Sunday, June 18, 2017
On many occasions this blog has made the point that, despite frequently-repeated claims that the US has “the best healthcare in the world”, we do not. This point is also made by dozens of other sources, recently including Kaiser Health News (KHN) editor-in-chief Elisabeth Rosenthal in her book “American Sickness”. In my book, “Health, Medicine and Justice: Designing a fair and equitable health care system”, and in many lectures I have given to physicians and students, I have cited the “37th in the world” ranking the US achieved in the comprehensive World Health Organization (WHO) report of 2000. The report’s Table 10, available as a pdf at that site, indeed lists the US as #37 in Overall Performance, just below Costa Rica and just above Slovenia. On an equally telling scale, Performance on Health Level (measured by Disability-Adjusted Life Expectancy, DALE) the US ranked #72, between Argentina and Bhutan. When many US news media led their stories with “Just ahead of Slovenia!”, the Slovenian ambassador took exception, noting that his country was working hard to improve their people's health status.
But, as I also pointed out in my lectures, this table is old, based on 1997 data, and I use it because it is the last time that WHO released such rankings. I supplement it with newer data, such as the Commonwealth Fund’s “Mirror, Mirror on the Wall” from 2014. This compares fewer countries, albeit appropriate, developed, wealthy, OECD countries. In this study, the US also ranks last overall and in many subscales; I have published this graphic before as well.
Now, we have new rankings to refer to, the Bloomberg Global HealthIndex from 2017. It would be nice to be able to say that the US had moved up from the 2000 WHO report, but now, at #34 (and still just behind Costa Rica) the change is really insignificant. Slovenia, it might be noted, has moved up, to #27, so maybe their efforts are paying off!
Given the recalcitrance of US health status to improvement, it is obviously important to look at the ”why” as well as the “what could be done?”. This is especially now, given that these ranking do not yet reflect any negative impact that may happen through the repeal of the Affordable Care Act (ACA) and its replacement by a a Republican plan (#Trumpcare). The contents of the bill that the Senate is currently working on, and which Majority Leader McConnell hopes to bring to a vote by July 4, remain secret not only to the public but also, apparently, to many or most senators. Therefore, the bill passed by the House of Representatives, the American Health Care Act (AHCA) remains our best guide to what the final plan may look like.
And it is not encouraging; the Congressional Budget Office (CBO) estimates that 23 million Americans willlose health insurance, about equally from loss of Medicaid expansion and from cuts to support for the health insurance exchanges set up by ACA. This will unquestionably mean that the overall health status of Americans will go down, both in absolute terms and relative to other nations. Without health insurance, people will not access health care, especially for prevention and “minor” problems (or problems that are not really minor but so far not, or minimally, symptomatic). This means that by the time that their health is so bad that they seek care, they are less likely to survive or do well, and also that the cost of their care will be far higher. This is not a plan to most efficiently use healthcare dollars to maximize the health of the American people.
So what is going on? In a recent blog post (“Pre-existing conditions and profit-taking: the causes of our healthcare problems, May 29, 2017) I wrote “The AHCA is basically a tax-cut-for-the-1% bill, with the money coming from the health care coverage for the rest of us.” That is true, but the question that still needs to be answered is “why”? Ultimately, it is a question of values: if the goal was to have the best possible health status for the American people, rich or poor, white or black, native born or immigrant, rural or urban, this would not be the system that we have and #Trumpcare would be designed to fix the problems with the ACA, not to exacerbate them. President Trump and the GOP have emphasized, in the campaign and since, that for many the ACA has not made insurance accessible because the premiums are too high. This is a good point, and a solution would be great; unfortunately, the AHCA would make them higher, and price out far more people. The values of the Republican leadership are clearly to maximize tax cuts and other financial benefits to the richest American people and corporations, and this AHCA will do. The perpetrators are not among those at the margins; even those congresspersons and pundits who are not truly wealthy have outstanding health insurance for life, and are certain that they will not be in the marginalized group, and that they will be able to access the “best health care in the world”.
Of course, even when you have great insurance and access to “everything”, it is not always better. Sometimes if you are too well-insured you get too much care, tests and procedures and drugs that can put you at risk of harm. And even in the “best” facilities things don’t always go well – medical errors are common, communication can be poor, and even when there are no screwups bad things can happen. Donald Berwick, head of the Institute for Healthcare Improvement (IHI), and former interim head of the Center for Medicare and Medicaid Services (CMS) talks about the US perhaps having the best “rescue care” in the world. But even that is not so good; many IHI initiatives are focused on changing that system to work better, including improvement capability, patient safety, and population health. Anyone who has been sick, or in the hospital, or had a close friend or relative in such a situation recently, can testify to the failings of our health care delivery system even for the well-insured.
So the situation in the US was not good up until now, and will almost certainly get worse with #Trumpcare. Many of the people who will suffer most are those who voted for the President and the GOP members of Congress. Maybe they think that the bad things will not happen to them and their families, but only to “others”. But they will, and we need to move up in the rankings, to be closer to other OECD countries.
Maybe the solution for the US is not to mimic France, or Italy, or Canada. But whatever the solution is, it has to pass the empiric “does it make our people’s health better?” test. And clearly #Trumpcare will not.
Monday, May 29, 2017
Elisabeth Rosenthal, the editor-in-chief of Kaiser Health News and author of “An American Sickness” (discussed in this blog on April 15, 2017, United Airlines, health care, and a system designed to privilege the powerful) has an op-ed in her old newspaper, the New York Times, on May 29, 2017 titled “We all have pre-existing conditions”. That is a good and accurate title, but a little different from the print title “The cost of pre-existing conditions”. That cost is high, to the people with those conditions, and less obviously, to the overall society. This includes their families and friends, of course, but also their employers. When a potentially treatable condition excludes you from having health insurance, you are less likely to get it treated, and more likely to get sick and miss work. The spectrum of conditions that insurance companies used in the pre-ACA era to exclude people was broad. Rosenthal notes specific examples including having had an abnormal Pap smear, a history of being on anti-depressants, a history of taking thyroid medication, and being on post-menopausal hormone treatment. Of course, once you are excluded and have no insurance, you don’t seek care for other conditions either, either pre-existing or those that develop later or might have not been recognized. Not only could insurers exclude you for having a pre-existing condition, but there was no regulation of what or how significant that condition had to be. We have heard stories of people being denied treatment for cancer because, on signing up, they had “failed to report” a pre-existing history of treatment for things as minor as an ingrown toenail or acne!
The ACA, also known as Obamacare, changed that. It eliminated the ability of insurance companies to exclude people based on their pre-existing conditions, thus rendering moot the question of what conditions could be excluded. It also prevented those insurance companies from charging more money to people with those pre-existing conditions by requiring “community rating”; they had to set their rates based upon the overall actuarial risk of the entire community in which they sell insurance. The same principle is why those of us who receive our health insurance via employers, especially large employers, usually have lower rates for better coverage – because the risk pool is everyone who works for that company, and while many are sick, many more are younger and healthier (after all, this excludes all the people who are not working). Thus, the requirement that the individual policies sold under ACA had to be based on the community rating was critical for many Americans to be able to get even close to affordable health insurance.
For many, the cost on the individual marketplace was still too high. For those whose pre-existing conditions had previously made them unable to get insurance, it was often still a boon. For those who were younger and healthier, though, who had had cheaper policies or gone without coverage altogether, they now had to pay more. After all, community rating means an average, so those at lower risk will pay more than they would have with individual rating, and certainly more than with no insurance since the ACA had the “individual mandate” requiring them to get coverage. The bigger problem is that in some geographic areas, many (or most or in some cases all) insurers decided that the benefit of offering insurance (i.e., making money) was not worth the risk of paying out for actual medical care. This is especially true in rural areas, where low population density and a higher proportion of older and therefore sicker people make for a poor risk/return ratio.
The problem, of course, for those younger and healthier people who chose to forgo coverage or, after the individual mandate, to buy the cheapest and crappiest policies, is that they can get sick. They can discover that they have cancer, whatever their age. Or get into a car accident, requiring many surgeries and long treatment and rehabilitation (did they have car insurance?). Or be burned in a fire started by smoking (did they have homeowner’s insurance? Did they opt to not pay the higher premiums that they can legally be charged for being smokers?) Or they can have a premature baby that needs treatment in a neonatal ICU. Or, particularly for the older group who knew they had a problem like hypertension, diabetes, or arthritis but were hoping they’d stay relatively asymptomatic, they can have a downturn – have a stroke or a heart attack or a serious infection or pain so bad that they can no longer work. And then they find that the “affordable” (i.e., crappy) health insurance that they bought is almost as bad as none.
So we have a conundrum. To work, health insurance has to include everyone, the sick as well as the healthy. But the healthy, especially those with lower incomes, don’t want to pay what seems to be the unfairly high rates that they have to in order for the whole system to be fair. The older and less healthy may want health insurance, but still be dissuaded by the high premiums. The sick need the coverage, but again, without the healthier paying in, the cost for them is too high, and results in either their being unable to afford it or the insurers being unwilling to cover them even if it means leaving an entire market.
Let’s look at some facts:
1. The US spends more on health care than any other county, by far.
2. The US has, on a population basis, worse health outcomes than most other developed countries, far worse than many.
1. The US spends more on health care than any other county, by far.
2. The US has, on a population basis, worse health outcomes than most other developed countries, far worse than many.
This is the true conundrum. How can we pay so much for so little? It is because we pay an enormous percent of our “health care” expenses for drug company (and drug “middlemen”, pharmacy benefits managers) profits, insurance company profits, and income for for-profit and function-like-for-profit non-profit hospitals. As documented by Eric Lipton and Katie Thomas in the May 29, 2017 Times (“Drug lobbyists’ battle cry over prices: blame the others”), there is plenty of blame to go around! In addition, the percent that is actually spent on health care on treatments (and sometimes cures) is primarily for far advanced disease, not prevention and early diagnosis and treatment. We spend almost nothing on public health and prevention.
We keep telling ourselves lies (our healthcare system is the best in the world, the ACA is the problem, drug companies need to charge so much because they spend so much on research and development, etc.) but fewer and fewer of us are believing it. Many of the people who are worst affected voted for Donald Trump and for Republican congressmen who have devised the AHCA (American Health Care Act) that will “solve” the problem by essentially eliminating health insurance coverage for 23 million Americans, 14 million in the first year alone, according to estimates by the non-partisan Congressional Budget Office (CBO). The AHCA is basically a tax-cut-for-the-1% bill, with the money coming from the health care coverage for the rest of us.
Is there any way out of this conundrum? Yes. We have the money, obviously; we are spending it. Fifty percent of health care spending is already government, 60% if you include the lost taxes from the employer portion of health insurance. We make the community being rated everyone in the US. We all have one health plan. We are all covered. We all get all necessary services. We don’t lose coverage by leaving or jobs for any reason, from family needs to an entrepreneurial start-up. The old and vulnerable among us are covered and have their needs met, and the healthy among us win by staying healthy and having coverage when we need it. We pay for it by eliminating the profit centers, and not by cutting taxes on the wealthiest of us.
It can be done. It has been done. In every other developed country. We have the resources to do it here. We must need to stand up to the entrenched and powerful profiteers.
Sunday, May 21, 2017
The headline on a recent article by Marilynn Marchione of the Associated Press, as featured in the Arizona Daily Star, is “Few doctors discuss cancer costs with patients, study finds”, and that about covers it. The actual study previewed in the article, which will be presented at the American Society for Clinical Oncology (ASCO) conference in Chicago in June, was led by Dr. Rahma Warsame of Mayo Clinic. It recorded clinical encounters at three cancer sites (Mayo, USC, and LA County) and discovered that the often extraordinarily high cost of cancer care was not usually discussed; discussion happened in just 151 of 529 visits, and in only 45 of those cases, less than 1/3, was the issue brought up by the doctor rather than the patient.
The article suggested several reasons for this. One was that the visits were short, 15 minutes at USC and LA County (about typical, though, across the country), and 30 minutes at Mayo. Another was that doctors are trained to diagnose and recommend treatment rather than to focus on the cost. A third is that the doctors themselves might not know the costs of the treatment. And, for a combination of both of those reasons, they might be uncomfortable talking about the cost. Given that these treatments can easily cost $100,000 a year or more, this is not fair to patients. While good insurance might cover the cost, not everyone has good insurance. In addition to the uninsured, many more people have crappy insurance plans with poor benefits and lifetime caps that are easily exceeded with the cost of cancer care. For most of these folks, the answer is go broke and bankrupt, or die without treatment. From a health point of view, this is not a desirable state of affairs. From a medical point of view of trying to do the best for a patient, it is an abrogation of the obligation to provide the best care. From a moral point of view, it is reprehensible. From some points of view, however, it must be ok, because this is the situation we are in, and it is not by accident. And that is tremendously distressing.
But who would have such a despicable point of view? We can start with the organizations that make money from such care. Of course, this includes the very clinical oncologists who are the members of the ASCO, but they are the least of the beneficiaries. Indeed, I feel comfortable saying that most oncologists would enthusiastically welcome lower costs for chemotherapy. The biggest winners are the drug manufacturers, who charge fantastic amounts for these drugs, and the hospitals and “cancer centers” that provide them. A large part of this profit comes from the reimbursement from insurance companies, which, in addition to paying the cost of the drug, also pay an fee to the hospital for administering the drug that is, frankly, exorbitant and far more than is paid for comparable work in provision of most other care. Indeed, this is why there is such an apparent explosion of cancer centers. It is not because of the explosion of cancer; it is because they are big profit centers and every hospital wants their own to try to lure cancer patients (those who are well-insured, it goes without saying) away from their competitors. And, in a step back from my confidence in the patient-centeredness of oncologists, those groups of oncologists who own independent cancer centers outside of hospitals, and make lots of money on it.
Why would insurers pay such high prices? Medicare pays a pretty high “administration fee”, and most private insurers reimburse at multiples of Medicare. Also, insurers can just raise their rates to cover these costs, especially if they value (as in “appreciate the clout because of the number of patients they control”) the relationship with a particular hospital, cancer center, or health system as described in Elisabeth Rosenthal’s “An American Sickness” and discussed in my blog post “United Airlines, health care, and a system designed to privilege the powerful” (April 15, 2017).
Students learn very little about the cost of care in medical school. There are beginning to be some courses that introduce cost-consciousness, but they are uncommon and limited, although even residents and students have access to smartphone information, through apps such as ePocrates®, that provides information about drugs, and often cost. But is true that these doctors do not know the cost of the care that they are providing? Certainly while the clinical oncologist may not know the exact dollar amount, they know that it is a lot. And it is irresponsible to not discuss this with patients, to help them understand what they are getting into when they start treatment.
Drugs are only one component of the cost of care; a huge one in cancer, but radiation therapy can be even more. As I have discussed before, the real problem is that no one knows what anything actually costs. Yes, hospitals have “charge masters”, but they are not only dense and hard to find (especially for patients) but not that relevant; these charges are adjusted dramatically depending upon insurance. Medicare is unique in that it sets the amounts that it will pay (a lot for chemotherapy), but other insurers pay varying amounts depending upon the contracts that they have arranged with the hospital. Thus we have the irony (which I discussed in “Integrated Health Systems and Cost: The Price is the thing!”,December 20, 2015) that smaller cities with large integrated health systems have some of the lowest costs for Medicare (because they can create efficiencies) but some of the highest costs for private insurers (because they “own” the market and can charge more).
The real issue is that people should be able to get the care that they need and is medically indicated and has evidence to back its effectiveness without going broke. Physicians can no longer hide behind the first half of that sentence, saying “I recommended the care that they need and is evidence-based” (although certainly their recommendations should always be evidence-based!) without considering the cost. On the other hand, the health system of the US should ensure that everyone is covered for necessary care. One way of having enough money to do this is not providing unnecessary, evidence-free care to some people just because they or their insurance will pay for it.
This also means that people should not expect it. As horrific as it is for you or a loved one to be dying of cancer, it is unreasonable to expect that experimental, hopeful, or completely wishful-thinking treatments would or should be paid for by someone else, and it is generally a bad idea to try to pay for them yourself since they won’t work. Some years back, my friend was dying of an aggressive cancer. A bone marrow transplant failed. The genetics of his cancer were such that it was destined to fail. The cancer center (arguably the “best” place in the US for his type of cancer) offered him the opportunity for a second transplant, but the insurance company rightly refused to pay. His family cashed in his entire retirement to pay. Predictably, the transplant failed, and his family was left without any savings. The doctors knew that it would almost certainly fail, and should have known what it would cost, and thus not recommended it. An agnostic stance on cost is unacceptable.
The media coverage of the ACA and the Republican repeal plan makes clear that there are many people who do not want to pay for insurance coverage when they are healthy, but want everything taken care of when they or their family are sick. Then they get desperate and might spend the last of their savings on treatments that will not work, whether quack drugs like laetrile or futile attempts offered by the medical community, such as happened to my friend. It is the responsibility of doctors to know the cost of treatments they recommend and discuss this with their patients, and to not offer ineffective treatments. It is wise for patients also to ask for this, although many are unempowered and intimidated by the medical system.
But if we all pay in when we can and benefit when we need it, the system would work. It’s called single payer, or Medicare for all. Unfortunately, our system, with or without ACA, is nowhere close.
Sunday, May 14, 2017
A bill before the Maine legislature would allow women to obtain a year’s worth of oral contraceptives at a time, rather than the previous 3-month limit. This is a good thing, as argued by its sponsors and supporters. Women typically take oral contraceptives for long periods of time, and the requirement that they return to refill their prescriptions every 3 months is at best an inconvenience and at worst a burden. It is a burden women should not have. Indeed, there is no good reason to require a prescription for oral contraceptives at all.
This does not mean that there are no reasons put forward by opponents; if there were none, there would be no opponents. Overall, the opposing arguments fall into 3 categories: money, control, and wacko paranoia. If women only have to fill prescriptions once a year there will be fewer prescriptions being filled, which could be a small hit to pharmacies. The bigger objection is from insurers, as addressed in an article in the Portland Press-Herald of April 19, who worry that it could become a “mandate” for coverage with no cost share for other contraceptives, particularly those that are more expensive for insurers.
Control is a big and insidious issue. The idea that women are incapable of making their own decisions, particularly with regard to their reproductive systems, is as outrageous as it is persistent. For generations women have fought and often won struggles to be considered legally as “people” (implicit definition: men); to have the vote, to own property, to divorce. But no area has been as fraught with (yes, “fraught” requires a preposition!) opposition as the entire area of women’s reproduction. From before the time of Margaret Sanger, every source of pressure – religious, economic, and legal – has been brought to bear against the idea that women should have control of their own bodies and particularly their reproduction. The struggle continues; abortion rights are the most vulnerable today, but as the opposition to the Maine bill illustrates, contraceptive rights are scarcely secure.
Even among the biggest supporters of contraception, there can be poor decisions. Nearly 20 years ago I sat on a Planned Parenthood advisory board, and many of its members were surprised that I strongly opposed a requirement that women have a Pap smear before receiving a contraceptive prescription. The logic of those who supported it was that the inducement of receiving contraceptives would encourage women to get their Pap, which was then recommended. My position was that the negative incentive of the Pap (and associated pelvic examination, see below) would keep women, especially young women and teens, from getting their contraceptives, and thus likely increase unwanted pregnancies. I am sure that that Planned Parenthood, and other contraceptive providers, no longer have such a requirement. Indeed, we no longer recommend Pap smears for women under the age of 21, and for others, they are recommended only every 3 years. Regarding the screening pelvic examination, it simply violates the first criterion for a screening test – there must be condition that can be screened for in an asymptomatic person. This has led the American College of Physicians, having reviewed the evidence, to recommend against it, while the US Preventive Services Task Force (USPSTF) somewhat incomprehensibly, gives it an “I” (evidence is insufficient to recommend for or against) recommendation. This is summarized in a recent review from the Agency for Health Research and Quality (AHRQ). The American College of Obstetricians and Gynecologists still basically advocates it, although it suggests the decision be made individually between the woman and her doctor, no real change from when I discussed it on July 3, 2014 (”The screening pelvic examination: not annual, not ever”).
Being a major provider of contraception does not save PP from the wrath of Congressional Republicans; indeed, while abortion is the flaming tip of the spear of conservative opposition, the right’s opposition to PP is also against those that do not do abortions, but mainly provide contraception and other women’s health services. The good news is that the GOP may be unable to attach defunding PP to the “health” bill (Obamacare repeal) because it is being done at a budget resolution. You might think that providing contraception would be seen as a good thing, since fewer unwanted pregnancies would lead to fewer abortions, but this is not their logic. [I think that they are, basically, anti-sex, at least that practiced by others, as demonstrated by all the patently false claims we hear constantly in school-based clinics that prescribing contraception will “encourage” sex.]
Of course, it does not. Hormones encourage sex, yes. Social pressure encourages sex, for sure. But not contraceptives; what they do is prevent pregnancy. Amazing. And if the whole campaign against PP, as well as opposition to allowing a year’s worth of OCPs, is grounded in a mindset that wants to control women, the issue for young women (and their partners) is far worse. They are seen as not only women, but immature and incapable of making wise decisions. There is some basis for the idea that they are immature, as parents know; the brain is not fully developed until at least the mid-20s and the last part to develop is the ability to make “executive decisions” – taking the information that you have, looking at it completely and objectively, and making a smart choice. This is why teens and young adults make poor decisions in driving and, conversely, make the best soldiers.
But this is not a justification for restricting access to contraceptives, condoms, or other health services that might prevent bad outcomes. Because teens make not make the most mature decisions, and often regret them later, it doesn’t mean that they won’t make them. So we need to make it as easy as possible for them to not have long-lasting negative consequences, like STIs and unintended pregnancy. There need to be as few barriers as possible for young people to not get (or make another) pregnant, to not get preventable sexually-transmitted infections (STIs). These would include making oral contraceptives over the counter, making condoms in front of the counter, and preferably free. Should a young woman (or man) come to a clinic for care, invite them in, see them quickly, meet their needs. For goodness sake, don’t make it hard, don’t send them somewhere else to register as they’ll walk out the door!
The editorial in the New York Times, May 13, 2017, “The health care bill’s insults to women”, documents the degree to which women in rural and underserved areas, where more than half of PP’s clinics are, will lose if Medicaid doesn’t cover services at PP. It notes that in 105 counties, PP is the only provider of reproductive health services. The editorial starts with insensitive “sophomoric” quotes from several congressmen and senators, including one from Kansas Sen. Pat Roberts that “I wouldn’t want to lose my mammograms!”. Sen. Roberts would be well advised to identify which of the areas in Kansas, particularly in the very rural “Big First” district he once represented as a congressman, would be among those losing services. A lot, actually, especially since one OB/Gyn from Great Bend is now busy representing the district in Congress. Of course, Dr. Roger “the poor just don’t want health care” Marshall probably didn’t take care of many underserved folks.
This is not the way to go. Our goal must be to increase health as much as possible, not to create obstacles to it.
Saturday, April 15, 2017
The spectacle of Chicago Department of Aviation security officers beating and dragging a passenger off of a United Airlines flight was recorded by other passengers and quickly went viral on the Internet, generating outrage across the country (and internationally, particularly in China, where the fact that the passenger was Asian was a source of fury). A series of statements from United and its CEO, Oscar Muñoz escalated from tone-deaf explanation (essentially “well, we told him to get off first”) to most recently apparent contrition, saying it should never, ever, happen to anyone and that United would never, ever, have local police board its planes to take off a legitimate, paying customer.
It is unlikely that this too-little too-late response is going to appease anyone, and it is profoundly to be hoped that United suffers severe financial repercussions; the passenger, who suffered a broken nose and lost teeth, almost certainly will sue. It is not clear how to make this happen to the Chicago Aviation Department. The fury of the public is almost certainly increased by the personal experience of (coach) airline passengers. It also is not limited to either United or to airline travel, as Helaine Olen articulately describes in her NY Times op-ed “United Airlines is not alone”, on April 12, 2017. Ms. Olen goes through the list of issues that were raised by this incident, including not only the concerns about racism (would it have been worse if he were black?), but about the militarization of our police response to relatively minor issues. Although the officers involved were from Aviation Security and not the Police Department, it is understandable that a friend from Chicago posted the question “Was anyone surprised that the Chicago PD used such violence?” on Facebook, given that department’s history of “overreaction” and use of military-type tactics.
But Olen’s main point is that this event (if not necessarily the attendant violence) reflects the vast disparity in treatment provided, not only by United and other airlines but across our society, of people in different socioeconomic situations. She goes through the multiple enhancements to the first class cabins (sleepable seats with Saks 5th Avenue bedding, better meals, etc.) and compares them to the growing level of discomforts and indignities inflicted on coach passengers, with no food, increased crowding, baggage fees, and the like. The crowding is worse than on a bus, and Greyhound doesn’t charge for baggage. Full-fare first class passengers are a big profit center, but most people in first class are not the 1%ers who can pay these fares, they are business travelers whose companies have bought coach tickets and upgraded to first based on miles earned through an airlines loyalty program. And airlines love that, because it means they will keep flying with them. The rest of us, tough. And don’t believe that they “need” to stay so lean; Olen notes that United made $2.3 Billion in profit last year.
Olen also makes the connection to health, observing that
In a study published in 2014, Martin Gilens at Princeton University and Benjamin Page at Northwestern University found government policy and actions rarely reflected majority sentiment, but instead favored corporate interests and the wealthiest Americans. When congressional Republicans offered up a health insurance reform package earlier this year that would have covered fewer people than the Affordable Care Act, Representative Jason Chaffetz, Republican of Utah, initially defended it by claiming Americans needed to choose between spending on necessary medical care or buying an iPhone. Meantime, the fabled 1 percent would have received an average tax cut totaling $37,000 if the legislation were fully enacted.
And if anyone doubts that this is how the health system functions (although I doubt that many readers of this blog do), I recommend the new book “An American Sickness: how healthcare became big business and how you can take it back”, by Elisabeth Rosenthal (Penguin Random House, 2017). Rosenthal, a former New York Times reporter whose fantastic series “Paying till it hurts” ran in the Times a couple of years ago, is now the editor-in-chief of Kaiser Health News. I have cited her reporting frequently in this blog and in my 2015 book “Health, Medicine and Justice: designing a fair and equitable healthcare system” (Copernicus Healthcare). Indeed, “An American Sickness” overlaps considerably with my book, but is by a much better-known figure, and hopefully will be widely read. Rosenthal, a physician, pulls few punches in this work, saying unequivocally that the US health system is designed and functions to maximize the income and profit of providers (especially hospitals), insurance companies, and pharmaceutical and device manufacturers. (An excellent review of the book by Jacob Hacker, Professor of Political Science at Yale, can be found here.) Rosenthal identifies the ten “Economic rules of the dysfunctional medical market” (which I have reproduced in the figure); all are important but #10, “Prices will rise to whatever the market will bear” is particularly critical, and reflects that the health system bears little or no relationship to a true market, and does not play by Adam Smith’s rules.
ECONOMIC RULES OF THE DYSFUNCTIONAL MEDICAL MARKET
(E. Rosenthal, “An American Sickness”)
1. More treatment is always better. Default to the most expensive option.
2. A lifetime of treatment is preferable to a cure.
3. Amenities and marketing matter more than good care.
4. As technologies age, prices can rise rather than fall.
5. There is no free choice. Patients are stuck. And they’re stuck with buying American.
6. More competitors vying for business doesn’t mean better prices; it can drive prices up, not down.
7. Economies of scale don’t translate to lower prices. With their market power, big providers can simply demand more.
8. There is no such thing as a fixed price for a procedure or test. And the uninsured pay the highest prices of all.
9. There are no standards for billing. There’s money to be made in billing for anything and everything.
10. Prices will rise to whatever the market will bear.
Rosenthal supports each of these rules with data and examples. Regarding rules #8 and #9, in an NPR interview with Terry Gross on “Fresh Air” ,she emphasizes the importance of getting an itemized bill from the hospital and going through it line by line, citing a person who found $70,000 in outpatient surgery charges for an inpatient hospitalization, and others billed for circumcisions their newborn sons did not have. But it is not always easy; in the book she tells of a person who demanded an itemized bill rather than the one she received, where the total of $45,000 was simply labeled “Miscellaneous”! The hospital never sent it, despite it being her legal right, but did send her to a collection agency! Rosenthal says we would never tolerate shopping at a supermarket with no prices where they just sent us a $2000 bill every week. We should not tolerate this in healthcare. Every single service must have a listed, easily accessible public price. It may be fine to discount it for some insurers, and even more for some than for others, but the list price must be as clear as we expect it to be for anything else that we buy.
I learned some things from Rosenthal that had not even occurred to me; for example, the ACA’s 85% limit on “medical loss ratio” (i.e., the percent of premiums that insurers actually have to spend on medical care) ironically helps encourage them to be willing to pay higher prices to providers. Why would they pay $130,000 for a treatment that cost $19,000 only 15 blocks south (the opening example in the book)? Well, they get to keep 15%. And 15% of a bigger number is more in their pockets. And they just pass on the cost as higher premiums! Rosenthal discusses an important conservative health economist who is known for saying the high cost of US healthcare is overblown, but (amazingly) sings a very different tune when confronting the hospital bill for his father!
“Dysfunctional” is the wrong word for our health non-system. It functions just fine to make lots of money for the biggest corporate (including ostensibly “non-profit”) players. For the rest of us, it doesn’t always provide the best, or even adequate care, and it drains our individual and collective pockets, significantly contributing to individual bankruptcies and bad health outcomes when folks go without care. It also results in governments at federal, state, and local levels not having funds for other social programs that might actually improve health more.
Yes, we can change it but it will require resolve and a lot of work, because the opponents of change are rich, powerful, and entrenched. We cannot accept any excuses from our bought-off politicians or “pragmatists” who are the ones who suffer the least. We are least able to fight when we are sick and need care, just as we are least able to object to our conditions when we have a ticket and are on a plane bound for where we need to go. But just as we can fight the latter, we can fight the former; the social media response to United is an example of a good start.
But it is going to take more than a good start to get the thieves and profiteers out of healthcare, and get a system that benefits us all. It is going to take a long fight with a lot of hard work. Up for it?
Friday, April 7, 2017
My recent post, Doctors and health reform: maybe they do stand for health!, March 25, 2017, lauded the positions of many medical organizations, including the American Medical Association (AMA) for their positions in opposition to the American Health Care Act (AHCA), the Trump-Ryan bill that never even got to a vote, and apparently was never even available to House members to read before the vote was scheduled. But I also pointed out some “bad” doctors, defined as those who advocate policies that are bad for the health of the American people. They argue that they are really for health, but this means mostly health care, especially medical care, for those who can afford it. There is no small tinge of racism as well as classism in these positions, because poor people and minorities are those most likely to be left out, and because, well, these perpetrators don’t care.
The prime example I cited was Secretary of Health and Human Services Tom Price, who, as a representative from a wealthy suburban Atlanta House district, continuously railed against the Affordable Care Act (ACA), as well as, in fact, Medicare. Dr. Price is an orthopedic surgeon, and my essay noted that this specialty is over-represented in the cohort of opponents of expansion of access, possibly because their high average income puts them in an elite economic group, and many are more concerned with their self-interest than the health of the overall population. Price was not the only bad doctor I mentioned; I also cited the “tone-deaf” comments of Rep. Roger Marshall of Kansas, an obstetrician-gynecologist. “Tone deaf”, of course, is a mild and polite term for his racist, classist comments, summarized as “the poor just don’t want health care”. Tone deaf, by the way, is also the term commonly used to describe the demeaning commercialization of the Black Lives Matter protest movement evident in Pepsi’s commercial featuring Kendall Jenner, now mercifully withdrawn. That was a result of the strong and sustained protest of a large number of people, especially on social media.
Price and Marshall are abetted by the non-physician politicians in Congress and the administration who also would deny health care to a lot of people, and even, through changes in Medicare and Medicaid, make the coverage of many people who now feel moderately secure in their insurance status greatly at risk and much more expensive. Speaker of the House Paul Ryan and Vice President Mike Pence met with the “Freedom” Caucus of the House to discuss just how regressive a health care bill would have to be to get their support. Pretty bad, it turns out. Its chairman, Rep. Mark Meadows of NC, is quoted by the NY Times as saying “Lower premiums have to be our first and only priority. By repealing community rating and the essential health benefits, it allows for lower premiums across the board.” Well, lower premiums are something everyone wants (except probably insurance companies) but there are different ways to get there. “Repealing community rating” means that insurers would no longer have to cover people who have chronic disease and are often older (and, ironically, often Trump and Freedom Caucus voters) at the same rates as less sick people. Those people would not have lower premiums; their premiums would either be fantastically higher, as they were before the ACA passed (and when many of them were without coverage) or be altogether unavailable. This is not something that the vast majority of Americans want. Similarly, “essential health benefits” are, well, essential. Like, for example, maternity care, and preventive health care. The fact that Rep. Meadows used that word and didn’t replace it with some euphemism, illustrates how tone-deaf he is.
But not all doctors who I would characterize as “bad” are reactionaries who are trying to figure out how to deny health care to the American people. Some are just traditionally greedy, seeking to fill their own pockets with as much money as possible. This is not a problem limited to the right; even folks who are progressive on social policies can be guilty of “going where the money is”. An excellent example is Trump’s nominee to head the FDA, Dr. Scott Gottlieb. Gottlieb, like many researchers, has been highly paid (at least on the order of hundreds of thousands of dollars) by drug manufacturers. Gottlieb assures us that this will not affect his decision making at FDA, and that he can be trusted, as in the title of the NY Times article of April 5, 2017, in which he “deflected” criticism. While some Democrats, like Sen. Patty Murray of Washington, noted that he had ‘“unprecedented financial entanglements with the industries he would regulate,”’ Republicans like Lamar Alexander of Tennessee agreed with Dr. Gottlieb that “his experience with the pharmaceutical industry would be an asset in regulating it.” This is terrific tortured fox-guarding-the-henhouse logic, like having Goldman Sachs financiers regulating Wall Street, or petroleum company flaks running EPA (which we, in fact, have). This concept worked fine on “It Takes a Thief”, but not so much in real life.
Taking huge amounts of money from drug companies may be morally reprehensible (or not, depending on your view; in mine it is), but more concerning are the positions that Gottlieb has taken. While he is open (he says now) to lowering drug prices by importing drugs from Canada, something Trump has occasionally voiced support for, he has previously written against it (when he was in the pay of the drug companies). The issue is what the policies pursued by the FDA, HHS, CMS, and the overall Trump administration and Congress regarding the people’s health will be. Disrespect for preventive care (“essential services”) and environmental pollution bodes very poorly for public health, as the core principle of “cut benefits” does for medical care. And, as always, the most vulnerable – from poverty, age, illness, geographic region – will suffer the most. It would be really good if we could count on doctors like Price, Marshall and Gottlieb to protect the health of the people, but don’t count on it. We are going to need huge public protest, at least as big as those that ending up canceling the Pepsi commercial.
Well, it could be worse. Another physician, Dr. Bashar al-Assad, is gassing his own people with chemical weapons. And there was also Dr. Josef Mengele. So far, none of Trump’s nominees are in that league.
Saturday, March 25, 2017
The new GOP health plan, the American Health Care Act (AHCA), aka “Trumpcare”, has crashed to defeat. The President, who pushed hard for it, looks like his greatest nightmare, a “loser”. It is worth thinking, however, about who opposed it. In Congress it was Democrats and (the few) moderate Republicans and very right-wing Republicans are against it, for different reasons. From outside government the response was pretty negative, with a 17% approval rating (amazing they could still think they could pass it!). Far-right “conservatives” thought that AHCA was too much like Obamacare in that it actually provides some federal support for some people, and they don’t believe in the government ever helping anyone, except maybe themselves and their friends. (Oh, yes, and fabulously rich people. They deserve a lot of help.) The criticism from most of the rest of the universe (to say “the left” would be inaccurate, since it includes many quite a bit right of center, since, in fact, “Obamacare” started life as a Republican plan) was mostly because it would be a disaster for health coverage for Americans. Projections by the Congressional Budget Office (CBO) were that 24 million people would lose their health insurance, that access to care would be more and more limited, especially for the middle class and poor, and that costs would rise for patients exponentially. Also that the public health and preventive health infrastructure would be gutted and many of our advances in those areas lost.
The main “positive” in the CBO’s projection was that it would reduce the federal deficit by $337 billion over 10 years. This was only because it shifted costs to others, to states and employers and individuals. Those who could not pay with money would pay with their health and sometimes their lives. While, as I have pointed out (‘We have a bill! The GOP's plan to cut taxes on the rich and health care for the rest of us, March 16, 2017) many would have lost their insurance because of cuts in subsidies through the exchanges, the biggest impact would have been through the loss of Medicaid. This is clearly explained by Dr. Daniel Derksen, a family physician and director of the University of Arizona’s Office of Rural Health in a video on MedPage Today.
Among the many groups criticizing the draconian cuts in health care (as well as taxes on the rich) are almost all of the major hospital associations (including the American Hospital Association, the Catholic Hospital Association, and others), and physicians’ groups, most notably the American Medical Association (AMA) as well as most specialty societies including the American Academy of Family Physicians (AAFP), the American College of Physicians (ACP), as well as many others. They have been joined by the major nursing organizations and by patient advocacy groups. It should not be surprising, I suppose, that most of these groups would be critical of such a devastating attack on health care for Americans, but if it isn’t, it is at least a relief. The AMA is important in part because of its major role in opposing most historical expansions of health care access by the government, including President Truman’s attempt to get a national health insurance program (where they were successful) and President Johnson’s creation of Medicare and Medicaid (where they were not).
Of course, not all health providers and certainly not all physicians opposed the AHCA’s changes. MedPage Today published quotes from a number of physicians, and some were quite supportive; Darrell S. Rigel, a dermatologist at NYU, for example, said “It looks like it is a significant improvement over the ACA [the Affordable Care Act, aka Obamacare].” The most noteworthy physician advocate for the AHCA and Trumpcare was naturally Tom Price, MD, the Secretary of Health and Human services. As I discussed before his appointment (“Trump, Price, and Verma: Bad news for the health of Americans, including Trump voters, December 3, 2016), Secretary Price, as a congressman from Georgia was a leader in the Tea Party caucus and an opponent of ACA or any other program to expand health coverage to Americans. Another recent voice to both support AHCA and channel the administration and GOP’s contempt for regular people is Rep. Roger Marshall, an obstetrician from Great Bend, KS who is the Representative from Kansas’ “Big First” district. Dr. Marshall told the Washington Post that “the poor just don’t want health care”. He kind of walked back those remarks later, but his analysis is telling:
“Just like Jesus said, ‘The poor will always be with us,’ ” Marshall said in response to a question about Medicaid, which expanded under Obamacare to more than 30 states. “There is a group of people that just don’t want health care and aren’t going to take care of themselves.” He added that “morally, spiritually, socially,” the poor, including the homeless, “just don’t want health care….The Medicaid population, which is [on] a free credit card as a group, do probably the least preventive medicine and taking care of themselves and eating healthy and exercising. And I’m not judging; I’m just saying socially that’s where they are,” he told STAT, a website focused on health-care coverage. “So there’s a group of people that even with unlimited access to health care are only going to use the emergency room when their arm is chopped off or when their pneumonia is so bad they get brought [to] the ER.”
I may not be the best person to comment on his bizarre interpretation of the Gospel, but I can say that for many of us the challenges that poor people face in just getting through their lives are reasons why we need to make health care accessible, not reasons to just write them off. I also wish that I could say that, in my experience, physicians with attitudes like those of Price and Marshall are rare, but sadly they are not. To some degree, there are differences by specialty, with primary care physicians and psychiatrists more likely to support government-involved health care and even single payer plans than surgeons (including orthopedists). I am sure that at least in part this difference is driven by income; while all physicians have relatively high incomes compared to most Americans (top 10%), some specialties, including orthopedics (at the top), radiology, cardiology, surgery, and dermatology make much more; the mean reported income for orthopedists, about $467K (which seems low to me based on those I know) is about the cutoff for the top 1%. When a friend of mine (who later became a surgeon) was on his surgical rotation in medical school, he was impressed by all the talk in the surgeon’s lounge about the “Big Board” – until he found out they meant the stock market, not the board listing upcoming surgeries! And primary care doctors are not immune; when I lived in Texas one family physician regularly railed against the liberal government spending our money. One day, however, his attacks were on delays in payments to doctors from Medicare. Umm…
Doctors are, of course, like other people. Their perspectives vary widely, with most being caring and some caring mostly for themselves. My family physician colleague’s self-centered view is not so different from that of those Trump voters who are now against the AHCA because they see that their benefits are being cut; see “Trump budget cuts put struggling Americans on edge”, NY Times March 18, 2017. The authors cite a retired nurse with lung cancer whose heat was cut off in the middle of the winter; she was rescued by a heating subsidy funded by the federal government and likely to be cut. “I understand what he’s trying to do, but I think he’s just not stopping to think that there are people caught in the middle he is really going to hurt,” she said. Somehow, I suppose, she thought that the cuts would only be to other people…
So, while it is true that doctors, like others, often share the perspectives of their class, and callously disregard or rationalize opposition to ensuring health care for everyone, they often do understand the situations their patients are in and serve as advocates for them. In 2001, the AMA passed its “Declaration of Professional Responsibility: Medicine’s Contract with Humanity”. It includes the following “Advocate for social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being.” The AMA was on the right side of the AHCA fight. I hope that most doctors agree with, and even practice, that principle.
I hope Tom Price and Roger Marshall are aberrant exceptions.
Thursday, March 16, 2017
Every day it gets more difficult to write about the new “American Health Care Act” (AHCA) that has been introduced in the House of Representatives by Speaker Paul Ryan because every day there is so much more news about it, and so much more criticism of it that appears in the press. Even before its introduction, the bill was attacked for being likely to significantly increase the number of uninsured Americans while providing windfall tax cuts for the wealthiest.
It did not disappoint. Consistent with predictions, the nonpartisan Congressional Budget Office (CBO) estimates that initially 14 million people will lose coverage, with the number rising to 24 million in 10 years. These estimates are discussed in detail, and clarified, in “Deciphering CBO estimates” at the Kaiser Health News site. The largest number of people who will lose coverage will do so because of the changes – but let’s call them what they are, “cuts” – to federal funding of Medicaid (discussed by the Health Affairs blog), which would shift costs to the states, most of which will be unable or unwilling to absorb these costs. The 31 states that have expanded Medicaid to all those under 138% of the federal poverty level under the Affordable Care Act (ACA) will be faced with having to fund a lot more from their own coffers; poor people in the states that have not expanded Medicaid eligibility will continue uncovered. The other group that will lose coverage will be those who have bought subsidized insurance on the ACA-created marketplaces and who will no longer be able to afford the premiums. Yes, the new GOP plan calls for tax credits to help pay premiums, but they will be far less than under the ACA and far from enough to cover the actual cost.
This change will have the biggest impact on the older, sicker poor who are not yet eligible for Medicare (and, while I we will not address it here, the GOP leadership certainly has plans for cutting Medicare!), whose premiums will go up because of two important changes the AHCA will make. It will end the “individual mandate” of ACA, so that those who feel that they do not need health insurance can pass on buying it, which means the pool of insured will lose those healthier people and have a pool more skewed to those who are sicker and will actually use health care. This will tend to drive premiums up for them, and the AHCA also allows insurers to charge 5 times as much to older people as younger. As reported by Thomas Kaplan and Robert Pear in the NY Times on March 13, 2017
Under current law, in 2026, a single 21-year-old earning $26,500 with an insurance policy that costs $5,100 a year would get a tax credit of $3,400 and would have to pay $1,700 of the premium. Under the Republican bill, that person’s share of the cost would drop to $1,450.
By contrast, a 64-year-old earning the same amount would fare much worse. That person’s $15,300 health plan would be offset by a $13,600 tax credit under current law, leaving the consumer responsible for $1,700. Under the Republican plan, health insurers would be free to charge older people more, raising that person’s premium to $19,500. But the tax credit would be only $4,900, and that person’s share of the premium would then be $14,600.
That’s a bite! And, ironically, as pointed out by Noam Levey in the Los Angeles Times (March 12, 2017), it will hurt Trump/GOP voters more than Democratic voters, because those Trump voters – and the counties and states which went for Trump in which they live -- are more likely to be in this older, sicker, group. This group of Republican voters did not like Obamacare because the premiums, co-pays, and deductibles were going too high and the coverage was not always great, especially for the plans they could afford. Trump, and the GOP, promised them high-quality, affordable coverage. These folks believed them. They voted for them. And they are not going to get it, certainly not from the AHCA. Levey notes that “…In nearly 1,500 counties nationwide, such a person stands to lose more than $6,000 a year in federal insurance subsidies. Ninety percent of those counties backed Trump…[a]nd 68 of the 70 counties where these consumers would suffer the largest losses supported Trump in November.” What can you do. Politicians lie. This one was a whopper.
What is the reason for this? Many of Congress’ and Washington’s leading “conservatives” say that they believe that the role of government should be as close to zero as possible, and certainly think that the government has no business being involved in the insurance marketplace to ensure that people without resources have health coverage; to them, the AHCA is too much like the ACA in that it actually makes some effort to help some people, if weakly. There are a few of these “conservatives”, in and out of Congress, who really believe this and act on such beliefs. Uniformly, they are not poor, are not close to poor, and are not likely to be negatively affected. There is a much larger contingent that only believe government should not help most people. They support legislation that benefits rich people, like the AHCA, which uses the money it will save (and the CBO says that it will reduce the deficit over 10 years by $337 billion) to give tax cuts, not evenly distributed, but very much skewed to the highest incomes. This is where the [mean] rich people come in; they fund the Congresspersons, and this is what they want. Rep. Michael Burgess (R, TX), Chairman of the Energy and Commerce subcommittee on health, is quoted in the Times on March 11 (“The GOP’s high-risk strategy for health law repeal”) as saying “If you ask someone to give up something, there will be resentment,” and he is correct. That it is regular people who are being asked to give up something by Mr. Burgess and his colleagues, so that his rich patrons can save even more on their taxes, is something he doesn’t focus on.
One of the most iconic differences between ACA and AHCA focuses on equity: the subsidies (and tax credits for those who paid taxes) under ACA were tiered to income. The tax credits that replace subsidies under AHCA are tiered to age. Of course, as I have noted, older people are more likely to be sick, but they are not all of the same need; some older people have lots of money, and some have none. The same is true for younger people, including those with medical need. In any case, the tax credits in AHCA will not, as demonstrated above, be sufficient for those without significant other resources to buy health coverage, even if they are in the more-highly-subsidized older group. The Times’ Alan Rappeport reports on March 16, “One certainty in health bill: tax cuts for the wealthy”, with 40% of the cuts going to the top 1%, and the bill providing the necessary basis for further tax cuts for the rich. Rappeport quotes Mike Mulvaney, the White House budget director: “We promised at the outset that we were going to repeal all of the taxes. Who cares if someone else benefits?” Well, maybe the people who will suffer for their benefit? The same issue of the Times contains a brief and informative piece by Mr. Pear, “Putting Republicans’ plan on the Obamacare scale”, examining the criticisms of ACA and how the AHCA solves them (or not).
President Trump apparently feels conflicted; he promised the repeal of ACA, and the Congress wants to do that. He also knows that any plan that comes out that does this will be called “Trumpcare”, just as the ACA was called “Obamacare”. Enough Republican senators are concerned that the House’s AHCA will make it too hard for too many people to afford insurance that they might vote against it, so “Mr. Trump was left to strike a balance between siding with House Republicans while also distancing himself from the details, with top aides conceding that the legislation needed modifications before it could pass the full Congress,” (”G.O.P. Senators Suggest Changes for Health Care Bill Offered by House” NY Times, March 14).
Saturday, March 4, 2017
An editorial in the New York Times on February 20, 2017 (“Ryancare: You can pay more for less!”) does a very good job of concisely demonstrating what the new Republican plan is likely to do to access to health care, the cost of health insurance, and what it covers. The key to House Speaker Paul Ryan’s plan for replacement of Obamacare involves “…flat tax credits unrelated to income, that could be applied to the purchase of insurance” (Paul Krugman, “Death and tax cuts”, NY Times February 24, 2016). As Krugman makes clear, the credits would be insufficient for low and middle income families to buy insurance, but would be a small benefit to high income households. The obvious result would be the loss of health insurance for millions of Americans who gained it through either the ACA exchanges and accompanying subsidies or through Medicaid expansion.
Giving tax credits or deductions is a long-standing Republican strategy that pretends to be equitable but in reality always benefits the financially better off. Ivanka Trump (the President’s daughter who is not, it should be observed, elected or even appointed to anything) has her pet project, tax deductions for childcare. Again, this sounds good, especially to the more well-off, two-income couples who would benefit (but don’t get your hopes up; the $500 billion tab makes it unlikely to pass even with the First Daughter’s support), but would be of less benefit to the poor. The one thing that is certain about Republican and Trump policy is that it will benefit the better-off; the problem with such deductions, from their point of view, is that it is costly and doesn’t benefit a narrow enough slice of the highest income individuals and corporations (sorry, Ivanka).
As summarized in MedPage’s Washington Watch Policy Papers on ACA Repeal: Many Question, Few Answers, no one, outside the Republicans pushing it, has any belief that the Ryan plan will provide coverage for most of the people who gained coverage from the components of the ACA, not to mention those who remained uninsured even with ACA in place, mostly poor people in states that did not expand Medicaid and undocumented people, as well as those who risked the penalties for violating the individual mandate rather than buy health insurance that they felt they could not afford. The first two groups are completely left out of any “replacement” plan (and of course undocumented people were never part of Obamacare). None of these plans will in any way benefit the middle and lower income people who voted for Trump in part because they wanted to get rid of Obamacare, which was costing them too much, and get the terrific, affordable health care coverage that the President promised them in the campaign. It is not going to happen, and people are beginning to understand that; CNBC reports that Obamacare is getting more popular in the first month of Trump’s presidency.