Saturday, June 24, 2017
“Mr. McConnell has always taken pride in protecting his members.” -- NY Times, June 23, 2017
First, let’s start with a reminder about how insurance works. Money (“premiums”) is collected from everyone, or as many people as possible, and when the bad thing happens (insurance is almost always about protecting against bad things, like car accidents, or fires, or death, or illness), the victims are compensated. If it pays out more than it collects, then the insurance company goes bankrupt and can no longer pay out. This works for all types of insurance, whether for-profit (as most is in the US), not-for-profit (like many health-insurance companies in other countries), or social insurance where everyone is a client and government is the insurer. Insurance companies, especially for-profit insurance companies, have to build in a profit margin as well. In addition, they prefer insure people who are at low risk of requiring payout, and not to insure or charge higher premiums to those who are at higher risk (e.g., younger drivers, for car insurance). This process is known as “underwriting”.
If an insurance company is forced to insure a lot of high-risk people (as they were under ACA) and can’t charge them really a lot (under ACA they could charge 3 times as much), they need a lot of low-risk people to pay premiums to be able to fund their probable payouts; thus the “individual mandate”. For social insurance, such as government financed health insurance programs (as in many other developed countries, or Medicare and Federal employee and military programs in the US), it is actually not necessary that more money come in from premiums than is paid out, because the government can (if it wishes) subsidize the loss from other funds. This is, of course, a political decision on how to allocate tax dollars and how many tax dollars to collect.
The Senate Republican leadership has made its position on this completely clear with its recently unveiled “health care” bill, the “Better Health Care Act” (BHCA). Crafted by Majority Leader McConnell and a small group of white men from a small group of places (for example, 2 senators each from Utah, Wyoming, and Texas). It will and should be called #Trumpcare; while the President didn’t write it, he has endorsed it and will sign it if it passes the Senate and the House reconciliation. It is clearly a tax-cut-for-the-wealthy bill that derives funding from the reduction (and sometimes elimination) of health care coverage for a very large percent of Americans; this is detailed by the NY Times’ Margot Sanger-Katz in “Shifting Dollars From Poor to Rich Is a Key Part of the Senate Health Bill”, June 22, 2017. The Times also has a piece by Sanger-Katz and Haeyoun Park that contains a clear listing of what will be cut from the ACA in order to fund these tax cuts, “How Senate Republicans plan to dismantle Obamacare”, summarized in the graphic. However, the details are important; even the parts of the ACA that the BHCA “keeps” are largely undercut by other parts of the bill. For example, it keeps the requirement that insurers must issue policies to people with pre-existing conditions (which can range from heart disease and cancer to endometriosis and broken bones and everything else), which is good. But it raises the amount that insurers can charge these people from 3 times as much under ACA to 5 times as much. This is a big deal, and a bad deal, for people with disabilities and for older people who are, (surprise!), much more likely to have pre-existing conditions.
While BHCA (Trumpcare) repeals the individual mandate, which will make some people happy (until they get sick) and the employer mandate (which will make employers happy), it also repeals the subsidies for out-of-pocket costs and decreases funding for subsidies to make policies on the exchanges affordable. The new bill would make either premiums or deductibles (or both) unaffordable for many Americans. It limits and sometimes eliminates the requirement that insurers provide “essential health benefits”, like preventive care and contraception, allows insurers to set annual and lifetime limits on how much they have to pay, and makes major negative changes to Medicaid. Medicaid is currently largely paid for by the federal government, 50%-80+% depending on the average state income, and 90-100% for people covered by Medicaid expansion. The “changes” include (gradually, so the impact won’t be seen for the 2018 election) cutting and capping the amount the federal government pays, shifting costs to the states, which often will not be able (or willing) to cover them.
This will affect a lot of people. Medicaid is now the largest insurer in the US, covering 69 million Americans, even though many states did not expand it under the ACA to cover poor adults. What it does is summarized in “How Medicaid works and who it covers” by Abby Goodnough and Kate Zernike. It covers, as seen in the accompanying chart, 79% of poor children (and more than a third of ALL children), 64% of nursing home patients (many of whom were middle class before the NH wiped out their savings!), 60% of children with disabilities, 49% of births, 30% of adults with disabilities. The people who will suffer from Medicaid cuts are old people in nursing homes, children, and disabled people (many of whom are able to stay in the community and even keep jobs rather than being in nursing homes because of this support). With the caps on lifetime benefits, it means, as Dr. Eve Shapiro points out in an Op-Ed in the Arizona Daily Star, “that a premature baby on private insurance could exceed her lifetime limit on coverage before she even leaves the hospital”! And, with the right convergence of decisions by the state, the same could happen to an infant with Medicaid.
This is a big deal. Ideologues and pundits and politicians like to debate theoretical issue to see who scores the most points. They want to be the “most conservative”, the most “anti-abortion”, the most “pro-industry”, the most “anti-tax”. If they are articulate they may think that making their smarmy points makes them win. And I guess it does. Except the losers are not those on the other side of a debate podium, they are the majority of the American people, the politicians’ constituents, who don’t get treatments, don’t get diagnosed, do get sick and die. Lives, not ideologies, are at stake.
Except, of course, it is about ideology. This is made clear in “A debate that shows what each party cares about” by Neil Irwin the Times. No one, certainly not a senator who has to run for re-election, wants to say that they are about making it harder or impossible for many (often the majority) of their constituents to be able to access health care, or to pay for it, or to get the treatments and therapies they need. But make no mistake: every senator who votes for this bill is saying exactly that, that they value tax cuts for the most privileged above basic health care for the rest of us. “This plan will improve the affordability of health insurance,” lied Sen. McConnell in a recent opinion piece in the Cincinnati paper.
Yes, “Mr. McConnell has always taken pride in protecting his members.” And his donors. It is too bad that he has no interest in protecting the rest of us.
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.