What do the American people want in a healthcare plan? Not what Trump, Price and the GOP will give them

Readers of this blog are probably aware that I am a member of Physicians for a National Health Program (PNHP) and, like that organization, support the creation of a single-payer health system in the US. Sometimes referred to as a Canadian-type health system, or as in Sen. Bernie Sanders’ presidential campaign, “Medicare for All”, it is pretty easy to understand, and is a system that has worked not only in Canada but, in modified forms, in most developed countries in the world. The key feature of such a system is that it is one program that covers everyone in the country, “Everybody In, Nobody Out”in the title of the book by the late Quentin Young, MD, a former President and executive director of PNHP and a “tiger for social justice” in the words of his Chicago Sun-Times obituary.

Such a system would replace the bewildering, dazzling, complex, confusing mess of the current US health care system, with its hundreds of different private insurance policies with widely varying benefits, premiums, and coverage, as well as the federal programs of Medicare, federal-state partnerships like Medicaid and the ACA’s health insurance exchanges, and of course that persistent, pesky mass of 30 million or so uninsured. And the underinsured, who are effectively uninsured, because they buy the only policy that they feel that they can afford only to find out when they need it that it, surprise, doesn’t cover what they need!

Much of the defense of the ACA has been based on the fact that an insurance pool must have healthy as well as sick people. This is a core tenet of insurance, which would otherwise be unaffordable. Life insurance cannot work if it only covers people on their deathbeds; car insurance cannot work if it only is purchased at the time of an accident, homeowner’s insurance cannot work if it is only bought by people in the midst of a fire. If this were how insurance worked, there would be no need for it, for the premiums would be basically the same as paying for the cost of the services. To have it otherwise, as insurance, requires a pool of money contributed by folks, whether directly or through their taxes, who are not immediately benefiting to cover those who need it. In fact, though, understandably but impossibly, people want coverage for when they are sick, but don’t want to pay when they are not. People may not want to pay a lot when they are healthy (or think that they are) but they want coverage for their sick parents, or newborn with health problems, or when they are diagnosed with cancer, or when their adolescents are in a car wreck. These are things that don’t happen to most of us most of the time but happen to enough of us over our lives that we know enough to fear or expect it. A national single-payer system gets rid of this problem, by having the largest possible risk pool.

But the people of the US did not elect Bernie Sanders, and he did not even get the Democratic nomination. We elected (OK, the Constitutional unfairness of the Electoral College elected) Donald Trump, whose positions may be erratic and change frequently, but whose appointments to Cabinet-level posts are remarkably consistent. Most are from the most right wing of the Republican Party, not unlike we would have expected from Ted Cruz. Despite a campaign that attacked Wall Street and the support Hillary Clinton received from the financial sector, he has appointed many Wall Streeters, including several former (and current) folks from Goldman Sachs -- most recently, their lawyer whose wife still works for them, to head the SEC. Foxes guarding the henhouse abound; climate change deniers will head the EPA and Department of Energy. And in the same vein, we have, for Health and Human Services nominee, Rep. Tom Price, the orthopedic surgeon from Georgia about whom I wrote recently (“Trump, Price, and Verma: Bad news for the health of Americans, including Trump voters”, December 3, 2016).

Rep. Price certainly does not stand for a single-payer national health system. Nor does he stand for ensuring health care for the vulnerable, whether poor, elderly, rural, or sick, as demonstrated in an excellent piece in the New England Journal of Medicine by Sherry A. Glied and Richard Frank, “Care for the vulnerable vs. cash for the powerful – Trump’s pick for HHS”. It notes that he “…favors converting Medicare to a premium-support system and changing the structure of Medicaid to a block grant,” which would mean that not only Medicaid, and the coverage people have received under ACA, but even Medicare which has protected seniors for 50 years, would be under threat. The article contains information about his positions on other issues, including favoring greater access to armor-piercing bullets, opposing regulations on cigars and on tobacco as a drug, opposing the reauthorization of the Violence Against Women Act and laws prohibiting discrimination against LGBT people. In terms of ensuring health coverage he is as mean as they come:

His voting record shows long-standing opposition to policies aimed at improving access to care for the most vulnerable Americans. In 2007–2008, during the presidency of George W. Bush, he was one of only 47 representatives to vote against the Domenici–Wellstone Mental Health Parity and Addiction Equity Act, which improved coverage for mental health care in private insurance plans. He also voted against funding for combating AIDS, malaria, and tuberculosis; against expansion of the State Children’s Health Insurance Program; and in favor of allowing hospitals to turn away Medicaid and Medicare patients seeking nonemergency care if they could not afford copayments.

But he is the President-elect’s health guy, and we might think that the folks who voted for Mr. Trump will get what they wanted. Except they probably won’t, other than that small slice of voters representing the wealthiest providers, insurers, drug manufacturers, corporate executives, and pundits (like the Wall St. Journal’s Kim Strassel). The health situation in the US is bad, particularly for lower income whites, whose mortality rate has, remarkably, as reported by the Commonwealth Fund, been static rather than decreasing or in some cases (low income women) increasing. These are many of the same folks who voted for Donald Trump, and are presumably looking for a solution. The Kaiser Foundation recently conducted focus groups among Trump voters in states have been hard hit by job losses and were key swing states in the election – Ohio, Michigan, and Pennsylvania. The participants either had Medicaid or were covered by ACA. The results are summarized by an op-ed in the New York Times by Kaiser’s CEO, Drew Altman, “The health care plan Trump voters really want”, January 5, 2017.

If these Trump voters could write a health plan, it would, many said, focus on keeping their out-of-pocket costs low, control drug prices and improve access to cheaper drugs. It would also address consumer issues many had complained about loudly, including eliminating surprise medical bills for out-of-network care, assuring the adequacy of provider networks and making their insurance much more understandable.

That’s what they want. That’s what I want. It is what I believe a single-payer system would deliver. But it sure isn’t what they are going to get from Tom Price, or from whatever “replacement” the Republicans come up with for ACA.

And that’s more than a shame.  It’s a scandal.

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Trump, Price, and Verma: Bad news for the health of Americans, including Trump voters

The election of Donald Trump as President continues to be extensively analyzed. It demonstrates major divisions among our populace. One of those that has been discussed a lot is that the “white working class” that voted for him by a 2:1 margin will suffer a lot from the policies likely to be implemented by his administration. Not more, and probably less, than minority people, but a lot.

Healthcare and health insurance is one of those areas, as discussed by me in several recent posts and by Paul Krugman in the New York Times, December 2, 2016, “Seduced and betrayed by Donald Trump”. He notes that anger about their health care coverage, and in particular the dramatic increases in premiums under the ACA exchanges, drove many people to choose Mr. Trump’s promise to replace it with “something terrific”. Of course, he never specified what that would be, for the same reason that the Republicans in Congress have never been specific, which is that any replacement plan that does not move “left” toward a more universal coverage plan such as the single-payer advocated by Senator Bernie Sanders (and me) will be much worse for most people, including most Trump voters, who will either lose or have to pay a lot more (if they can!) for their health insurance coverage. Repealing Obamacare means that many of the 13 million newly insured (a majority white, for the record) who received insurance under the exchange will not get rate cuts, but rather they will get no coverage. Certainly not those who need the insurance most, because they have pre-existing conditions that insurance companies were mandated by ACA to cover. As Krugman puts it, “we’re probably looking at more than five million Trump supporters, many of whom have chronic health problems and recently got health insurance for the first time, who just voted to make their lives nastier, more brutish, and shorter.” This is made clear in the Times article on December 3, 2016 “GOP plans immediate repeal of health law, then a delay” by Robert Pear, Jennifer Steinhauer and Thomas Kaplan. The reason is because the only plan they have will yank health insurance coverage for so many people, and despite their vociferous opposition and multiple votes to repeal ACA, they do not want to do that, at least right away.

The best evidence for their long term plan to, basically, remove health insurance coverage from many Americans including their base of support is the appointment of Rep. Tom Price (R, GA) as HHS Secretary. Mr. Price has been a leader of the Tea Party movement and a major Congressional figure calling for the repeal of Obamacare. His solution is not completely fleshed out, but does include eliminating guaranteed issue, community rating, and federal support for the exchanges. He is a fan of vouchers, an idea advocated for decades by conservative think tanks, and which, I guarantee (and this is far more of a certainty than Mr. Trump’s promises), can NEVER work, especially over the long term. Vouchers will never cover the cost of a decent insurance policy; people with health problems will naturally be the first to seek coverage, and faced by the adverse selection insurers will raise the premiums, co-pays, and deductibles for them. If there are problems with this under Obamacare, vouchers will make those look pale by comparison. And by getting out of the running-the-infrastructure business, the government will ensure that it never gets better.

Price, a wealthy orthopedist from suburban Atlanta, does not really care. He represents rich doctors who want to be able to charge whatever they want to be able to charge, and care only for the people who have insurance good enough to pay it. Sorry, Trump voters with not much money, chronic disease, and difficulty paying even ACA premiums, that isn’t you. And when you get to an age that you can get Medicare, finally having federally-supported coverage, Mr. Price has another answer for you – privatize Medicare! Make it subject to the same market forces that have made health care and health insurance so unaffordable and unavailable to younger folks affect the elderly too! The ACA has modified the egregiously negative impact of private sector health insurance for the under-65 group; the crumbum Price wants to both reverse that benefit and extend the damage to seniors too.

When Lyndon Johnson signed the Medicare law at the Truman Library in 1965, presenting Harry and Bess Truman with cards #1 and #2, he quoted the former President from nearly 20 years earlier: "Millions of our citizens do not now have a full measure of opportunity to achieve and to enjoy good health. Millions do not now have protection or security against the economic effects of sickness. And the time has now arrived for action to help them attain that opportunity and to help them get that protection."LBJ then added that “There are more than 18 million Americans [in 1965; way more now] over the age of 65. Most of them have low incomes. Most of them are threatened by illness and medical expenses that they cannot afford. And through this new law, Mr. President [referring to Mr. Truman], every citizen will be able, in his productive years when he is earning, to insure himself against the ravages of illness in his old age.”

This is what Tom Price and his colleagues want to reverse. The AMA, with its shameful history of actually having blocked Truman’s health plan, and unsuccessful opposition to Medicare, is endorsing him. The Association of American Medical Colleges (AAMC) is endorsing him as well. The American Academy of Family Physicians (AAFP) more tepidly expresses optimism. Presumably these are political decisions, to maintain access. After all, in the ongoing battles between insurers and providers (patients are rarely a real player), at least he is a provider. But many others, including Physicians for a National Health Program (PNHP)and Common Dreams, as well as the medical students of Future Docs, have appropriately condemned Price and these organizations endorsing him.

Mr. Price will be joined by Seema Verma, who will head the Center for Medicare and Medicaid Services (CMS). Verma helped Mike Pence design the Indiana version of Medicaid expansion. On the plus side, that state did expand Medicaid, helping people more than those states that did not. On the minus side, the requirement that everyone covered has to pay meant at least 1/3 of those who would have been eligible did not sign up. I guess she is the moderate!

Mr. Trump’s cabinet picks are, so far, a panoply of people who are either right-wing ideologues who wish to destroy everything that has been done to help the American people at least back to the Great Society and maybe to the New Deal, or are billionaires who speak for the corporate financial ruling class that he attacked so effectively during his campaign, or both. An example of the latter is anti-public education billionaire Betsy DeVos to head the Department of Education. Myron Ebell, a noted climate-change denier, will head EPA. Steven Mnuchin, a leading Goldman Sachs banker, will be Treasury Secretary. Senator Jeff Sessions (R, AL), denied a judgeship because of his racist beliefs and practices will be Attorney General. Trump's nominee for Commerce Secretary, Wilbur Ross, according to Money, alone has 10 times the net worth of the entire cabinet of President George W. Bush. Talk about foxes guarding the henhouse! Compared to these folks, naming El Chapo to head the DEA, as suggested in a New Yorker satire by Andy Borowitz,would be a moderate pick.

The future of not only public health, but also your individual private health, now and when you get to retirement age, is in great jeopardy. But, then, so is everything else that helps people. Not to mention the earth, since global warming is likely to accelerate during a Trump administration. There is an endless string of battles before us.

And we must join every one.