p>
<p>Moreover, we should not forget that <a href="https://theconversation.com/how-trump-and-tom-price-can-kill-obamacare-without-the-senate-76489">further regulatory actions</a> and the <a href="https://theconversation.com/beyond-the-cbo-score-how-trump-budget-and-the-ahca-are-dismantling-americas-safety-net-78308">Trump administration’s budget</a> are bound to further reduce coverage and eliminate benefits for male and female Americans alike.</p>
<p>Without the crucial protections of the ACA, America’s women – our mothers, grandmothers, wives, daughters, sisters, neighbors and friends – will be worse off. So will the rest of America.</p><img src="https://counter.theconversation.com/content/79819/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Almost nine million women gained insurance coverage from the Affordable Care Act. Here’s why women could be set back by Republican bills to undo the ACA.Simon F. Haeder, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/801752017-06-29T00:43:13Z2017-06-29T00:43:13ZRepublican health care bills defy the party’s own ideology<figure><img src="https://images.theconversation.com/files/175914/original/file-20170627-24813-1dsbdu5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Senate Majority Leader Mitch McConnell, who announced June 27 that a vote on the Senate health care bill has been delayed until after the July 4 recess.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Congress-Health-Overhaul/36b1273fd7f24263858fdab35af5dacd/14/0">Carolyn Kaster/AP</a></span></figcaption></figure><p>The Senate’s health care proposal made it clear that Republicans, despite their rhetoric, are not interested in market-based reform. Instead, they prefer pro-business, pro-privileged reform. </p>
<p>With Senate Republicans <a href="http://www.politico.com/story/2017/06/27/republicans-key-repeal-vote-delay-240010">planning to rewrite</a> their bill, it’s hard to predict the details of the final proposal. Nonetheless, gauging the House and Senate bills, one can guess that the broad outlines of the final package will be similar. </p>
<p>Because Senate Republicans proposed <a href="https://www.nytimes.com/2017/06/22/us/politics/senate-health-care-bill.html">reducing Medicaid coverage and health care exchange subsidies</a> for low-income individuals, reaction to their bill from consumers, patient advocates and pundits has been <a href="http://www.businessinsider.com/what-doctors-think-of-republican-healthcare-plan-2017-5">overwhelmingly negative</a>. But missing from the national discussion is how the GOP’s legislation also fails to do what party leaders promised their voters. </p>
<p><iframe id="liAt0" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/liAt0/2/" height="500px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>Republicans have repeatedly assured their base that repealing the Affordable Care Act (ACA) will solve health care cost problems by returning the system to a <a href="http://www.heritage.org/health-care-reform/report/competitive-markets-health-care-the-next-revolution">land of competitive markets</a>. But out-of-control medical costs have been an issue at least since the 1950s. Moreover, the health care system was not based on market forces even before the ACA’s passage. </p>
<h2>Breaks for the rich, rollbacks for the poor</h2>
<p>To pay for expanded coverage, the ACA raised taxes on drug and insurance companies while imposing an excise tax on the sale of medical devices. It also <a href="http://www.foxbusiness.com/features/2017/06/22/senate-health-bill-gives-huge-tax-cuts-to-businesses-high-income-households.html">levied a special investment tax</a> and an income surcharge on individuals earning over US$200,000 a year. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/175917/original/file-20170627-7455-s7wpmj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/175917/original/file-20170627-7455-s7wpmj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=416&fit=crop&dpr=1 600w, https://images.theconversation.com/files/175917/original/file-20170627-7455-s7wpmj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=416&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/175917/original/file-20170627-7455-s7wpmj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=416&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/175917/original/file-20170627-7455-s7wpmj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=522&fit=crop&dpr=1 754w, https://images.theconversation.com/files/175917/original/file-20170627-7455-s7wpmj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=522&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/175917/original/file-20170627-7455-s7wpmj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=522&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Taxes on drug companies, such as AstraZeneca, helped pay for expanded health insurance coverage under the Affordable Care Act.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/521453077?src=2FR_QUCwjR_H025maLluWg-1-0&size=huge_jpg">From www.shutterstock.com</a></span>
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<p>The Senate’s proposal seeks to <a href="http://www.politifact.com/truth-o-meter/article/2017/jun/22/senate-health-care-bill-whats-it/">rescind these taxes</a>, granting financial relief to both corporations and the rich. </p>
<p>The result is that the aged and those at the lower end of the earning scale stand to lose benefits. For example, the GOP bill would <a href="http://www.politifact.com/truth-o-meter/article/2017/jun/22/senate-health-care-bill-whats-it/">roll back Medicaid coverage</a> and decrease the income threshold necessary to qualify for subsidies on the ACA’s state exchanges – from 400 percent of the <a href="https://www.nytimes.com/2017/06/22/us/politics/senate-health-care-bill.html">federal poverty line</a> to 350 percent.</p>
<p>Both the House and Senate proposals would change the formula for <a href="https://www.nytimes.com/2017/06/22/us/politics/senate-health-care-bill.html">how subsidies are calculated</a>, with an overall effect of reducing them. </p>
<p>The Senate bill would also <a href="http://www.politifact.com/truth-o-meter/article/2017/jun/22/senate-health-care-bill-whats-it/">eliminate the individual mandate</a> to purchase insurance and continue requiring that insurers accept applicants with preexisting conditions. </p>
<p>To prevent the state exchanges from being left with only the sickest policyholders and even more rapidly rising premium prices, a proposal introduced on June 26 institutes a waiting period. Anyone who allowed their insurance to <a href="http://www.cnbc.com/2017/06/26/us-senate-republicans-to-issue-revised-health-care-bill-senate-aide.html">lapse for more than 63 days</a> would have to wait six months for their new policy’s coverage to kick in.</p>
<h2>The Republicans’ political problem</h2>
<p>The House and Senate bills obliterate the idea – for which their party purportedly stands – of competitive markets lowering prices and enhancing consumer welfare. That’s both a political and a policy problem for Republicans.</p>
<p>In the U.S. health care system, neither public officials nor market forces order <a href="https://www.amazon.com/Ensuring-Americas-Health-Creation-Corporate/dp/1107622875/ref=mt_paperback?_encoding=UTF8&me=">pricing and delivery</a>. Instead, a messy mixture of government and private-sector power has evolved over decades. This framework has driven up costs so high that the average family now pays over $18,000 a year for insurance. </p>
<p>A key component of this unwieldy public-private system is the insurance industry’s dominance over health care. </p>
<p>Many people assume that insurance companies play a natural function in the financing and organization of health services. Yet <a href="https://www.amazon.com/Ensuring-Americas-Health-Creation-Corporate/dp/1107622875/ref=mt_paperback?_encoding=UTF8&me=">insurers did not gain</a> their central position through competitive market processes that sought efficiency. As I wrote in a previous <a href="https://theconversation.com/why-insurance-companies-control-your-medical-care-62540">article for The Conversation</a>, in the early part of the 20th century, the American Medical Association (AMA) swept away a bevy of elegant and cost-effective health care arrangements, which they branded “commercial” and “unethical.” </p>
<p>To replace these health care programs, AMA leaders designed the insurance company model at the end of the 1930s. The insurance company model pushed up costs because it <a href="https://theconversation.com/why-insurance-companies-control-your-medical-care-62540">incentivized doctors</a> to run up a bill that they then sent off to a faraway, faceless corporation.</p>
<p>One reason the insurance company model took hold is that <a href="https://theconversation.com/why-insurance-companies-control-your-medical-care-62540">federal tax policy rewarded companies</a> for providing employees with fringe benefits, including medical insurance. This tax subsidy spread insurance coverage to more people, helped along by the fact that escalating prices were largely hidden from consumers who usually split premium costs with their employer. </p>
<p>As the insurance company model expanded, rapidly mounting medical costs compelled insurers to extend their influence over health care. Over the course of many decades, insurers evolved beyond simply financing health services to also supervising physicians and regulating medical care – all in the name of cost containment. The insurance company model grew. And both the 1965 Medicare program and the 2010 ACA incorporated its logic.</p>
<p>Despite this history, the Republicans’ legislation neglects structural changes, somehow imagining that 2009, the year before the ACA passed, represented halycon days for the U.S. health care system.</p>
<p>True, it’s helpful that Republicans propose reducing ACA requirements so that consumers are permitted to purchase good, but not necessarily gold-plated, coverage. Consumers would instead be able to choose lower-priced policies with smaller deductibles in lieu of high-cost policies with more generous benefits – for example, mental health and drug rehabilitation coverages – that are nonetheless difficult to tap into because of high annual deductibles. But this policy change is weak medicine to remedy our ailing system. Do Republicans really believe that changing mandatory benefits guidelines will be the one tweak that finally gets our country’s health care costs under control?</p>
<p>At bottom, Republican proposals have left vulnerable populations either without coverage or with reduced benefits, but still trapped inside a high-cost system. </p>
<p>This is a key weakness before the Republican base and before conservative ideologues. For many low-income individuals, no amount of bootstrapping or hard work ethic will get them adequate health insurance because coverage is simply too expensive. And that flies in the face of the Republican political narrative.</p>
<h2>Does this make economic sense?</h2>
<p>Republicans may be too timid or lack the votes to advance structural reform. And they may feel it necessary to prop up insurance companies struggling with the costs of insuring high-risk patients. That’s a fair calculation.</p>
<p>But are they ready to create a health care system that aids every group except the working poor? The wealthy will have their health care and their tax cuts. The middle classes will continue to enjoy expensive, generous insurance that’s indirectly funded through the tax code. And insurance companies will accept whatever assistance the government provides – from tax cuts to coverage penalty periods – to continue increasing their authority over the medical system. </p>
<p>That’s an arrangement that leaves out the very groups that are most desperate for health care reform: lower-income families and the working poor.</p><img src="https://counter.theconversation.com/content/80175/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christy Ford Chapin receives funding from Johns Hopkins University, the University of Maryland College Park, the Harvard Business School, and the Library of Congress.</span></em></p>The health care bill proposed by Senate Republicans was little better than the House version, which begs an important question: Who’s driving health care law – a free market or insurance companies?Christy Ford Chapin, Visiting scholar at Johns Hopkins University and Assistant Professor of History, University of Maryland, Baltimore CountyLicensed as Creative Commons – attribution, no derivatives.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>
</figcaption>
</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/799892017-06-23T17:04:29Z2017-06-23T17:04:29ZWhat happens when the federal government eliminates health coverage? Lessons from the past<figure><img src="https://images.theconversation.com/files/175400/original/file-20170623-17499-1tb4buv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Larissa Pisney of Denver protests outside the Aurora, Colorado offices of Rep. Mike Coffman (R-Colorado) to show her displeasure with efforts to dismantle the ACA. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Health-Overhaul-Coffman/1a12889ec3c84bc9ac122bfc913ba5a4/35/0">David Zalubowski/AP</a></span></figcaption></figure><p>After much secrecy and no public deliberation, Senate Republicans finalized release their “draft” repeal and replace bill for the Affordable Care Act on June 22. Unquestionably, the released “draft” will not be the final version.</p>
<p>Amendments and a potential, albeit not necessary, conference committee are likely to make some adjustments. However, both the House version – American Health Care Act (AHCA) – and the Senate’s Better Care Reconciliation Act (BCRA) will significantly reduce coverage for millions of Americans and reshape insurance for virtually everyone. The Congressional Budget Office (CBO) is expected to provide final numbers early the week of June 26.</p>
<p>If successful, the repeal and replacement of the Affordable Care Act would be in rare company. Even though the U.S. has been <a href="http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=9914748&fulltextType=RA&fileId=S0898030615000330">slower than any other Western country to develop a safety net</a>, the U.S. has rarely taken back benefits once they have been bestowed on its citizenry. Indeed, only a small number of significant cases come to mind.</p>
<p>My academic work has analyzed the <a href="https://www.cambridge.org/core/journals/journal-of-policy-history/article/inching-toward-universal-coverage-statefederal-healthcare-programs-in-historical-perspective/E94A03DD1F60F9DCBE3DDE9728DA3224">evolution of the American health care system</a> including those rare instances. I believe historical precedents can provide insights for the current debate.</p>
<h2>Providing help to mothers and infants</h2>
<p>The first major federal grant program for health purposes was also the first one to quickly be eliminated. The program was authorized under the <a href="http://history.house.gov/Historical-Highlights/1901-1950/The-Sheppard%E2%80%93Towner-Maternity-and-Infancy-Act/">Sheppard-Towner Maternity and Infancy Protection Act</a> of 1921. It provided the equivalent of US$20 million a year in today’s dollars to states in order to pay for the needs of women and young children.</p>
<p>Sheppard-Towner, which provided funding to improve health care services for mothers and infants, was enacted after a <a href="http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=9914748&fulltextType=RA&fileId=S0898030615000330">long debate in Congress</a> amid accusations of socialism and promiscuity. Interestingly enough, the act may have passed only due to <a href="http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=9914748&fulltextType=RA&fileId=S0898030615000330">pressure from newly voting-eligible women</a>. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/175397/original/file-20170623-17488-1j7rt82.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/175397/original/file-20170623-17488-1j7rt82.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=861&fit=crop&dpr=1 600w, https://images.theconversation.com/files/175397/original/file-20170623-17488-1j7rt82.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=861&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/175397/original/file-20170623-17488-1j7rt82.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=861&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/175397/original/file-20170623-17488-1j7rt82.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1081&fit=crop&dpr=1 754w, https://images.theconversation.com/files/175397/original/file-20170623-17488-1j7rt82.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1081&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/175397/original/file-20170623-17488-1j7rt82.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1081&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Jeanette Rankin, the original sponsor of the Shepard-Towner Act and the first woman elected to Congress, pictured in 1970.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Watchf-AP-DC-USA-APHS53252-JEANETTE-RANKIN/7ef4ae1aaf8242f991b92a6d646cb1cf/4/0">John Duricka/AP</a></span>
</figcaption>
</figure>
<p>Overall, the <a href="http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=9914748&fulltextType=RA&fileId=S0898030615000330">program was responsible</a> for more than 3 million home visits, close to 200,000 child health conferences and more than 22 million pieces of health education literature distributed. It <a href="http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=9914748&fulltextType=RA&fileId=S0898030615000330">also helped</a> to establish 3,000 permanent health clinics serving 700,000 expectant mothers and more than 4 million babies.</p>
<p>The <a href="http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=9914748&fulltextType=RA&fileId=S0898030615000330">program continued until 1929</a>, when Congress, under pressure from the American Medical Association, the Catholic Church and the Daughters of the American Revolution, terminated the program. Without federal support, a majority of states either eliminated the programs or only provided nominal funding. Fortunately for America’s children and mothers, the <a href="http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=9914748&fulltextType=RA&fileId=S0898030615000330">Social Security Amendment of 1935 reestablished</a> much of the original funding and expanded it over time.</p>
<h2>Helping America’s farmers during the New Deal</h2>
<p>America’s next major program confronted a similar fate. To address the challenges of rural America during the Great Depression, the federal government developed a variety of insurance and health care programs that offered extensive and comprehensive services to millions of farm workers, migrants and farmers.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/175409/original/file-20170623-17464-oug6co.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/175409/original/file-20170623-17464-oug6co.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/175409/original/file-20170623-17464-oug6co.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=575&fit=crop&dpr=1 600w, https://images.theconversation.com/files/175409/original/file-20170623-17464-oug6co.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=575&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/175409/original/file-20170623-17464-oug6co.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=575&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/175409/original/file-20170623-17464-oug6co.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=723&fit=crop&dpr=1 754w, https://images.theconversation.com/files/175409/original/file-20170623-17464-oug6co.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=723&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/175409/original/file-20170623-17464-oug6co.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=723&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Grandmother and sick baby of a migratory family in Arizona. These types of families were targeted for help by the Farm Security Administration.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:On_Arizona_Highway_87,_south_of_Chandler,_Arizona._Grandmother_and_sick_baby_of_migratory_family_ca_._._._-_NARA_-_522206.jpg">NARA/ Dorothea Lange</a></span>
</figcaption>
</figure>
<p>Some of these programs provided subsidies to farmers to form more than 1,200 insurance cooperatives nationwide. At times, <a href="http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=9914748&fulltextType=RA&fileId=S0898030615000330">the federal government’s Farm Security Administaton (FSA)</a> provided extensive services directly to migrant farm workers through medical assistance on agricultural trains, mobile and roving clinics, migratory labor camps that included health centers staffed with qualified providers, full-service hospitals and Agricultural Workers Health Associations (<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1615088/pdf/amjph00461-0128.pdf">AWHA</a>).</p>
<p>In all cases, services were generally comprehensive and included ordinary medical care, emergency surgery and hospitalization, maternal and infant care, prescription drugs and dental care.</p>
<p>Although these services were accepted during wartime, the American Medical Association and the Farm Bureau opposed them, which ultimately led to their demise shortly after World War II. Millions of farmers lost their insurance.</p>
<h2>Medicaid in the 1980s</h2>
<p>Perhaps the most indicative expectations on what will happen in case congressional Republicans are able to pass their proposal hails from the Medicaid program itself.</p>
<p>In the early 1980s, <a href="https://www.amazon.com/gp/product/087766398X/ref=oh_aui_detailpage_o00_s00?ie=UTF8&psc=1">Medicaid underwent a series of cuts and reductions</a> leading to the first contracting in the program’s history. These involved both a reduction in federal funding and in eligibility, and an increase in state flexibility to run the program, as do the Republican proposals in Congress.</p>
<p>The cuts pale in comparison to those currently proposed by both the Senate and House. Nonetheless, the results was the <a href="https://www.amazon.com/gp/product/087766398X/ref=oh_aui_detailpage_o00_s00?ie=UTF8&psc=1">first slowing of the Medicaid growth rate</a>. However, this came at a steep cost for many Americans in the form of a <a href="https://www.amazon.com/gp/product/087766398X/ref=oh_aui_detailpage_o00_s00?ie=UTF8&psc=1">significant reduction in enrollment, benefits and access even during a recessionary period</a>.</p>
<h2>Protecting America’s seniors</h2>
<p>The 1980s also saw the creation and quick demise of another health care program. The <a href="https://www.amazon.com/gp/product/0271014660/ref=oh_aui_search_detailpage?ie=UTF8&psc=1">Medicare Catastrophic Coverage Act of 1988</a> sought to fill in the gaps of the original Medicare program for America’s seniors. Specifically, it sought to provide them with protection from major medical costs and offer them a prescription drug benefit for the first time.</p>
<p>Similarly to the Affordable Care Act, the law had a <a href="https://www.amazon.com/gp/product/0271014660/ref=oh_aui_search_detailpage?ie=UTF8&psc=1">redistributive foundation</a> by requiring richer seniors to contribute more than poorer individuals. Also, similarly to the Affordable Care Act, it phased in benefits over a period of time.</p>
<p>Congress, confronted by affluent seniors who would have shouldered much of the financial burden of the program, quickly repealed much of the law before its provisions came into effect.</p>
<p>It took more than a decade to provide America’s seniors with a prescription drug benefit through Medicare Part D, while only limited steps have been taken to protect seniors from major medical losses.</p>
<h2>A serious setback looming?</h2>
<p>While a latecomer, the United States has <a href="http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=9914748&fulltextType=RA&fileId=S0898030615000330">inched closer</a> to the development of a comprehensive welfare state when it comes to health care. While the development has been incomplete, health benefits, once granted, <a href="http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=9914748&fulltextType=RA&fileId=S0898030615000330">have rarely been revoked except in those few cases described above.</a></p>
<p>The <a href="http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=9914748&fulltextType=RA&fileId=S0898030615000330">consequences of those rare cases are nonetheless instructive</a>. States were unable to continue the program without federal support or offer a valid replacement. Indeed, the programs quickly faded away. With them, millions of Americans lost access to health care.</p>
<p>In all three previous cases, the federal government <a href="http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=9914748&fulltextType=RA&fileId=S0898030615000330">eventually renewed its financial support</a>. However, at times it took time for a replacement program to emerge.</p>
<p>The current changes proposed by congressional Republicans, particularly to the <a href="https://theconversation.com/not-just-for-the-poor-the-crucial-role-of-medicaid-in-americas-health-care-system-78582">Medicaid program</a>, are tremendously more consequential than anything we have previously experienced.</p>
<p>Indeed, in scale and extent, the proposed changes are unprecedented and would significantly roll back, likely for the foreseeable future, America’s safety net.</p><img src="https://counter.theconversation.com/content/79989/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>Cutting back or cutting out social safety net programs, as the Senate and House health care proposals would do, is rare. Here’s a look at how such actions have fared.Simon F. Haeder, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/799762017-06-23T01:15:43Z2017-06-23T01:15:43ZHow to make sense of the Senate health care bill: 4 essential reads<figure><img src="https://images.theconversation.com/files/175276/original/file-20170622-13061-z8pclp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Senate Majority Leader Mitch McConnell (R-Kentucky) smiles after he unveiled the Senate health care bill on June 22, 2017. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/APTOPIX-Congress-Health-Overhaul/88619c7a54af46edb7dd293eb93931bf/5/0">Scott Applewhite/AP</a></span></figcaption></figure><p><em>Editor’s note: The following is a roundup of archival stories related to the health care bill presented by Senate Republicans June 22, 2017.</em></p>
<p>When President Trump ran on a promise to “repeal and replace the disaster that is Obamacare,” he had plenty of support from congressional Republicans. They had tried dozens of times to strike down President Obama’s signature health care law, but so long as Obama was in office, he could block their efforts. </p>
<p>That was then, and this is now an entirely different era. </p>
<p>Stymied <a href="https://theconversation.com/essential-health-benefits-suddenly-at-center-of-health-care-debate-but-what-are-they-75125">previously</a>, the Republican-led Congress and Trump are determined to enact a new health care law. They moved another step closer on June 22, when Senate Majority Leader Mitch McConnell (R-Kentucky) unveiled the Senate plan.</p>
<p>While it is a modified version of a plan the House passed in May, the Senate bill retains many of the House bill’s provisions. Republican sponsors and backers say it softens the blow of some of the previous bill’s provisions that could result in people becoming uninsured by extending the period over which the changes would be enacted. Opponents are saying it only extends the time for enacting changes so that senators who will be up for reelection in six years might be spared the ire of voters who have lost their insurance.</p>
<p>Now that the Senate has revealed its plan, we’ve gone back into our archives to identify and explain the key issues of the health care law, including Medicaid expansion, the individual mandate and essential health benefits. </p>
<h2>One of the biggies: Medicaid rollback</h2>
<p>One of the key provisions of the Affordable Care Act, or Obamacare, was the expansion of Medicaid coverage to adults whose incomes are so low that they could not afford to buy insurance. Before expansion, most states’ Medicaid programs paid for insurance coverage for children, disabled adults and seniors’ nursing care. </p>
<p>The federal government provided money to the states to fund the expansion, but 19 states refused the money – and thus the expansion.</p>
<p>The new bill would phase out Medicaid expansion in the states that participated. That could be a disastrous move, many health care advocates fear, even though Republicans view that as a way to control costs. </p>
<p>West Virginia University public policy scholar Simon Haeder explained in a <a href="https://theconversation.com/not-just-for-the-poor-the-crucial-role-of-medicaid-in-americas-health-care-system-78582">June 7, 2017 article</a> that Medicaid long ago ceased to be a program for the poor and instead “provides the backbone of America’s health care system.” </p>
<blockquote>
<p>“Indeed, it is the largest single payer in the American health care system, covering more than 20 percent of the population. This amounts to 75 million American children, pregnant women, parents, single adults, disabled people and seniors.</p>
<p>"To put this in perspective, this is about the same number of individuals as the nation’s two largest commercial insurers combined. Roughly half of all enrollees are children.”</p>
</blockquote>
<p>University of Southern California health economist Darius Lakdawalla, University of Chicago economist Anup Malani and Stanford University professor of medicine Jay Bhattacharya explained that Medicaid is far from a perfect program, however, and <a href="https://theconversation.com/why-america-needs-a-do-over-on-medicaid-reform-75524">could stand an “do-over.”</a> Low reimbursement rates to doctors are a big problem, they wrote. </p>
<blockquote>
<p>“Medicaid provides lower reimbursements to physicians than private insurance or Medicare, the federal health program for elderly and disabled Americans. The result: fewer physicians accepting Medicaid coverage and fewer choices for Medicaid beneficiaries.</p>
<p>"Prior studies suggest that about one-third of physicians nationwide refuse to accept new patients on Medicaid, and this problem is even worse in urban areas.</p>
<p>"Rural areas have their own problems with the program. Their residents are poorer and more likely to be on Medicaid. The prevalence of Medicaid coverage, and its stingier reimbursements, is one reason why hospitals in rural areas have closed down.”</p>
</blockquote>
<h2>Mandate gets nixed</h2>
<p>Republicans detested one provision of Obamacare so much that they contested it – all the way to the Supreme Court. This is the so-called individual mandate, or the requirement that all people above a certain income buy insurance or else face a penalty. Opponents of the mandate said the requirement was unconstitutional. In a 5-4 decision on June 28, 2012, the court disagreed, upholding the mandate and drawing the wrath of Republicans, many of whom turned on Chief Justice John Roberts, who authored the majority opinion.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/175278/original/file-20170622-12021-1emm4gi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/175278/original/file-20170622-12021-1emm4gi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=890&fit=crop&dpr=1 600w, https://images.theconversation.com/files/175278/original/file-20170622-12021-1emm4gi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=890&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/175278/original/file-20170622-12021-1emm4gi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=890&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/175278/original/file-20170622-12021-1emm4gi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1118&fit=crop&dpr=1 754w, https://images.theconversation.com/files/175278/original/file-20170622-12021-1emm4gi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1118&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/175278/original/file-20170622-12021-1emm4gi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1118&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Chief Justice John Roberts, a George W. Bush appointee, drew rebukes from conservatives after the 2012 ruling on Obamacare upheld the individual mandate.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Supreme-Court/f31bf42cfbd54c5fb9d357e9770816ab/41/0">J. Scott Applewhite/AP</a></span>
</figcaption>
</figure>
<p>The Senate bill, like its sister House bill, would kill that mandate. </p>
<p>But the purpose of the mandate is to bring healthy people into the insurance market, health policy scholars have written in The Conversation. Insurers need those healthy people to lower risk and buffer against the higher costs associated with sicker people. And without such a mandate, healthy people will not enroll, and the marketplace would crumble. </p>
<p>Georgia State University scholar <a href="https://theconversation.com/could-the-individual-insurance-market-collapse-in-some-states-heres-how-that-could-happen-74354">Bill Custer explained</a> it this way in a March 2017 piece for The Conversation:</p>
<blockquote>
<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 death spiral results when insurers can’t raise their premiums enough to cover their costs and they leave the market.”</p>
</blockquote>
<h2>Essential health benefits would change</h2>
<p>Obamacare required that insurers provide coverage for certain services deemed to be basic, or essential, to good health. The goal was to prevent insurers from offering pared-back plans that would leave consumers empty-handed in time of medical need. These included such things as maternity benefits, emergency care and hospitalization. </p>
<p>This provision has long irked conservative Republicans, who view it as not only costly but also an example of governmental intrusion. Like the House bill, the Senate bill allows states more choice about these essential health benefits.</p>
<p>West Virginia’s Simon Haeder explained in a March 2017 piece how 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> came about:</p>
<blockquote>
<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 34 percent lacked coverage for substance abuse disorder treatment.</p>
<p>"Thus, the EHB provisions were included in the ACA, for many reasons. First, the ACA was intended to provide coverage that offers viable protection against some of the most basic health care costs Americans experience.”</p>
</blockquote><img src="https://counter.theconversation.com/content/79976/count.gif" alt="The Conversation" width="1" height="1" />
The Senate released its new health care bill on June 22, 2017, and it differs slightly from a bill passed by the House in May. Read what our experts have written in recent months about key pieces.Lynne Anderson, Senior Health + Medicine Editor, The Conversation, USLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/785822017-06-08T02:36:32Z2017-06-08T02:36:32ZNot just for the poor: The crucial role of Medicaid in America’s health care system<figure><img src="https://images.theconversation.com/files/172780/original/file-20170607-5408-1s5sis7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Nurse Jane Kern administers medicine to patient Lexi Gerkin in Brentwood, New Hampshire. Lexi is one of thousands of severely disabled or ill children covered by Medicaid, regardless of family income.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/Search?query=Medicaid&ss=10&st=kw&entitysearch=&toItem=15&orderBy=Newest&searchMediaType=excludecollections">Charles Krupa/AP</a></span></figcaption></figure><p>Despite many assertions to <a href="http://thehill.com/homenews/senate/336493-lindsey-graham-i-dont-think-gop-can-pass-healthcare-bill-this-year">the contrary</a>, Senate leaders are <a href="https://www.vox.com/policy-and-politics/2017/6/6/15750078/voxcare-new-factions-of-senate-health-care-debate">now saying</a> they want to vote on the <a href="https://www.congress.gov/bill/115th-congress/house-bill/1628">replacement bill for Obamacare</a> before the month is out. </p>
<p>Front and center is the planned transformation of America’s Medicaid program, which covers 20 percent of Americans and provides the backbone of America’s health care system.</p>
<p>As a professor of public policy, I have <a href="http://simonfhaeder.wixsite.com/home/academic">written extensively</a> about the <a href="https://www.cambridge.org/core/journals/journal-of-policy-history/article/inching-toward-universal-coverage-statefederal-healthcare-programs-in-historical-perspective/E94A03DD1F60F9DCBE3DDE9728DA3224">American health care system</a> and the <a href="http://jhppl.dukejournals.org/content/40/2/281">Affordable Care Act</a>. </p>
<p>Living in West Virginia, perhaps the nation’s poorest state, I have also seen the benefits of the ACA’s Medicaid expansion since 2014. </p>
<p>To understand how the ACHA’s proposed changes to Medicaid would affect people and our health care system, let’s look more closely at the program.</p>
<h2>What is Medicaid?</h2>
<p>Created in 1965, Medicaid today provides health care services for <a href="http://www.kff.org/health-reform/state-indicator/total-monthly-medicaid-and-chip-enrollment/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">75 million Americans</a>. It is jointly administered by the federal government and the states. The federal government pays at <a href="http://kff.org/medicaid/state-indicator/federal-matching-rate-and-multiplier/">least 50 percent</a> of the costs of the program. For particularly poor states, the federal government’s contribution <a href="http://kff.org/medicaid/state-indicator/federal-matching-rate-and-multiplier/">can exceed 75 percent</a>.</p>
<p>Medicaid was initially envisioned to provide medical assistance only to individuals <a href="https://kaiserfamilyfoundation.files.wordpress.com/2010/06/7334-05.pdf">receiving cash welfare benefits</a>. Over time, the program has been significantly expanded in terms of benefits and eligibility to make up for the growing shortcomings of private insurance markets, including <a href="http://www.kff.org/private-insurance/issue-brief/trends-in-employer-sponsored-insurance-offer-and-coverage-rates-1999-2014/">rapidly growing premiums and increasing rates of uninsurance</a>. </p>
<p>Like all health care programs, spending on Medicaid has increased dramatically since its inception in 1965. Today, we are spending about <a href="http://kff.org/medicaid/state-indicator/total-medicaid-spending/">US$550 billion annually</a>. This compares to about <a href="https://kaiserfamilyfoundation.files.wordpress.com/2013/01/8152.pdf">$300 billion in 2007</a>. </p>
<h2>What does Medicaid do?</h2>
<p>As Medicaid evolved, it has become more than just a program for America’s poor. Indeed, it is the largest single payer in the American health care system, <a href="http://www.kff.org/other/state-indicator/total-population/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">covering more than 20 percent of the population</a>. This amounts to <a href="http://files.kff.org/attachment/Fact-Sheet-Medicaid-Pocket-Primer">75 million American children, pregnant women, parents, single adults, disabled people and seniors</a>.</p>
<p>To put this in perspective, this is about the same number of individuals as <a href="http://www.healthcarefinancenews.com/news/anthem-membership-overtakes-unitedhealthcare-one-count">the nation’s two largest commercial insurers combined</a>. </p>
<p>Roughly half of all enrollees <a href="http://files.kff.org/attachment/Fact-Sheet-Medicaid-Pocket-Primer">are children</a>. </p>
<p>Medicaid also pays for about <a href="https://www.abqjournal.com/977267/nm-has-highest-rate-of-medicaidcovered-births.html">50 percent of births in the U.S.</a> In some states like New Mexico, Arkansas, Wisconsin and Oklahoma, close to <a href="https://www.abqjournal.com/977267/nm-has-highest-rate-of-medicaidcovered-births.html">two-thirds of births are paid for by Medicaid</a>. </p>
<p>Medicaid helps many Americans who are generally not considered “needy.” For example, the <a href="http://files.kff.org/attachment/report-medicaid-financial-eligibility-for-seniors-and-people-with-disabilities-in-2015">Katie Beckett program</a> provides support to families with children with significant disabilities without regard to parental income. </p>
<p>Medicaid is also critical for elderly Americans. It is Medicaid – not the federally run insurance program for the elderly, Medicare – that is the largest payer for long-term care in the United States. These services include, for example, <a href="http://www.kff.org/medicaid/report/medicaid-and-long-term-services-and-supports-a-primer/">nursing facility care, adult daycare programs, home health aide services and personal care services</a>. It pays for roughly <a href="http://kff.org/medicaid/report/medicaid-and-long-term-services-and-supports-a-primer/">50 percent of all long-term care expenses and about two-thirds of nursing home residents</a>. And it also provides help with Medicare premiums for <a href="http://files.kff.org/attachment/Fact-Sheet-Medicaid-Pocket-Primer">about 20 percent of seniors</a>.</p>
<p>Indeed, the vast majority of costs in the Medicaid program, <a href="http://www.pewtrusts.org/en/research-and-analysis/analysis/2015/07/29/state-spending-on-medicaid">about two-thirds, are incurred by elderly or disabled individuals who make up only a quarter of enrollment</a>. </p>
<h2>How did the Affordable Care Act, or Obamacare, change Medicaid?</h2>
<p>One of main components of the Affordable Care Act was the <a href="http://jhppl.dukejournals.org/content/40/2/281">expansion of Medicaid</a> to 138 percent of the Federal Poverty Line (FPL). For a family of four, this amounts to $2,800 per month. </p>
<p>However, the <a href="http://jhppl.dukejournals.org/content/40/2/281">Supreme Court rejected the ACA’s mandatory expansion of Medicaid and made it optional</a>. To date, 31 states and Washington, D.C. have chosen to expand their Medicaid program. Not surprisingly, <a href="http://kff.org/uninsured/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/">the uninsurance rate in those states has dropped significantly more</a> than in states refusing to expand their Medicaid programs.</p>
<p>Nonetheless, Medicaid enrollment increased <a href="http://kff.org/health-reform/state-indicator/medicaid-expansion-enrollment/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">by about 30 percent since the inception of the ACA</a>. </p>
<p>The expansion has also resulted in <a href="http://www.fiercehealthcare.com/population-health/medicaid-expansion-linked-to-better-care-access-better-health">better access and better health</a> for individuals. </p>
<p>It has also helped to <a href="http://www.statenetwork.org/wp-content/uploads/2016/07/State-Network-Manatt-Medicaid-States-Most-Powerful-Tool-to-Combat-the-Opioid-Crisis-July-2016.pdf">fight the nation’s opioid epidemic</a>.</p>
<p>In states that did not expand Medicaid, <a href="http://kff.org/report-section/a-look-at-rural-hospital-closures-and-implications-for-access-to-care-three-case-studies-issue-brief/">hospital closures occurred disportionately</a>.</p>
<h2>What would the Republican-backed AHCA and the Trump budget do to Medicaid?</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/172783/original/file-20170607-21294-1y1r2mq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/172783/original/file-20170607-21294-1y1r2mq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/172783/original/file-20170607-21294-1y1r2mq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/172783/original/file-20170607-21294-1y1r2mq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/172783/original/file-20170607-21294-1y1r2mq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/172783/original/file-20170607-21294-1y1r2mq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/172783/original/file-20170607-21294-1y1r2mq.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">Tom Price, secretary of the Department of Health and Human Services, whose department includes the oversight of Medicaid, pictured in the Rose Garden the day House Republicans passed a bill that would overhaul Medicaid.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Trump-Congress-Health-Care/a130d64a97514786b6e584fa4d1176e8/19/0">Evan Vucci/AP</a></span>
</figcaption>
</figure>
<p>Overall, the <a href="https://www.congress.gov/bill/115th-congress/house-bill/1628">American Health Care Act</a> cuts more than $800 billion from Medicaid by 2026. The cuts focus on two major components.</p>
<p>First, the AHCA significantly reduces funding for the Medicaid expansion under the Affordable Care Act. These changes reduce the federal government’s contribution from 90 percent to an <a href="https://www.medicaid.gov/medicaid/financing-and-reimbursement/">average of 57 percent</a>. The large associated costs for states
<a href="http://www.wvgazettemail.com/gazette-op-ed-commentaries/20170513/simon-f-haeder-time-to-be-honest-american-health-care-act-bad-for-wv">would virtually eliminate the expansion in most if not all states</a>. </p>
<p>However, the American Health Care Act goes further. Specifically, it alters the funding mechanism for the entire Medicaid program. Instead, it provides a set amount of funding per individual enrolled in Medicaid. In doing so, it ends the federal government’s open-ended commitment to providing health care to America’s neediest populations. </p>
<p>Over time, these per capita payment are adjusted based on the Medical Consumer Price Index. In states like West Virginia, these increases <a href="http://www.wvgazettemail.com/gazette-op-ed-commentaries/20170513/simon-f-haeder-time-to-be-honest-american-health-care-act-bad-for-wv">will not keep pace with rising costs for the state’s sick and disabled</a>. </p>
<p>In addition to the more than $800 billion in cuts to Medicaid under the AHCA, the <a href="https://www.documentcloud.org/documents/3728643-Putting-America-s-Health-First-FY-2018-President.html">proposed budget by President Trump</a> would further cut Medicaid by more than $600 billion over ten years. </p>
<p>One major way to achieve this is to further reduce the <a href="http://www.kff.org/medicaid/fact-sheet/presidents-2018-budget-proposal-reduces-federal-funding-for-coverage-of-children-in-medicaid-and-chip/">growth rate of the per capita payments</a>. </p>
<h2>What would be the effects of dismantling Medicaid?</h2>
<p>Both the American Health Care Act and the Trump budget would be challenging for the program. In combination, I believe they would be truly devastating.</p>
<p>The cuts would force millions of Americans into uninsurance. Confronted with medical needs, these Americans will be forced to choose between food and shelter and medical treatment for themselves and their families. They would also <a href="http://www.consumerreports.org/personal-bankruptcy/how-the-aca-drove-down-personal-bankruptcy/">force millions of Americans into medical bankruptcy</a>, similar to the situation prior to the ACA. </p>
<p>The cuts would also affect the broader American health care system. They would create incredible burdens on American hospitals and other safety net providers. Many of them are already operating <a href="https://www.ruralhealthweb.org/news/nearly-700-rural-hospitals-at-risk-of-closing">on very thin margins</a>. </p>
<p>Medicaid is particularly important in keeping doors open at <a href="http://kff.org/report-section/a-look-at-rural-hospital-closures-and-implications-for-access-to-care-three-case-studies-issue-brief/">rural</a>, <a href="https://essentialhospitals.org/tag/medicaid/">inner-city and essential service hospitals</a>.</p>
<p>The cuts would cause tremendous burdens for million of Americans <a href="http://www.kff.org/medicaid/report/medicaid-and-long-term-services-and-supports-a-primer/">with disabilities and their families</a>. </p>
<p>They would shrink the program <a href="https://www.nytimes.com/interactive/2017/05/24/us/politics/trump-medicaid-budget-cuts.html?_r=0">virtually in half</a> over the next decade. </p>
<p>Unable to raise the necessary funds, states will be forced to <a href="http://www.wvgazettemail.com/gazette-op-ed-commentaries/20170513/simon-f-haeder-time-to-be-honest-american-health-care-act-bad-for-wv">cut either eligibility, benefits or both</a>.</p>
<p>In my view, both the American Health Care Act and the proposed budget by the Trump administration will cause dramatic, avoidable harm to millions of our families, friends, neighbors and communities.</p><img src="https://counter.theconversation.com/content/78582/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>As Republicans seek to repeal Obamacare, they have added an overhaul of Medicaid to their plans. Here’s a look at the program and the surprising number of people who would be affected by cuts.Simon F. Haeder, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/783082017-05-25T16:02:46Z2017-05-25T16:02:46ZBeyond the CBO score: How Trump Budget and the AHCA are dismantling America’s safety net<figure><img src="https://images.theconversation.com/files/171018/original/file-20170525-23224-nbrwvx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">President Trump and House Speaker Paul Ryan, to his left, celebrating the House passage of the AHCA on May 4. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Trump-Congress-Health-Care/73cecd998d2f4a7fb66082493c523a1b/17/0">Evan Vucci/AP</a></span></figcaption></figure><p>The Congressional Budget Office (CBO) on May 24 released its <a href="https://www.cbo.gov/publication/52752">long-awaited analysis</a> of the <a href="https://www.congress.gov/bill/115th-congress/house-bill/1628">American Health Care Act</a> (AHCA) passed by the House of Representatives three weeks ago. </p>
<p>While the score was not dramatically different from an earlier one, it nonetheless drew a significant amount of news coverage. Countless articles talk about the AHCA’s dramatic effects on insurance coverage and premiums.</p>
<p>However, this focus is decidedly too narrow and missed the larger endeavor by President Trump and Speaker Paul Ryan to initiate a dramatic disinvestment from the nation’s disadvantaged, particularly in terms of health care. </p>
<p>Working in one of the nation’s poorest states, West Virginia, I encounter the challenges of poverty firsthand. It complements my academic work on the <a href="http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=9914748&fulltextType=RA&fileId=S0898030615000330">historic development of the American safety net</a> and the <a href="http://search.proquest.com/openview/bf39b86775e074685e579cd03284e9f7/1.pdf?pq-origsite=gscholar&cbl=18750&diss=y">historic role of public hospitals</a>. The combination of the AHCA and the Trump administration’s budget would hollow out America’s safety net that has evolved since the New Deal and the Great Society.</p>
<h2>The Congressional Budget Office and the American Health Care Act</h2>
<p>The <a href="https://www.cbo.gov/">Congressional Budget Office (CBO)</a> is a nonpartisan congressional agency created in the early 1970s during the Nixon administration. It was envisioned as a counterweight to the dominance of the executive branch and the president in policymaking, particularly when it comes to budgeting. It was also supposed to infuse policy decisions with nonpartisan, analytical information. The <a href="http://search.proquest.com/openview/bf39b86775e074685e579cd03284e9f7/1?pq-origsite=gscholar&cbl=18750&diss=y">assumption is that policymaking is better</a> when it is informed by facts and when we are aware of the effects of the legislation before passing it.</p>
<p>By and large, the CBO has lived up to its expectations. While far from perfect in its projections, it is generally held in high regard by politicians and scholars alike. As such, it has held a dominant role in some of the nation’s major legislative efforts, including the Clinton-era <a href="https://books.google.com/books?id=e4MYDQAAQBAJ&pg=PT104&lpg=PT104&dq=cbo+score+health+security+act+clinton&source=bl&ots=5-k10nsMYB&sig=hCNlQ_Ak6u_BpcBFsnQ7gVB8g0Q&hl=en&sa=X&ved=0ahUKEwiX8OCtionUAhXLD8AKHZgMAdIQ6AEISzAH#v=onepage&q=cbo%20score%20">Health Security Act</a>, the <a href="https://www.cbo.gov/topics/health-care/affordable-care-act">Affordable Care Act</a> and now the <a href="https://www.cbo.gov/publication/52486">American Health Care Act</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/171020/original/file-20170525-23224-o7ko8p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/171020/original/file-20170525-23224-o7ko8p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/171020/original/file-20170525-23224-o7ko8p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/171020/original/file-20170525-23224-o7ko8p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/171020/original/file-20170525-23224-o7ko8p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/171020/original/file-20170525-23224-o7ko8p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/171020/original/file-20170525-23224-o7ko8p.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">President Trump and Seema Verma, administrator for the Center for Medicare and Medicaid Services, at March meeting in which work requirements for Medicaid were discussed.</span>
<span class="attribution"><span class="source">Evan Vucci/AP</span></span>
</figcaption>
</figure>
<p>In March, the CBO had scored a previous version of the <a href="https://www.cbo.gov/publication/52486">American Health Care Act</a>, saying 24 million Americans would lose their insurance under the AHCA. The score also showed that insurance premiums in the individual market <a href="https://www.brookings.edu/blog/up-front/2017/03/16/how-will-the-house-gop-health-care-bill-affect-individual-market-premiums/">would actually increase</a> because fewer benefits would be included. </p>
<p>At the same time, the AHCA would provide a massive tax cut to America’s wealthiest and reduce the federal deficit just over US$100 billion over 10 years. It would do so because of massive cuts to Medicaid and the ACA’s insurance premium subsidies.</p>
<p>However, the version ultimately passed by the House of Representatives had not been scored until yesterday. Some have argued that Speaker Paul Ryan (R-WI) <a href="http://thehill.com/policy/healthcare/health-reform-implementation/331954-ex-cbo-head-voting-with-no-repeal-score">deliberately rushed the bill to a vote to avoid being confronted</a> with what experts expect to be abysmal numbers by the CBO.</p>
<p>And the numbers were bad indeed. The most recent <a href="https://www.cbo.gov/publication/52752">CBO estimate</a> expects 23 million Americans to lose insurance coverage. Moreover, it shows reduced savings, higher premiums if benefit design and age distribution remain constant, and inadequate protections for Americans with preexisting conditions.</p>
<p>Importantly, the CBO also expects one-sixth of the nation’s individual insurance market to collapse due to the newly added provisions in the AHCA allowing states to eliminate the ACA’s <a href="https://theconversation.com/essential-health-benefits-suddenly-at-center-of-health-care-debate-but-what-are-they-75125">Essential Health Benefits</a> and charge higher premiums for <a href="https://theconversation.com/how-pre-existing-conditions-became-front-and-center-in-health-care-vote-77138">individuals with preexisting conditions</a>. Overall, 51 million Americans are expected to be without insurance in 2026.</p>
<h2>The bigger picture: Disinvesting in the disadvantaged</h2>
<p>Not surprisingly, the focus of countless media articles and TV news has been on the CBO’s scoring of the American Health Care Act. However, while important, this loses sight of larger, more concerning developments.</p>
<p>Indeed, the CBO’s dire prediction for America’s uninsured under the American Health Care Act is made significantly worse by the <a href="https://www.whitehouse.gov/sites/whitehouse.gov/files/omb/budget/fy2018/2018_blueprint.pdf">Trump administration’s recently released budget</a>.</p>
<p>While the AHCA’s drastic $834 billion cuts to the Medicaid program are estimated to cost 14 million Americans their coverage, the Trump budget will cut an additional $610 billion. This would basically slash the current Medicaid program in half and destroy a mainstay of America’s safety net since the Great Society.</p>
<p>While the dramatic cuts to the Medicaid program will affect more than 70 million Americans, there is more. The bipartisan and popular Children’s Health Insurance Program (CHIP) is slated for a 21 percent cut as well as significant reductions in eligibility. Some states like Arizona and West Virginia have automatic triggers that would eliminate CHIP with these funding reductions.</p>
<p>Moreover, the proposed budget cuts or eliminates funding to agencies and programs helping the most vulnerable in our communities beyond the immediate provision of health care.</p>
<p>It cuts funding to the <a href="https://www.samhsa.gov/">Substance Abuse and Mental Health Services Administration</a> (SAMHSA), tasked with reducing the ill effects of substance abuse and mental illness.</p>
<p>It cuts funding to the <a href="https://www.cdc.gov/ncbddd/index.html">National Center on Birth Defects and Developmental Disabilities</a> (NCBDDD), which addresses birth defects and improves the health of individuals with disabilities.</p>
<p>It cuts funding to the National Asthma Control Program (NACP), intended to <a href="https://www.cdc.gov/asthma/nacp.htm">“help the millions of people with asthma in the United States gain control over their disease.”</a></p>
<p>It cuts funding to the <a href="https://www.fns.usda.gov/snap/supplemental-nutrition-assistance-program-snap">Supplemental Nutrition Assistance Program</a> (SNAP), which provides food for million of Americans.</p>
<p>It cuts funding to the <a href="https://www.fns.usda.gov/wic/women-infants-and-children-wic">Special Supplemental Nutrition Program for Women, Infants, and Children</a> (WIC), which provides nutritious food for pregnant women, young children, and half of all infants in the country.</p>
<p>It cuts funding to the <a href="https://www.arc.gov/">Appalachian Regional Commission</a>, which provides loans to improve sewers and provide safe drinking water in rural Appalachia.</p>
<p>It cuts funding for a number of programs which support rural hospitals and minorities, such as the <a href="https://www.hrsa.gov/ruralhealth/programopportunities/fundingopportunities/?id=b56d4504-7bf6-4f79-b0e8-37b766f2213e">Rural Hospital Outreach Grant</a> and the <a href="https://www.multiplan.com/providers/ruralhealthgrants.cfm">Rural Hospital Flexibility Grant</a>.</p>
<p>It cuts funding for important medical and public health research as places like the <a href="https://www.cdc.gov/">Centers for Disease Control and Prevention</a> (CDC) and the <a href="https://www.nih.gov/">National Institutes of Health</a> (NIH).</p>
<p>The list, unfortunately, goes on. </p>
<h2>Moving forward</h2>
<p>Just months ago, the nation reached a milestone when the uninsured rate fell to a <a href="http://money.cnn.com/2017/03/13/news/economy/uninsured-rate-obamacare/">historic low</a>. Meanwhile, Republicans and Democrats are heatedly debating the future of the nation’s health care system.</p>
<p>What often gets lost in the numbers and the public debate is that they involve people’s lives and livelihoods. With all its shortcomings, the Affordable Care Act has brought relief to millions of Americans who are no longer scared to fall sick.</p>
<p>When a person loses health care, it often means having to choose between food and medications. It means delaying necessary care, exacerbating medical conditions with at times irreversible consequences. </p>
<p>Much remains to be done to improve the American health care system. But the changes proposed by President Trump and Speaker Ryan would reverse decades of gains made for America’s disadvantaged <a href="http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=9914748&fulltextType=RA&fileId=S0898030615000330">since the 1920s</a>. </p>
<p>Perhaps most importantly, both the AHCA and the Trump administration’s budget would cause tremendous amounts of suffering and pain across all of our communities.</p><img src="https://counter.theconversation.com/content/78308/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The CBO analysis of the new health care bill not only shows that tens of millions would lose insurance. It is a major shift in this country’s attitudes and policies toward helping the poor.Simon F. Haeder, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/764892017-05-24T02:24:25Z2017-05-24T02:24:25ZHow Trump and Tom Price can kill Obamacare without the Senate<figure><img src="https://images.theconversation.com/files/170614/original/file-20170523-5799-1ibzrw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Pres. Trump and HHS Secretary Tom Price in the Oval Office on March 24, 2017, the day the original version of the AHCA was pulled. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Health-Overhaul-Insurance-Woes/06fc908af42245288532b7c0810ed925/54/0">Pablo Martinez Monsivais/AP</a></span></figcaption></figure><p>Senate leadership has indicated that passage of the American Health Care Act <a href="http://www.newsmax.com/Politics/AHCA-Senate-Mitch-McConnell-repeal-and-replace/2017/05/08/id/788850/">“will not be quick,”</a> but it may not matter. </p>
<p>Individual insurance markets already are shaky, in limbo by a lawsuit that challenges subsidies to help pay out-of-pocket costs for low-income people.</p>
<p>Even without congressional or judicial actions, the White House and Health and Human Services Secretary Tom Price have many tools at their disposal to significantly reshape the Affordable Care Act through <a href="https://www.cambridge.org/core/journals/american-political-science-review/article/influence-and-the-administrative-process-lobbying-the-us-presidents-office-of-management-and-budget/638F34BC73235AB4833C852B24C431AF">regulatory action</a>. </p>
<p>The ACA’s Essential Health Benefits provisions provide an illustrative example, and one that is not getting nearly the attention of the subsidies.</p>
<p>Having conducted research on <a href="https://www.cambridge.org/core/journals/american-political-science-review/article/influence-and-the-administrative-process-lobbying-the-us-presidents-office-of-management-and-budget/638F34BC73235AB4833C852B24C431AF">regulatory policymaking</a> and the <a href="http://jhppl.dukejournals.org/content/40/2/281.short">Affordable Care Act</a>, particularly the <a href="http://www.healthpolicyjrnl.com/article/S0168-8510(14)00260-7/fulltext?cc=y=">implementation of its Essential Health Benefits provisions</a>, I can show you how. </p>
<h2>Where we are with Essential Health Benefits</h2>
<p>The Essential Health Benefits have long been a bane for conservatives, who see them as <a href="https://theconversation.com/essential-health-benefits-suddenly-at-center-of-health-care-debate-but-what-are-they-75125">unnecessarily driving up premiums and denying consumer choice</a>. These provisions require health plans sold in the ACA insurance marketplaces to offer a set of <a href="http://www.sciencedirect.com/science/article/pii/S0168851014002607">10 basic benefits including hospitalization, prescription drugs and outpatient coverage</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/170621/original/file-20170523-5749-1vkl0r0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/170621/original/file-20170523-5749-1vkl0r0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=359&fit=crop&dpr=1 600w, https://images.theconversation.com/files/170621/original/file-20170523-5749-1vkl0r0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=359&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/170621/original/file-20170523-5749-1vkl0r0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=359&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/170621/original/file-20170523-5749-1vkl0r0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=451&fit=crop&dpr=1 754w, https://images.theconversation.com/files/170621/original/file-20170523-5749-1vkl0r0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=451&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/170621/original/file-20170523-5749-1vkl0r0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=451&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Hospitalization has been considered one of 10 essential health benefits.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/479848288?src=R1P9l2D-alILjqnx4o7Hfg-1-8&size=huge_jpg">Press Master/Shutterstock</a></span>
</figcaption>
</figure>
<p><a href="http://www.sciencedirect.com/science/article/pii/S0168851014002607">Implementing the EHB provisions of the ACA</a>, like hundreds of its components, was delegated to the Department of Health and Human Services (HHS). At the time the ACA was passed, the secretary of that department was Kathleen Sebelius, a moderate Democrat from Kansas.</p>
<p>Now the secretary is Tom Price, a very conservative Republican and a doctor who has been one of the ACA’s <a href="https://www.nytimes.com/2016/11/28/us/politics/tom-price-secretary-health-and-human-services.html">most ardent critics</a>.</p>
<p>With the help of the Institute of Medicine (IOM), the Obama administration HHS developed a broad set of guidelines. Shying away from setting a national standard, states were left with significant leeway in implementing the EHB.</p>
<p>Not surprisingly, states took many <a href="http://www.sciencedirect.com/science/article/pii/S0168851014002607">approaches to developing their EHB based on the HHS guidelines</a>. While all states are required to cover the bare minimum services outlined by the ACA as defined by HHS, states differ significantly in what additional benefits were included. For example, <a href="http://www.sciencedirect.com/science/article/pii/S0168851014002607">19 states do not cover autism treatments and 28 do not cover any infertility treatments</a>.</p>
<p>Fast forward to 2017, with a Republican majority in Congress and a Republican in the White House. </p>
<p>Unable to obtain the necessary votes for the original version of the American Health Care Act, Speaker Paul Ryan (R-WI) initially sought to woo conservatives by offering the elimination of the ACA’s Essential Health Benefits provision. </p>
<p>The final version of the AHCA passed in the House did not eliminate the Essential Health Benefits outright. However, it allowed states to seek a waiver to come up with their definition to exclude any or all of the 10 basic benefits included in the Affordable Care Act.</p>
<h2>What’s Next for the EHB</h2>
<p>Even while the AHCA meanders through the congressional lawmaking process, major changes to the EHB are possible through regulatory action. </p>
<p>The hands-off approach taken by the Obama administration in developing the EHB was based on pragmatism and political expediency. Hoping to limit opposition, it sought expert counsel and provided states with significant discretion. </p>
<p>The White House and HHS Secretary Price could equally use the <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1541-0072.2012.00446.x/full">vast delegated powers of the ACA</a> to significantly reshape the signature accomplishment of President Obama. This particularly applies to the EHB.</p>
<h2>Option 1: New HHS regulations preempting state regulation</h2>
<p>One option is a wholesale reversal of the Obama administration’s approach with regard to the implementation of the EHB. The Obama administration relied on setting broad guidelines and a benefits floor while <a href="http://www.sciencedirect.com/science/article/pii/S0168851014002607">relying on states to select their preferred approach</a>. </p>
<p>Instead, HHS and Secretary Price could exclude states from the decision-making process on EHBs. Specifically, the federal government could issue a standard national package that would be applicable nationwide. </p>
<p>Given the history of opposition to the ACA and the EHB in particular <a href="http://files.kff.org/attachment/Proposals-to-Replace-the-Affordable-Care-Act-Rep-Tom-Price">by Secretary Price</a>, it seems likely that the federally defined EHB would be reduced to the absolute minimum package of benefits required by the ACA. This approach would constitute a dramatic shift from the Obama administration, <a href="http://journals.cambridge.org/article_S0898030615000330">but it would not be without historical precedent</a>. </p>
<h2>Option 2: New HHS regulation giving more leeway to states</h2>
<p>Of course, strong-arming states into accepting federal regulations clashes ideologically with traditional Republican concerns about the preservation of <a href="http://onlinelibrary.wiley.com/doi/10.1111/puar.12065/full">state sovereignty</a>. The more likely option follows the procedural precedent of the Obama administration. It preserves the current regulatory division of labor: The federal government continues to set broad standards and relies on states to develop state-specific benefit packages. </p>
<p>However, this approach would likely also involve the softening of current EHB standards. To do this, Secretary Price would first reduce the minimum benefit package required to make insurance plans ACA-compliant. The implementation of actual standards would continue to rest with the states.</p>
<p>The important question here is whether the Trump administration and Secretary Price would allow progressive states like California to maintain more comprehensive benefit packages. Most importantly, it remains to be seen whether states would be required to incur any additional financial burdens, or whether federal subsidies would fully apply to the more comprehensive benefits package. </p>
<h2>Moving forward</h2>
<p>Despite <a href="http://kff.org/interactive/kaiser-health-tracking-poll-the-publics-views-on-the-aca/">increasing support by a majority of Americans</a>, the future of the ACA remains far from certain. The same applies to the so-called Essential Health Benefits provisions and hundreds of other components of the Affordable Care Act. </p>
<p><a href="https://theconversation.com/essential-health-benefits-suddenly-at-center-of-health-care-debate-but-what-are-they-75125">As I have written previously</a>, the EHBs are a crucial component of the insurance market reforms enacted in the ACA. Others include the requirement for most Americans to obtain insurance coverage and the requirement for insurers to accept all comers regardless of preexisting conditions. However, while congressional efforts to alter the ACA receive significant media and public attention, regulatory approaches to undoing the ACA are <a href="http://journals.cambridge.org/article_S0003055415000246">much less transparent, more complex and attract much less scrutiny and public involvement</a>. </p>
<p>Ultimately, Republicans may prove much more successful in undoing the ACA through the regulatory pathway, while leaving many if not all of its statutory portions intact.</p><img src="https://counter.theconversation.com/content/76489/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>Pres. Trump has been saying for months that Obamacare will ‘explode’ on its own. He and HHS Secretary Tom Price have a lot of power to make it do so, thus making it appear that law was a failure.Simon F. Haeder, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/775912017-05-15T00:07:33Z2017-05-15T00:07:33ZWhy the US does not have universal health care, while many other countries do<figure><img src="https://images.theconversation.com/files/169006/original/file-20170511-32613-edj2t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">House Speaker Paul Ryan walking into the Capitol on May 4, when the House voted narrowly to accept a bill he shepherded to replace Obamacare. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Congress-Rdp/42feb4969aa84e64ae1345633357a69d/39/0">Andrew Harnik/AP</a></span></figcaption></figure><p>The lead-up to the House passage of the American Health Care Act (AHCA) on May 4, which passed by a narrow majority after a failed first attempt, provided a glimpse into just how difficult it is to gain consensus on health care coverage. </p>
<p>In the aftermath of the House vote, many people have asked: Why are politicians struggling to find consensus on the AHCA instead of pursuing universal coverage? After all, <a href="https://www.theatlantic.com/international/archive/2012/06/heres-a-map-of-the-countries-that-provide-universal-health-care-americas-still-not-on-it/259153/">most advanced industrialized countries</a> have universal health care. </p>
<p>As a health policy and politics scholar, I have some ideas. Research from political science and health services points to three explanations. </p>
<h2>No. 1: American culture is unique</h2>
<p>One key reason is the unique political culture in America. As a nation that began on the back of immigrants with an entrepreneurial spirit and without a feudal system to ingrain a rigid social structure, Americans are <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447684/">more likely to be individualistic</a>.</p>
<p>In other words, Americans, and conservatives in particular, have a strong belief in classical liberalism and the idea that the government should play a limited role in society. Given that universal coverage inherently clashes with this belief in individualism and limited government, it is perhaps not surprising that it has never been enacted in America even as it has been enacted elsewhere.</p>
<p>Public opinion certainly supports this idea. Survey research conducted by the <a href="https://www.cambridge.org/core/journals/perspectives-on-politics/article/the-welfare-state-nobody-knows-debunking-myths-about-us-social-policy-and-welfare-discipline-discourse-governance-and-globalization-/5DB1392868DF638547F11B74EF111474">International Social Survey Program</a> has found that a lower percentage of Americans believe health care for the sick is a government responsibility than individuals in other advanced countries like Canada, the U.K., Germany or Sweden.</p>
<h2>No. 2: Interest groups don’t want it</h2>
<p>Even as American political culture helps to explain the health care debate in America, culture is far from the only reason America lacks universal coverage. Another factor that has limited debate about national health insurance is the role of interest groups in influencing the political process. The legislative battle over the content of the ACA, for example, <a href="https://www.publicintegrity.org/2010/02/24/2725/lobbyists-swarm-capitol-influence-health-reform">generated US$1.2 billion in lobbying</a> in 2009 alone.</p>
<p>The insurance industry was a key player in this process, spending over <a href="https://www.publicintegrity.org/2010/02/24/2725/lobbyists-swarm-capitol-influence-health-reform">$100 million to help shape the ACA</a> and keep private insurers, as opposed to the government, as the key cog in American health care.</p>
<p>While recent reports suggest <a href="http://www.cbsnews.com/news/doctors-health-groups-denounce-ahca-health-care-vote/">strong opposition from interest groups</a> to the AHCA, it is worth noting that even when confronted with a bill that many organized interests view as bad policy, universal health care has not been brought up as an alternative. </p>
<h2>No. 3: Entitlement programs are hard in general to enact</h2>
<p>A third reason America lacks universal health coverage and that House Republicans struggled to pass their plan even in a very conservative House chamber is that America’s political institutions make it difficult for massive entitlement programs to be enacted. As policy experts have pointed out in <a href="http://jhppl.dukejournals.org/content/20/2/329.abstract">studies of the U.S. health system,</a> the country doesn’t “have a comprehensive national health insurance system because American political institutions are structurally biased against this kind of comprehensive reform.”</p>
<p>The political system is prone to inertia, and any attempt at comprehensive reform must pass through the obstacle course of congressional committees, budget estimates, conference committees, amendments and a potential veto while opponents of reform publicly bash the bill.</p>
<h2>Bottom line: Universal coverage unlikely to happen</h2>
<p>Ultimately, the United States remains one of the only advanced industrialized nations without a comprehensive national health insurance system and with little prospect for one developing under President Trump or even subsequent presidents because of the many ways America is exceptional.</p>
<p>Its culture is unusually individualistic, favoring personal over government responsibility; lobbyists are particularly active, spending billions to ensure that private insurers maintain their status in the health system; and our institutions are designed in a manner that limits major social policy changes from happening. </p>
<p>As long as the reasons above remain, there is little reason to expect universal coverage in America anytime soon.</p>
<p><em>Editor’s note: this is an updated version of an article that originally ran on October 25, 2016.</em></p><img src="https://counter.theconversation.com/content/77591/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Timothy Callaghan 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>Arguments about the AHCA showed deep disagreement on health care coverage. Could this move us toward universal coverage, which some say could be simpler? Don’t hold your breath.Timothy Callaghan, Assistant Professor, Texas A&M University Health Science Center, Texas A&M UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/755242017-05-12T01:20:29Z2017-05-12T01:20:29ZWhy America needs a ‘do-over’ on Medicaid reform<figure><img src="https://images.theconversation.com/files/168661/original/file-20170509-7902-1jwki35.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">President Trump and House Speaker Paul Ryan after the House passed a bill to repeal Obamacare and cut back Medicaid funding. </span> <span class="attribution"><a class="source" href="http://www.newsweek.com/barack-obama-criticizes-responds-republicans-courage-health-care-vote-596093">Evan Vucci</a></span></figcaption></figure><p>One of the most important pieces of the newly passed House health bill is a possible <a href="https://www.nytimes.com/2017/03/15/us/politics/obamacare-repeal-tax-cuts.html">US$800 billion cut over 10 years to Medicaid</a>, the federal program designed to provide insurance coverage to the poor. </p>
<p>That bill, entitled the American Health Care Act (AHCA), rolls back part of the expansion of Medicaid that took place under the Affordable Care Act (ACA) by limiting federal contributions toward state coverage of individuals with <a href="http://www.coveredca.com/PDFs/FPL-chart.pdf">annual incomes above US$16,643 or families of four with annual incomes above $33,948</a>. With the reduction in federal support, states will now have to decide if they can afford to cover adults with incomes just above the federal poverty line. In addition, the AHCA freezes federal spending per Medicaid beneficiary <a href="http://files.kff.org/attachment/Proposals-to-Replace-the-Affordable-Care-Act-Summary-of-the-American-Health-Care-Act">at its 2016 levels</a>.</p>
<p>The bill’s exact financial impact on Medicaid remains uncertain, because the House passed it before the Congressional Budget Office had a chance to evaluate the numbers. The projected $800 billion cut is <a href="https://www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/hr1628.pdf#page=9">taken from a CBO analysis</a> conducted on a prior version of the AHCA. That version as well as the bill passed in May give more control to states to administer Medicaid.</p>
<p>Republican leaders have argued the <a href="https://finance.yahoo.com/news/gop-struggles-explain-ahca-880-093000297.html">current Medicaid system</a> is failing and in need of reform. Democrats, including former President Obama, have charged that the <a href="http://www.newsweek.com/barack-obama-criticizes-responds-republicans-courage-health-care-vote-596093">AHCA harms the well-being of poor</a> and vulnerable groups. </p>
<p>We wholeheartedly agree – with both sides. We question the wisdom of steep cuts to an already underfunded Medicaid system. But the status quo is not working either. </p>
<p>So what should we do?</p>
<h2>The AHCA underfunds an already struggling program</h2>
<p>Medicaid, the federal-state program that provides health coverage to about <a href="http://kff.org/health-reform/state-indicator/total-monthly-medicaid-and-chip-enrollment/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">75 million</a> poor and disabled people, fails to provide them <a href="http://www.heritage.org/health-care-reform/report/studies-show-medicaid-patients-have-worse-access-and-outcomes-the">adequate access</a> to the quality of medical care that other Americans enjoy. </p>
<p>The reason is straightforward: Medicaid provides <a href="https://www.advisory.com/daily-briefing/2016/06/20/low-reimbursement-limit-medicaid-expansion">lower reimbursements</a> to physicians than private insurance or Medicare, the federal health program for elderly and disabled Americans. The result: fewer physicians accepting Medicaid coverage and fewer choices for Medicaid beneficiaries. </p>
<p>Prior studies suggest that about one-third of physicians nationwide refuse to accept new patients on Medicaid, and this <a href="http://content.healthaffairs.org/content/31/8/1673.abstract">problem is even worse in urban areas</a>. </p>
<p>Rural areas have their own problems with the program. Their residents are poorer and more likely to be on Medicaid. The prevalence of Medicaid coverage, and its stingier reimbursements, is one reason why hospitals in rural areas <a href="http://kff.org/report-section/a-look-at-rural-hospital-closures-and-implications-for-access-to-care-three-case-studies-issue-brief/">have closed down</a>. </p>
<p>In theory, federal matching funds are designed to shore up the Medicaid budgets of poorer states. California, for instance, has a 50 percent match rate – tied for lowest in the country – while Mississippi has a 75.6 percent match rate, the <a href="http://kff.org/medicaid/state-indicator/federal-matching-rate-and-multiplier/">highest in the country</a>.</p>
<p>But in practice, federal matching funds do not go far enough. As an example, each disabled Medicaid beneficiary in Mississippi receives <a href="http://kff.org/medicaid/state-indicator/medicaid-spending-per-enrollee/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">about half as much in benefits as their peers in Maryland.</a> Mississippi ranks as the poorest state in the nation according to <a href="https://www.justice.gov/ust/eo/bapcpa/20140401/bci_data/median_income_table.htm">median household income</a> (for four-person households), while Maryland ranks as the richest. To make matters worse, the AHCA proposes to reduce federal matching funds below their current, already inadequate levels. </p>
<p>State control of Medicaid was designed to foster experimentation and competition among states to provide efficient, high-quality care for the poor. And, the AHCA relies heavily on the logic that Medicaid will run better when states have greater financial responsibility and control. </p>
<p>However, rising inequality between rich and poor areas of the country has undercut this rationale. As poorer states fall farther behind, they become ever less capable of mustering the resources needed to protect the growing ranks of vulnerable children, adults and seniors among their constituents. </p>
<p>From this standpoint, further cuts to Medicaid – as envisioned by the AHCA – make little sense. Why make an underfunded program even more underfunded? Replacing Medicaid with an adequately funded alternative would make more sense than retaining the program and rendering it even less capable of aid to the poor.</p>
<h2>The paradox of Medicaid expansions</h2>
<p>The Affordable Care Act expanded Medicaid coverage to <a href="https://www.cbo.gov/sites/default/files/recurringdata/51298-2017-01-healthinsurance.pdf">more than 20 million additional Americans</a> by providing financial assistance and incentives to states that extended Medicaid eligibility – up to annual incomes of $16,643 for an individual or $33,948 for a family of four. But even so, it has not done enough over the long term to increase the number of health care providers willing to care for Medicaid patients. </p>
<p>Research suggests that higher Medicaid reimbursements would lead <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2444286">more physicians to accept Medicaid</a>. And, in 2013 and 2014, the ACA increased Medicaid reimbursements, <a href="https://www.ncbi.nlm.nih.gov/pubmed/27355810">resulting in greater access to care</a>. </p>
<p>Unfortunately, the ACA’s increase in reimbursements were only temporary. Payments to providers went back down to pre-2013 levels in 2015. The result has been longer wait times and <a href="https://www.ncbi.nlm.nih.gov/pubmed/28273021">greater difficulty in accessing care among Medicaid beneficiaries.</a> </p>
<p>At the same time, the most compelling evidence suggests the <a href="https://scholar.harvard.edu/files/hendren/files/finkelstein_hendren_luttmer_mcaid_welfare_june_16_2015.pdf">government spends more on Medicaid than the value it provides to the poor</a>. For every dollar the government spends on Medicaid, the poor get roughly 20 to 40 cents of value. Much of the benefits accrue to third parties such as hospitals and employers who, in the absence of Medicaid, <a href="https://scholar.harvard.edu/files/hendren/files/finkelstein_hendren_luttmer_mcaid_welfare_june_16_2015.pdf">would have provided uncompensated medical care</a> to Medicaid’s beneficiaries.</p>
<h2>Democrats should demand providers be paid more – but only for value</h2>
<p>Let’s start with the Democrats. Saving Medicaid coverage may well be a worthy goal. But expanding Medicaid by expanding the number of Medicaid beneficiaries does the poor a disservice if it doesn’t provide greater access for them to doctors. Medicaid expansions should also come with higher payments to providers. </p>
<p>But if Medicaid pays physicians more, it should require that they deliver more value. Specifically, physicians who achieve better outcomes should be reimbursed more than those achieving worse outcomes. The institutional details of such “<a href="http://healthaffairs.org/blog/2017/04/03/strategies-to-address-the-challenges-of-outcomes-based-pricing-agreements-for-pharmaceuticals/">outcomes-based pricing</a>” deserve their own careful discussion, but we think <a href="https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Value-Based-Programs.html">pay-for-performance reforms</a> are consistent with core Democratic principles of fairness and protection of the vulnerable. </p>
<p>How could the Democrats pay for their desired expansions in both coverage and generosity? Getting rid of the highly regressive tax break for employer-sponsored health insurance would be a good start, especially for a party looking to level the playing field between the rich and the poor. </p>
<p>The tax code allows people to buy health insurance before they pay taxes. This lowers their taxable income. The value of this tax deduction increases with your tax rate – the higher your tax rate, the greater the value of reducing your taxable income. <a href="http://www.taxpolicycenter.org/briefing-book/how-does-tax-exclusion-employer-sponsored-health-insurance-work">This deduction costs the government over $250 billion in tax revenue each year</a>. Eliminating it and earmarking the revenue for Medicaid would help the poor and reduce inequality. </p>
<h2>Republicans should encourage competition among insurers</h2>
<p>And what about the Republicans? Expanding government-administered insurance programs does not comport with Republican values of competition and free choice. Yet, cutting government programs without providing a meaningful market-based alternative does not make sense, either.</p>
<p>For guidance, Republicans should look to the last major health care reform by a Republican administration: Medicare Part D, a prescription drug benefit for the elderly. Unlike the main physician and hospital care benefits in Medicare, Part D was set up as a system of government subsidies for the purchase of private prescription drug insurance. </p>
<p>By most measures, Part D has been a success – <a href="https://www.cbo.gov/sites/default/files/113th-congress-2013-2014/reports/45552-PartD.pdf">cost growth has been less than originally projected</a> by the Congressional Budget Office and <a href="https://www.ncbi.nlm.nih.gov/pubmed/28273626">it lowered deaths among the elderly by 2.2 percent annually</a>. </p>
<p>Republicans who oppose Medicaid should consider replacing it with a properly funded system of subsidies for private health insurance. Such a plan would take the savings from phasing out the current Medicaid system and invest it into more generous subsidies for the purchase of private health insurance. This approach would provide mainstream health care coverage to Medicaid enrollees. Integrating the poor into the middle class and above is a core Republican value, and this reform would provide an opportunity to advance that agenda.</p>
<h2>Moving forward</h2>
<p>The debate over the AHCA promises to intensify, as American politicians have now splintered into more than two camps. The rising number of factions makes compromise essential, as no single bloc of senators can push through legislation unaided.</p>
<p>We believe the best path forward starts with all sides putting their best ideas forward. This means the best ideas for government-administered health insurance on the left, and the best ideas for market-based health insurance on the right. All of these ideas should aim toward securing the health of the most vulnerable American children and families. Perhaps that is the one principle we all can agree on.</p><img src="https://counter.theconversation.com/content/75524/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Darius Lakdawalla is the Chief Scientific Officer of Precision Health Economics (PHE), where he also serves as the Executive Director of PHE's Innovation and Value Initiative. He is an investor in PHE's parent company, Precision Medicine Group. PHE conducts research for pharmaceutical, biotechnology, medical device, and health insurance firms. The article reflects the views of its authors and not those of PHE or Precision Medicine Group.</span></em></p><p class="fine-print"><em><span>Anup Malani consulted for Precision Health Economics in 2016 on the topic of rebates for HIV/AIDs drug purchases.</span></em></p><p class="fine-print"><em><span>Jay Bhattacharya is a senior researcher at Acumen, LLC, which provides economic consulting services for the Center for Medicare and Medicaid Services (CMS) which administer both Medicare and Medicaid programs for the federal government. Dr. Bhattacharya has also received grant funding from the National Institute on Aging to study issues related to healthcare access for the poor and other vulnerable populations. The article reflects his own opinions, and not those of CMS, the NIH, or Acumen LLC.</span></em></p>The health care bill recently passed by the House imposes big cuts to the underfunded Medicaid program. A new approach is needed, starting with the best ideas of both parties.Darius Lakdawalla, Professor of Pharmaceutical Development and Regulatory Innovation, Schaeffer Center for Health Policy and Economics, University of Southern CaliforniaAnup Malani, The Lee and Brena Freeman Professor at the University of Chicago Law School and Professor at the Pritzker School of Medicine., University of ChicagoJay Bhattacharya, Professor of Medicine, Stanford UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/747222017-03-22T00:45:02Z2017-03-22T00:45:02ZNew health care law would lead to more smoking, disease and tobacco industry profits<figure><img src="https://images.theconversation.com/files/161897/original/image-20170321-5384-uuruo2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Smoking kills close to 440,000 people in the U.S. each year. </span> <span class="attribution"><a class="source" href="http://tobaccofreeca.com/resources/">California Department of Health Services</a></span></figcaption></figure><p>House Republicans introduced their <a href="https://housegop.leadpages.co/healthcare/">American Health Care Act</a> on March 7 to “repeal and replace Obamacare” (the Affordable Care Act). Neither the bill nor <a href="http://www.speaker.gov/general/american-health-care-act-fact-sheet">Speaker Ryan’s website</a> announcement mentions “tobacco.” But as tobacco researchers, we believe it would have a substantial negative impact on control efforts.</p>
<p>The ACA includes a Prevention and Public Health Fund that supports prevention and public health programs, including tobacco prevention (<a href="https://www.hhs.gov/open/prevention/">US$931 million</a> for all programs in 2016).</p>
<p>In addition, the ACA Medicaid Incentives for Chronic Disease Prevention Program includes <a href="https://innovation.cms.gov/initiatives/MIPCD/MIPCD-The-States-Awarded.html">$85 million</a> for state Medicaid for tobacco cessation and other goals.</p>
<p>The ACA also:</p>
<ul>
<li>Requires most private and public insurers to cover tobacco cessation as one of 10 “essential health benefits” at no cost to the patient</li>
<li>Requires most insurers to cover treatment of substance use disorders, which may include tobacco dependence, as another essential health benefit on an equal basis with other medical and surgical benefits</li>
<li>Allows insurers to charge tobacco users up to 50 percent higher premiums </li>
<li>Allows employers to reward or penalize employees up to 50 percent of the cost of insurance coverage based on participation in wellness programs that include reducing tobacco use</li>
<li>Encourages community-based prevention through Community Health Needs Assessment requirements for nonprofit hospitals and funding for public health fellowship training, promotion of community health workforce and community health centers.</li>
</ul>
<h2>What the American Health Care Act would change</h2>
<p>Most discussion of the AHCA has focused on the estimate that <a href="https://www.cbo.gov/publication/52486">24 million people would lose insurance</a> and costs for many would go up. </p>
<p>But by our reading of the bill, the AHCA would also damage health in other ways.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/CRpA0-_zbgQ?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">A “tip” video from former smoker Rose, who later died of lung cancer. Such “tips” were very successful in showing the deadly effects of smoking.</span></figcaption>
</figure>
<p>It ends the Prevention and Public Health Fund that provides <a href="https://www.cdc.gov/funding/documents/cdc-pphf-funding-impact.pdf">12 percent of Centers for Disease Control and Prevention’s program funding</a>, including tobacco control <a href="https://wwwn.cdc.gov/FundingProfilesApp/Report_Docs/PDFDocs/Rpt2016/Projects-Funded-thru-Prevention-And-Public-Health-Fund-Report-2016.pdf">across the country</a>. Among other things, the fund allowed CDC to create the first federal paid anti-smoking media campaign: <a href="https://www.cdc.gov/tobacco/campaign/tips/">Tips From Former Smokers (Tips)</a>. </p>
<p>Tips <a href="http://www.sciencedirect.com/science/article/pii/S0140673613616864">cost-effectively</a> inspired 1.6 million smokers to attempt to quit and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4603744/">prevented over 17,000 premature deaths</a>. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/161659/original/image-20170320-9140-nxnuba.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/161659/original/image-20170320-9140-nxnuba.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=857&fit=crop&dpr=1 600w, https://images.theconversation.com/files/161659/original/image-20170320-9140-nxnuba.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=857&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/161659/original/image-20170320-9140-nxnuba.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=857&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/161659/original/image-20170320-9140-nxnuba.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1077&fit=crop&dpr=1 754w, https://images.theconversation.com/files/161659/original/image-20170320-9140-nxnuba.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1077&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/161659/original/image-20170320-9140-nxnuba.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1077&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Ads such as this spurred millions to quit.</span>
<span class="attribution"><span class="source">Centers for Disease Control</span></span>
</figcaption>
</figure>
<p>The AHCA also drops the requirement that some Medicaid programs cover preventive care like smoking cessation. It also fundamentally changes the structure of Medicaid funding, which will likely lead states to reduce eligibility and cut smoking cessation and other benefits.</p>
<p>While the AHCA does increase funding for Community Health Centers, this money will likely be needed to deal with the bill’s prohibition on funding Planned Parenthood. The AHCA also establishes a Patient and State Stability Fund, which could be used for preventive care and substance use disorder prevention, treatment, or recovery efforts, which could theoretically include tobacco cessation. However, it is unlikely that tobacco cessation will be a priority for this new fund, as it is projected to be used primarily to <a href="https://www.cbo.gov/sites/default/files/115th-congress-2017-2018/costestimate/americanhealthcareact.pdf">reimburse insurers for some high-cost enrollees</a>. In our view, neither of these new funding sources would make up for the loss of the Prevention and Public Health Fund, which has prioritized public health goals and provided support for effective tobacco prevention and cessation programs across the nation.</p>
<p>Who will be the losers if the bill becomes law? Smokers and the public who will have to absorb the increased costs of caring for them. The winner: Big Tobacco.</p><img src="https://counter.theconversation.com/content/74722/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Daniel Orenstein's research is currently supported by the National Institutes of Health. Preparation of this article was not supported by NIH.</span></em></p><p class="fine-print"><em><span>Stanton Glantz receives funding from the National Institutes of Health, Truth Initiative, and Laura and John Arnold Foundation. Preparation of this article was not supported by any of these organizations. </span></em></p>While many groups of people stand to lose health insurance benefits under the new health care bill, smokers would be particularly harmed. Here’s how cutbacks in cessation programs could harm them.Daniel Orenstein, Postdoctoral fellow, University of California, San FranciscoStanton Glantz, Professor of Medicine, University of California, San FranciscoLicensed as Creative Commons – attribution, no derivatives.