Posted on | March 31, 2017 | 2 Comments
Dr. Barbara Bollier
“I’m about health-care’d out.” Those are the words of Sen. Pat Roberts (R.,Kan.)
One can understand his exhaustion. After all, seven years of relentless opposition to the ACA have ended in defeat. The leader, Mitch McConnell, of this effort acknowledged as much last week when he said “It’s pretty obvious we were not able in the House to pass a replacement.” Add to this the ongoing fight in Se. Robert’s own state, where Gov. Sam Brownback has apparently decided that he will be the last man standing when it comes to opposing the ACA in the state of Kansas.
In the federal battle, Republicans have made ample use of two conservative orthopedic surgeons, Tom Price and John Barrasso to attest to the “patient-centeredness” of dismantling a program that has provided or improved the quality of health insurance coverage for 30 million Americans. They have been able to make their appeals with a straight face attesting to their full conversion from physicians to politicians.
No such conversion appears to have seized the hippocratic core of former anaesthesiologist, State Sen. Barbara Bollier (R). Last year, in support of her rural poor uninsured patients of eastern Kansas. After a year of campaigning, she finally gained support for a vote to expand Medicaid under the ACA. She was understandably excited stating, “I am just elated that we’re now at the point that we can debate this bill.”
She was not alone. The Kansas Hospital Association had been a vocal supporter as had the health care organization collaborative, Healthy Kansas, which pegged the job loss title of the Governor’s obstinance at 4000. Polls also indicated that 82% of Kansans supported the ACA Medicaid expansion. State Sen. Laura Kelly cited the 2015 closure of Mercy Hospital in Independence, Kansas as a seminal event labelling the institution “a significant rural hospital.”
A wide range of Kansas legislators agreed. Specifically 81 members of the House and 25 members of the state Senate voted this week for Medicaid expansion. Brownback was unimpressed, vetoing the Bill, saying, ““It fails to serve the truly vulnerable before the able-bodied, lacks work requirements to help able-bodied Kansans escape poverty, and burdens the state budget with unrestrainable entitlement costs.” And with that, 150,000 eligible adults remain uncovered in Kansas.
The Kansas legislature may have had just about enough of their governor. Their roads are falling apart and their credit rating is dropping like a rock, while tax breaks for the rich have hit record highs.
So it’s not surprising that this may be Brownback’s Waterloo. Republican state senator John Doll is in favor of pursuing a 2/3 majority vote to overturn the Governor’s veto. “It’s something we need to do,” he simply says. And they are only 2 votes shy in the Kansas Senate and 3 votes shy in the Kansas House. Signaling their seriousness, the Kansas legislature is in session this weekend.
Posted on | March 28, 2017 | 1 Comment
Posted on | March 28, 2017 | No Comments
“Don’t mess with my Medicaid!” That was clearly the takeaway for Republican legislators heard as they met with hometown crowds in the lead up to their historic Trumpcare defeat. Whether they have “given up the ghost” only time will tell. But as the facts below suggest, going back at Medicaid today means attacking a program with super-majority support.
Posted on | March 27, 2017 | No Comments
In a recent analysis of the U.S. and Canadian health care systems, two things were clear. First, Canada Health Care was planned, and our’s just happened. And second, both nations favored regional over federal delivery systems. In the U.S., that meant a strong bias toward state management, while in Canada the provinces and territories individually control the majority of funding, coverage, and execution. For Canada this has meant tolerance for variability, which has been counter balanced by a high degree of transparency.
In the U.S., we have preferred more opacity and fudging. Every time we’ve sided with total voluntary participation, we’ve landed with egg on our face. But that has begun to change as last week’s vote on Trumpcare revealed. And Medicaid is where we now see serious cracks in conservative armour.
To review, the ACA when passed in 2010 required that states offer Medicaid to all citizens of the state who fell below 138% of the poverty level ($32,913 for a family of four.) The federal government at first agreed to cover 90% of the expenses for new enrollees and then up’d it to 100%. As we all know, the Republican Congress then loudly announced a call to arms to kill the President’s signature legislation, driving loyal Republicans in state houses everywhere underground. All manners of deception and subterfuge were legitimized for the next 7 years.
Still, in 31 states and in DC, Medicaid expansion or a federally approved alternative has occurred, including 10 with Republican governors. More importantly, even in the short term (especially with the opioid epidemic surging) the positive health outcomes associated with Medicaid expansion have been dramatic. On multiple measures, the populations covered are healthier, have greater access to care, delay less in getting needed care, visit emergency departments less and are less financially strained. The states budgets have improved as well.
Pragmatic Republican governors like John Kasich delivered direct messages during the Presidential campaign, which might be roughly translated, “Don’t be stupid. Participate and work with the federal government.” The party however chose a different course, which last week ended in disaster.
It now appears that most Republican governors have gotten the message but the Republican state controlled legislatures (many infused with Tea Party loyalists) are seriously lagging behind. A few examples:
Florida: Gov. Rick Scott timidly offered support for a 3 year trial expansion. Florida legislature denied.
Utah: Governor proposed expansion. Legislature denids by adjourning without action.
Wyoming: Governor became a late day advocate. Legislature denied.
Missouri: Governor advocated. Legislature denied.
And then there’s Kansas, whose Gov. Sam Brownback has made some remarkable economic choices that have hurt his state, but he’s still there. He recently became a timid supporter in light of the fact that the state’s own Medicaid funding is “rock bottom” when it comes to coverage. You have to be below 38% of poverty ($9215 for a family of four) in Kansas to qualify for Medicaid. The state’s hospital association just handed the governor an independent study pegging the cost of the state Republican party’s intransigence over the past two years at over $700 million in lost federal funding and an additional 3,400 jobs for the state. Brownback is now “open” to expansion – his Republican led state legislature, not so much.
The Commonwealth Fund just came out with their 2017 Health Scorecard which ranks states based on 40 measures of health system performance. Those denying Medicaid expansion showed significantly less progress in measures of access than participating states. As for overall ranks in hold-out states, here they are. 13 of the 19 are in the lower half of states by performance.
In the wake of the Republican failure to repeal the ACA, reports suggest that some state Republican legislatures have gotten the message. North Carolina, Georgia, Idaho, Nebraska and South Dakota are expected to lead the way.
And how about Kansas? Ask Vicki Scmidt, Republican state legislator and chair of their Public Health and Welfare Committee. She said last week before the vote,“If you can predict what’s going to happen in Washington, that would be great if we could be sure what’s going to happen. But in the meantime, we have to move ahead as a state.” Her Democratic colleague added, “I hope the governor gives the people of Kansas what they want.” Seemingly hedging his bets, the governor last week said “I’ll look at whatever they decide to send and whatever the final product looks like.”
Not exactly courageous, but at this point, we’ll mark that as progress.
Posted on | March 24, 2017 | No Comments
As the House leadership twists arms today, the noose is getting tighter by the minute around the necks of the most loyal Trump voting block – white males with only a high school education or less.
As the twisted deliberations over a deeply flawed bill progress, Brookings is hosting the Nobel Prize winning economist Angus Deaton whose latest survey results could not be more timely. His lead: Deaths of white males with no higher education continue to escalate. For those age 50 to 54, white deaths are now 30% higher than mortality rates of blacks in this age bracket.
Deaton, who released the first indicators of a reverse in historic life expectancy advances for whites in 2015, has now labeled the human losses as “deaths of despair.” These tragic outcomes, he believes, are the result of a basket of deplorable conditions that began to trap whites economically over the past two decades. Globalization and technology caught vulnerable whites by surprise – even though they were warned. As Deaton said, “The company man job has gone away for working-class people.”
As jobs disappeared, marriages declined, relationships became stormy, children were born out of wedlock, and individuals were increasingly socially isolated. In response, whites turned to alcohol and drugs, especially opioids. At the same time, owing to the absence of national health care insurance, they put off health care, and their burden of chronic disease including heart attacks, stokes, hypertension, pain syndromes, and mental health deterioration made a bad problem even worse.
For many, Trump spelled hope. But the formula he supports as we speak, will predictably worsen their deplorable state of affairs. As Rand’s labor market expert, James Smith, recently said, “The bad things that are going on in America do not appear to be going on in Western European countries, and that’s a big deal.” Those countries have a secure safety net and health services that the Republicans are busy dismantling.
According to Deaton, this will only get worse if Trump policy prevails. He says, “As these people move into old age, they’re going to be sick, and that has disastrous consequences for Medicare and Social Security policy… People may want to soothe the beast. They may do that with alcohol, they may do that with drugs, they may do that with food.”
Posted on | March 23, 2017 | No Comments
Since the Republicans have stalled today in their eight year pursuit to repeal Obamacare, perhaps they should take the night off, and relax by reading UNC professor Jonathan Oberlander’s NEJM advice on next steps.
Here are a few selections to whet your appetite:
Romney Care Origins: “The ACA is a conservative reform model embodying ideas previously supported by Republicans: consumer choice, private insurer competition, regulated marketplaces, tax credits to aid the uninsured, and individual responsibility to obtain insurance. If they repealed the entire ACA, Republicans would essentially be renouncing their own health care ideas.”
Regressive Redistribution: “The bill distinguishes itself from the ACA largely by its commitment to regressive redistribution: it would give wealthier Americans more money (mainly through sizable tax cuts) while reducing government support to help low-income Americans afford insurance.”
Low-Income Take A Hit: “Relative to the ACA, premium subsidies for the uninsured would decrease substantially, on average by 40% in 2020 and reaching 50% by 2026…The ACA’s subsidies to assist low-income persons with deductibles and copayments would be eliminated altogether.”
Seniors Suffer: “Because insurers could charge older persons higher premiums, they, too, would face much higher costs, with premiums for a lower-income 64-year-old expected to rise by about $13,000 in 2026.”
Medicaid -Forgetaboutit!: “Medicaid spending would fall by a staggering $880 billion during the next decade, resulting in a 25% cut by 2026.”
Morally Reprehensible: “Health policies represent more than the product of technical analysis, economic evaluation, and fiscal calculations — they also embody moral judgments and social priorities… Given this belief in self-reliance, faith in markets, and disregard for the poor, the GOP’s health bill is understandable — even if its moral logic is reprehensible.”
Politically Shaky: “The bill’s political logic is also shaky… In addition to unified Democratic and significant Republican opposition in Congress and among governors, key stakeholders — including the American Medical Association, the American Hospital Association, and the seniors advocacy group AARP — oppose the bill.”
Making It Worse: “The ACA’s insurance marketplaces have encountered significant challenges enrolling persons with modest incomes for whom, even with subsidies, insurance premiums and deductibles remain unaffordable. Instead of fixing these problems, the GOP bill, with its reduced subsidies, Medicaid funding cuts, and lower benefit standards, would substantially worsen them.”
Posted on | March 22, 2017 | No Comments
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