28 December 2018
Dear Interested Readers
“Zwischen den Jahren” Is a Good Time For Reflection
We have a friend in Germany who lived with us as an au pair more than thirty years ago. She now has her own family and a successful public relations business. This week my wife received a Facebook message from her wishing us a pleasant Zwischen den Jahren, the week between Christmas and New Year’s Day. I hope that you are having a great “week in between the years” and it occurs to me that this is a perfect time to reflect on the healthcare events of 2018. Perhaps in the Tuesday post which will be on New Year’s Day I will offer you a collection of thoughts about what might lie ahead in 2019.
My greatest concerns and much of my focus for 2018 has been the thousand little cuts and slights that the ACA has endured. What was revealing, amazing, and inspiring was that as the year moved along each slight and each threat seemed to clarify for a growing number of people just how much the ACA means to them as individuals and members of a family. By the time the midterm election votes were cast healthcare had become the biggest issue of the election. It was not the only issue on the mind of the undecided swing voters who settled the election between Trump’s committed base and the enraged progressive wing of the Democratic Party, but it was probably a deciding factor in many of the very close races that replaced Republican Congressional incumbents with an impressively diverse field of new members of Congress that gave Democrats a solid majority and a better platform for negotiating much more than healthcare with Donald Trump.
The tone for 2018 was set in December of 2017 when Republicans passed their tax reform bill that disproportionately benefited big business and the wealthy. The “crumbs” thrown to the middle and lower classes in that bill included cancellation of the mandate giving many the option to “live free” until they might die or finally want access to care so that they might not die. There is no question that the most unpopular part of the ACA was the mandate.
In an excellent article in the New York Times in November of 2017 before the tax bill was passed Margot Sanger-Katz explained why the “mandate” was important and why the Republicans wanted to do away with it in their tax overhaul.
In a bill with many unloved parts, the Affordable Care Act’s individual mandate has long been the most loathed…
Now it turns out that getting rid of the mandate could help Republicans as they tackle the difficult math of tax reform. According to a recent Congressional Budget Office estimate, eliminating the mandate could lower the deficit by $338 billion over a decade. A third of a trillion dollars can help pay for a lot of tax cuts. Which is why Senate Republicans, trying to find funding and keep their promise to dismantle Obamacare, are now vowing to add a mandate repeal to their tax bill.
But there’s a reason that Obamacare’s authors kept a provision so unpleasant and unpopular. And there’s a reason the budget office said that cutting it would save so much money. Without the mandate, economic studies have suggested, fewer healthy people would buy health insurance. Their exit from the market would raise insurance prices, driving out still more healthy people in an unhappy spiral of rising prices and lower rates of insurance coverage.
The mandate was often compared to one support in a three-legged stool that made Obamacare work: Knock it out, and the whole apparatus would tip over, broken and useless.
That was the logic that persuaded Mr. Romney to put the mandate in his health bill, and the thinking that persuaded President Obama to change his mind and put it in the Affordable Care Act.
Sanger-Katz’s explanation makes sense. If fewer people buy insurance there will be a selection for a higher risk population and rates would have to rise to match the increased expenses. It would also be true that with fewer people choosing to buy healthcare and take the chance that they would remain free of illness and injury, the subsidies required for those between 137% of poverty and 400% of would drop and money would “be saved.” That “saved” money would look like it lowered the federal deficit. What would not be apparent would be that when medical expenses did occur they would be higher for sicker people with later stages of illness. Most of those expenses would be bad debt and never appear on the balance sheet of the government.
Besides being a source of bad debt it would also be true that those people who chose not to buy care after the mandate is gone would be people who do not have access to employer supported care, Medicaid, or Medicare. Those that lose their bet that they will stay well and accident free will not only produce bad debt for those who provide their care, but they will also have more bankruptcies when they do get care. Lowering the deficit by denying care is an example of fuzzy thinking. It is an incomplete economic analysis that arises when one’s only focus is on lower taxes and the federal budget, no matter what the impact on individuals or institutions.
In a libertarian world where “ individual freedom” and lower taxes are the primary objectives the eventual outcome is a smaller economy. Stephen Pinker asserts in his book Enlightenment Now: The Case For Reason, Science, Humanism and Progress that there is no successful modern economy that has been built on reducing entitlements. The best economies have strong social services programs that that do not slide down a slippery slope to communism. They also have robust capitalism that is well regulated. In essence the social programs enable, not hinder, the growth of the economy and the economies benefit from healthy, well educated, comfortably housed, well employed, and productive citizens who are also consumers of life improving products. The citizens of those countries always enjoy universal access to healthcare. As Pinker says:
…countries that combine free markets with more taxation, social spending, and regulation than the United States (such as Canada, New Zealand, and Western Europe) turn out to be not grim dystopias but rather pleasant places to live, and they trounce the United States in every measure of human flourishing, including crime, life expectancy, infant mortality, education and happiness…no developed country runs on right-wing libertarian principles, nor has any realistic vision of such a country ever been laid out.
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Perhaps the biggest surprise for most of us was the twisted thought that without the mandate the ACA may be unconstitutional. That became a theory worth testing for the Attorney General of Texas who was supported by the attorneys general from many of the states that did not accept the Medicaid expansion and the governor of Maine. Now, we all know that a district judge from Texas, Judge Reed O’Connor, who is well known as “step one” or the “go to guy” from previous conservative attempts to reverse laws they did not like, did rule a couple of weeks ago that without the mandate the ACA is unconstitutional. I am thankful that his opinion is not the last word. Now the question moves on to the appellate court and perhaps to the Supreme Court before the 2020 elections. Yogi Berra’s wisdom, “It ain’t over til it’s over…,” is reassuring for those of us who would hate to see the ACA die in the courts.
Will the last laugh in the saga of the much maligned and misunderstood ACA belong to the advocates of universal access to healthcare, those of us who believe that healthcare is an entitlement? I think so, but we probably will not know for sure until we are deep into 2020, perhaps all the way in to election night in November. I am betting that no matter what happens in the courts, the voters will be very clear about a set of things in the ACA that does appeal to them and finally realize that we would all be much better off paying a little more tax to avoid the cost of healthcare and all of the miscarriages of justice associated with its current distribution. Now that many people have moved from talking about the faults of the ACA to appreciating its accomplishments, attempt at fairness, and the fact that it is better than any of the alternatives produced by Republicans, the discussion is shifting from what people don’t like to what it is doing that they do appreciate. In a very recent article reviewing the ACA at the end of the December 2018 open enrollment period, the BBC listed what people like about the ACA.
Some of the more popular provisions include:
- Children can stay on their parent’s healthcare plan until age 26
- No one who is sick or has a medical condition can be denied insurance
- Companies can no longer charge women more than men
- Businesses with more than 50 full-time employees must offer health insurance
I think that is a good list, but I also believe that there are other things that the public likes as well even though some citizens can’t put everything they like in words. I think that the ACA’s emphasis on primary care and preventative care is very popular as is the elimination of lifetime limits on care. These are items that are often not a part of the cheaper “skinny” programs that the ACA forbade and that President Trump’s administration now allows. The BBC article is an excellent review of the current state of the ACA after two years of administrative abuse by Trump and company. One abuse that most voters ignore is the impact on the total cost to consumers created by ending the subsidies (CSRs) to the insurers in the exchanges. What consumers and voters do note is the impact of not paying the CSRs, rising costs on the exchanges. Another steadily increasing negative trend over the last year has been the introduction of work requirements in many states for some recipients of Medicaid. My state, New Hampshire, has recently been given the green light by CMS to introduce work requirements. I see these new regulations as another example of harassment directed at recipients of publicly funded healthcare with the intent meant to be to discourage people from signing up or facilitating their removal. It a perfect example of an abuse of “distributive justice.”
It is my hope that all of Trump’s ACA attacks continue to blow up his hold on the presidency and eventually terminate the Republican majority in the Senate. I hope that if Republicans continue their attacks on the ACA in 2019 they will be hastening the day when we return to the norms that have been violated in so many spheres over the last two years. As 2019 proceeds you can be sure that the story of the ACA will continue to unfold. It is my hope that the efforts have an unintended consequence which is to make some form of uniform national healthcare access for all a reality in 2021, which is probably the earliest possible date. I always saw the ACA as an intermediate step. A mandate would not be necessary if healthcare was an entitlement that we all enjoyed.
The Commonwealth Fund, Modern Healthcare, and I all agree that the big issue for 2018 was the continued attack on the ACA. I have already mentioned the first six items on the Commonwealth Fund’s list with my discussion of the ACA. I like the other four issues on the Commonwealth Fund’s big ten for 2018. Here is the full list of ten from the Commonwealth Fund.
1. The ACA under renewed judicial assault
2. Turnout for open enrollment in health insurance marketplaces surged at the end of the sign-up period: After lagging in the early weeks, enrollment ended just 4 percent lower this year than in 2017.
3. The administration continues efforts to hobble ACA marketplaces: The federal government spent $10 million on advertising for the 34 federally facilitated marketplaces this year (the same as last year but an 85 percent cut from 2016) and $10 million on the navigator program (down from $100 million in 2016), which provides direct assistance to hard-to-reach populations.
4. Insurers encouraged to sell health plans that don’t comply with the ACA: Another tactic the Trump administration is using to undercut the ACA is increasing the availability of health insurance products, such as short-term health plans, that don’t comply with ACA standards.
5. Medicaid expansion in conservative states: Few states have expanded Medicaid since 2016, but in 2018, a new trend toward expansion through ballot initiatives emerged. Following Maine’s citizen-initiated referendum last year, Idaho, Nebraska, and Utah passed ballot initiatives in November to expand Medicaid. Other red states may follow in 2019.
6. Red states impose work requirements for Medicaid: A number of states submitted federal waivers to make employment a requirement for Medicaid eligibility. Such waivers were approved in five states — Arkansas, Kentucky, Wisconsin, New Hampshire, and Indiana — and 10 other states are awaiting approval. At the end of 2018, lawsuits are pending in Arkansas and Kentucky challenging the lawfulness of work requirements for Medicaid eligibility. About 17,000 people have lost Medicaid in Arkansas as a result of work requirements.
7. Regulatory announcements respond to public outrage over drug prices: Public outrage over prescription drug prices — which are higher in the U.S. than in other industrialized countries — provided fodder for significant regulatory action in 2018 to help bring costs under control.
8. Corporations and Silicon Valley make deeper inroads into health care: Atul Gawande is leading the Amazon, Berkshire Hathaway, and J.P. Morgan Chase initiative. Apple teamed up with over 100 health care systems and practices to disrupt the way patients access their electronic health records. And CVS Health and Aetna closed their $69 billion merger in November.
9. Growth in health spending slows: The annual report on National Health Expenditures from the Centers for Medicare and Medicaid Services estimates that in 2017, health care spending in the U.S. grew 3.9 percent to $3.5 trillion, or $10,739 per person.
10. Drug overdose rates hit a record high: Continuing a tragic trend, drug overdose deaths are still on the rise. The Centers for Disease Control and Prevention reported 70,237 fatalities in 2017.
Modern Healthcare’s List was somewhat different after their discussion of the ACA related issues. They focused on hospital operations, the insurance industry, mergers and consolidations, gun violence and opioid deaths. Their conclusion seemed to be “It’s all about the money.” I would suggest that you read their article to judge the similarities and differences with the Commonwealth Fund’s analysis.
As I look back on 2018 I am impressed that with the exception of patient’s concerns about drug costs, and the tragedy of the opioid crisis most of the issues do not touch the daily experience of clinicians. I would predict that the issues will come closer to every day’s work in 2019, but we will see. I hope that raising some of the points that do not seem to be something that touches your practice now, you will begin to think about how you will respond when the issues begin to be problems that touch your practice in ways that create change that you feel and must address. Continuing problems of access and bad social policy are driving changes now even for clinicians and their patients although the majority of patients and practitioners may still be able to see the issues as someone else’s concern for a little while longer. It is my New Year’s hope and prayer that there will be an obvious reversal of many of the negative government policies of 2018 in the year to come.
Clear Skies, Thick Ice and Very Cold Air
The picture you see in today’s header is my very favorite view from my favorite walk. It is not my easiest walk, but hands down the most spectacular. The scene is the view from the highest point on Burpee Hill Road. It shows Mount Sunapee at the other end of Lake Sunapee, about ten miles away. The vistas in an arc of 270 degrees are spectacular and on a clear day you can see far into Vermont. The site is about three quarters of a mile from my home. On some days the clouds are low, the visibility is limited, and you can not see the mountain. The day that I took this picture was a little bit overcast, and the picture was snapped near sunset. Most of the days this week have been very cold with temps in the mid twenties and lower, but the sky has been crystal clear with very few, if any clouds. All that is to change today. We have rain on the agenda.
I have been delighted that the rain I complained about last week did not wash away our White Christmas. Once it got cold again the residual snow cover was pretty icy which made it poor for snowballs and snowmen, but we discovered that we had a killer toboggan run. My four and a half year old grandson has had a ball. Even his 15 month old brother gave it a big thumbs up after enjoying a shorter version of the downhill rumble.
The other big outdoor adventure has been ice fishing. I decided that this would be the year. I am making progress. Even though my old fishing buddy Bob left me his collapsible ice fishing rig, his power auger, and all of his gear, I had been intimidated by the complexity of the endeavor. My grandson wanted to try it so I bought an old fashioned hand powered auger because the power auger looked intimidating and I could imagine it running away from an amateur operator. The huge machine driven auger was daunting when my friend was alive to help me get it started.The old fashioned hand auger was a perfect fit for my temerity. It worked so well I have no idea why people want a gasoline powered version. The ice is about sixteen inches thick. The efforts were not totally in vain. So far we have hooked one index finger sized little yellow perch that got off our line as we were pulling him up through the ice. It is a start. It will be a little warmer this weekend, and who knows, that five pound largemouth bass that I caught and released last August may come by for a second visit and give us another thrill in the chill.
Whatever is on your schedule for “Zwischen den Jahren,” I hope that it will finish 2018 on the upswing for you. I will be writing on January first, but something tells me that between hangovers and football games reading it may be the first failed good intention of 2019 for many “Interested Readers.” That’s OK. I understand and wish you a fabulous 2019. It should be an interesting ride.
Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
