Tuesday, January 2, 2018

The Future of ACA and Health Care for Americans: We need Medicare for ALL!

It’s a new year. 2017 ended with the GOP passing a landmark tax bill that will provide huge long-term windfalls to corporations and the very, very rich, but little and time-limited benefit most folks. “Most”, in this case, being the vast majority. The “99%” probably underestimates it. Hey, how about I give you $10 once and you support my getting $1,000 a year in perpetuity? Well, why not? At least I get my $10. Except, whoops, you’ve raised prices on me by $20 a year.

The Republicans just missed out on their repeal of the Affordable Care Act in 2017, but there is a strong possibility they’ll try again in 2018. The decision will certainly be made on political grounds; maybe they’ll want to do it while they have a one-vote majority in the Senate if they think they might lose it. On the other hand, maybe doing it will increase the likelihood of them losing even more Senate seats. Tough one; you know the American people will stand for a lot of screwing-over, but it may be possible for you to push it too far.

In the meantime, however, the Trumpenik administration has slashed subsidies for people getting coverage on the federal exchanges. The President himself tweeted on December 26, 2017 that the “Tax Cut Bill…essentially Repeals (over time) ObamaCare”. It didn’t, but it did make it much more difficult for many Americans to obtain health insurance, and most of them are in states that voted for Trump and the GOP. As CBS reported on the same day, 80% of the 8.8 million newly covered are in these states. The four states with the highest enrollment, totaling 3.9 million, were Florida, Texas, North Carolina and Georgia. While these are states all went for Trump in 2016, all but Texas are in danger of going Democratic in the future. Florida has long been a swing state (remember the hanging chads of 2000!), NC is probably flippable in a presidential election (although, barring a court ruling overturning it, amazing gerrymandering will protect Republican House seats there), and Georgia is changing quickly. Of the 11 states with the biggest increases in enrollment, 8 voted Republican (Iowa, Kansas, Kentucky, Missouri, Nebraska, North Dakota, South Dakota and Wyoming). So cutting subsidies for buying insurance on the exchanges is a great way to punish your base.

There is even a school of thought that believes the cutbacks in funding for purchase of private insurance, along with the dramatic expansion of Medicaid (in the states that have done so), creates the opposite of GOP intentions, a more publicly-funded health insurance system. This topic is addressed in the NY Times article “Years of Attack Leave Obamacare a More Government-Focused Health Law” by Robert Pear, also on December 26. While only about 10 million have gotten coverage by private insurers through the exchanges, and this will drop as both the individual mandate and subsidies are eliminated, over 75 million people have benefited from Medicaid expansion. The “Medicare for All” movement advocated by Sen. Bernie Sanders is gaining increased momentum in many states (for example, Maine, where it may be pushed over the resistance of the Republican governor), as people increasingly realize that this is their only protection. Eliminating the mandate means healthy people will not buy insurance that they can no longer afford without subsidies, so that the cost of insurance for sick people will become truly unaffordable. If they do not qualify for Medicaid, they will be plumb out of luck, unless Medicare is expanded to cover everyone.

Some advocate for gradual expansion of Medicare, rather than going straight for Medicare for All, by extending it to those over 50 or 55 first. This is most often heard from “mainstream” (“centrist”) Democrats (the Republicans care about the health of the American people not at all), who have been most remarkable for their tentativeness and cautious incrementalism when in power, as opposed to the Republicans’ aggressiveness. And, while expanding Medicare to cover everyone is the simplest and most straightforward route to a single-payer insurance system, it must be an “improved and expanded” Medicare for all, as advocated and detailed by groups such as Physicians for a National Health Program (PNHP). Without this improvement people may legitimately fear an underfunded health system that requires major out-of-pocket expenses, that restricts access to certain procedures and specialties even when medically indicated, and that is more focused on cost-cutting than on health care.

Incremental efforts, such as gradually ratcheting down the age of Medicare eligibility, may seem to be tactically good ideas, but in fact they are silly and likely to cost more both in dollars and in worse health outcomes. Medicare, despite its limitations in funding, has made a phenomenal difference in the health of those eligible since its introduction in 1965. Those who receive Medicare now, the aged, blind and disabled, are the population with the greatest health care needs and costs. However, as physicians we regularly see those just under the age of 65 but with chronic illness suffering serious health outcomes and costs until they become eligible. While lowering the age to, say, 55 would enroll many of those with greatest need, there would always be people with need just below the age cutoff. More important, as the age of eligibility goes down, the marginal cost per covered life also goes down, because younger people are healthier. What makes sense is to simply wrap everyone together, getting both the benefit of an overall healthier younger population paying in and using little care and not excluding individuals of any age who (from chronic or acute illness or accident) do need care.

The day after all these appeared, December 27, a British physician named Rachel Clarke (@doctor_oxford), author of the current [British] Sunday Times bestseller “Your Life in My Hands”, posted a note on Twitter about her father dying of cancer after a long illness. “One major surgery,” she wrote, “countless chemotherapies, & a small army of community and palliative nurses so that he could be at home with us.”  She continued: “The bill? £zero. Grief, pain, emptiness – but not bankruptcy. Thank you, #NHS.”  How many of us could say the same in the US? Some, perhaps many, of us; those with money and good insurance, which is becoming increasingly rare. But MOST of us could not.

The lives of all of us, the health of all of us, and the commitment of society and government to the health of all of us, is what is at issue here. The Republican Party and its leader have demonstrated their clear and persistent opposition to it. And it is all of us, including their voters, who are suffering and will continue to suffer for it.

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