Sunday, March 19, 2017

Statements re health care

[Revised 3/23]
There have been no replies to the solicitation of statements from Alabama health care experts, which I made in Alabama expertise re health care. A House of Representatives vote is planned for today. Compiled below are press releases and other statements from Alabama's seven members of the House. They are of scant help in explaining to  Alabamians what Alabamians should want to understand. I believe "My statement" set out in Alabama expertise re health care is apt for the purpose (including an edit I added to the statement reflecting amendments under consideration).

Rep. Byrne has the below March 19 blog post

Why Obamacare Must Go








1

Mar 19, 2017 
Blog
“In a death spiral.” Those are the words Mark Bertolini, CEO of Aetna, one of our nation’s largest insurance companies, used to describe the Affordable Care Act, or Obamacare.
When I first ran for Congress in 2013, repealing and replacing Obamacare was a top priority. I introduced a bill to repeal the law, which passed the House but never reached the President’s desk. Unfortunately, with President Obama in the White House, our efforts never succeeded. Even when we finally got a repeal bill to the President’s desk, he vetoed it.
Thankfully, last year’s elections completely changed the dynamics. President Trump is committed to repealing and replacing Obamacare, and Republicans control both the House and the Senate. The stage is set to finally get rid of this failed law.
Why is this so important? Because Obamacare is a fundamentally flawed law that cannot simply be fixed or patched back together. Obamacare has cost the economy $53 billion and an estimated 176,897,428 paperwork hours.  Those are funds and time that employers can’t use to hire people and jumpstart the economy. 
More importantly, with its government mandates, higher taxes, and increased regulations, Obamacare is hurting hardworking American families. We have seen canceled plans, higher premiums, fewer choices, and increased deductibles. 
Believe it or not, former President Bill Clinton might have put it best when he called Obamacare “the craziest thing in the world.” He also pointed out that it has resulted in “people who are out there busting it, sometimes 60 hours a week, wind up with their premiums doubled and their coverage cut in half.”
I’ve heard story after story from people who live in Southwest Alabama who have been negatively impacted by this law. In fact, I have had people come up to me with tears in their eyes to show me their cancellation notice or premium increase letter.
Despite President Obama’s promise that “if you like your plan, you can keep it,” 4.7 million Americans were kicked off their health care plans by Obamacare. Many of these Americans liked the plan they had, only to have the federal government step in and tell them it was not good enough.
Premiums are also skyrocketing. Seven states have seen premium increases of more than 50% in 2017.  In Alabama, this year’s premiums on the exchange increased 58% on average for a benchmark plan and 36% for the individual market as a whole. For those with employer-sponsored coverage, individual premiums are up 27% on average nationwide, more than double the average rise in workers’ wages.  Deductibles are up an average of 60% since 2010.
Americans are also facing fewer and fewer health care choices, with five states – including Alabama – only having one insurer to choose from. In fact, next year, some counties in the United States may not have a single option on the Obamacare marketplace.  At that point, those Americans relying on Obamacare will have nowhere to turn and the law will have failed. 
The bottom line is that Obamacare is on a collision course. If Congress were to sit back and do nothing, Obamacare would implode. This would leave millions of Americans with no insurance and the overall insurance market for the rest of us in a dangerous condition. So, Congress must act and rescue the American people from this broken law.
I have pledged to repeal and replace Obamacare since being elected to Congress, and I remain committed to honoring that pledge. Now, under unified Republican government, we have the best opportunity we have ever had to get rid of this failed law and instead provide Americans with the freedom, choice, and control that they deserve.
Rep. Roby made the below March 22 press release

We Must Keep our Promise to Repeal and Replace Obamacare

Mar 22, 2017 Issues: Health Care, Repeal Obamacare
WASHINGTON, D.C. – U.S. Representative Martha Roby (R-Ala.) today voiced her support for the American Health Care Act (AHCA) and called on her fellow House conservatives to keep their promise to repeal and replace Obamacare.

In a speech from the House floor, Roby reminded her colleagues of the repeated promises Republicans have made to do away with Obamacare for the last seven years.

“I’ve heard from countless constituents negatively impacted by Obamacare,” Roby said. “And in response, I made a promise - the same promise President Trump and every conservative in Congress has made over and over: give us the majority in the House and Senate, give us a Republican in the White House, and we will repeal Obamacare and replace it with reforms that work.

Roby acknowledged that no bill is perfect, but she said that passing the ACHA this week is Republicans’ best opportunity to deliver on their promise.

“Mr. Speaker, I am confident that this bill puts us on a path toward lower costs and better care – and away from government-controlled health insurance.

“It represents our opportunity to undo the damage of Obamacare and help American families like we said we would. For seven years we have been promising, and this is our chance to deliver.”

The House of Representatives is scheduled to vote on the Affordable Health Care Act on Thursday, March 23. If passed, the bill will be taken up by the Senate.

The text of Rep. Roby’s remarks as prepared is below:

Thank you, Mr. Speaker.

Seven years ago this week, in this chamber, the House gave final passage to the Affordable Care Act, better known as Obamacare.

I wasn’t in Congress then. Many of us weren’t. But for my fellow conservatives here today, that vote seven years ago marked a decision point or a moment of affirmation to answer the call to public service and help chart a better way for this country.

And for seven years we have made the case against Obamacare. As the law has been implemented, that case has largely been made for us. Millions have been forced away from the health care plan and doctor they liked, despite promises to the contrary.

This year alone, in Alabama, health insurance premiums are rising by 58 percent. That’s on top of already steep increases the past two years.

Our average deductible for the supposedly affordable Bronze plan is now six thousand dollars.

I’ve heard from countless constituents negatively impacted by Obamacare. I’ve listened to their stories about how higher costs and fewer choices have made it that much harder to keep their families healthy and make ends meet.

And in response, I made a promise; the same promise President Trump and every conservative in Congress has made over and over: give us the majority in the House and Senate, give us a Republican in the White House, and we will repeal Obamacare and replace it with reforms that work.

So Mr. Speaker, I am pleased that we are finally in a position to deliver on that promise. The voters gave us what we asked of them, and it’s only right that we keep our end of the bargain.

With the American Health Care Act, we begin the process of repealing Obamacare once and for all.

This bill dismantles the taxes, mandates, and entitlement spending that make up the core of Obamacare.

It cuts taxes on prescription drugs, over-the-counter medications, insurance premiums, and medical devices.

It eliminates the individual and employer mandate penalties that have forced millions into expensive, inadequate plans.

It replaces the Obamacare entitlement with refundable tax credits so that people who don’t receive insurance through work can put their own tax dollars toward a health plan of  their choice.

Mr. Speaker, many have asked why our plan to repeal and replace Obamacare is a process. Why is this bill only one step and not the full package?

It’s an understandable question. For the last several years, Americans have been sold the false hope that the government has a magic wand with which it can quickly solve all their problems.

The truth is, of course, that it can’t. It never can. And the only proof you need is Obamacare itself.

That’s why Congressional Republicans and the Trump Administration are taking completely a different approach than President Obama and the Democrats used seven years ago.

Instead of claiming “we need to pass the bill so you can find out what is in it,” we have worked in a transparent way. The bill text has been posted online for three weeks. It has gone through three separate committee mark-ups, and will come to the House floor in regular order.

Instead of one giant bill like Obamacare, we are using a more responsible, three-step process. First, we’ll repeal Obamacare with all its taxes, mandates and spending through budget reconciliation. Next, the Trump Administration will use its executive authority to weed out the more intricate Obamacare policies one-by-one to stabilize the market and lower costs. And finally, Congress will move forward with legislation addressing more specific policies, such as allowing individuals to purchase insurance across state lines.

I believe this will ultimately lead to better, more stable health care policy that empowers patients, increases choices, and lowers costs.

Mr. Speaker, no bill is perfect. I’m sure if every member of this body came up with their ideal health reform bill, they’d each be pretty different. It’s supposed to be that way, because we all represent different districts with different needs.

There may well be some changes made here in the House or in the Senate that can make the bill better. That’s part of the process, so I certainly remain open to those.

But, Mr. Speaker, I am confident that this bill puts us on a path toward lower costs and better care – and away from government-controlled health insurance.

It represents our opportunity to undo the damage of Obamacare and help American families like we said we would.

For seven years we have been promising, and this is our chance to deliver.

I urge my colleagues to support the American Health Care Act, send it to the Senate, and get us one step closer to delivering on our promise.

Rep. Rogers
No press release or other statement found. https://mikerogers.house.gov/press-releases

Rep. Aderholt issued below statement on March 17th.
“President Trump called me to the Oval Office this morning to discuss the American Healthcare Act, because of his understanding that I could not support the current language of the bill.




Rep. Brooks March 11, 2017 press release

REP. BROOKS JOINS FOX NEWS TO DEMAND CLEAN REPEAL OF OBAMACARE

March 11, 2017 
Press Release
Huntsville, AL – Today, Congressman Mo Brooks (AL-05) appeared on America’s News Headquarters to discuss the House leadership health care replacement plan.  Brooks affirmed his commitment to deliver a clean repeal of Obamacare to the American people.  

To watch video of the interview, click HERE 
or on the image above. 
Excerpts from the interview:
Congressman Brooks stated, “We are being asked to vote for the largest Republican welfare plan in the history of the Republican Party.  That should be a hard swallow and a hard sell.  We’ll see how it plays out.  To get my support we have to keep our commitments to the American people.  We promised that we were going to repeal Obamacare.  The House leadership plan is not a repeal of Obamacare.  It keeps substantial parts of Obamacare in place, and it copies or repackages other parts of Obamacare.  A repeal bill is like what Congressman Steve King out of Iowa has, it’s a nice two page bill, two sentences, the Affordable Care Act is hereby repealed effective such-and-such a date.  What we have on the Republican side right now is a bill that is easily over a hundred pages long. That is not a repeal.  So let’s keep our promise, repeal it.”  
Brooks added, “Once we repeal it, then we need to in my judgement, interject competition into the marketplace.  Allow interstate competition amongst health insurance carriers and providers.  On the other hand, the health insurance industry has various parts that are exempt from antitrust laws which promote oligopolies and monopolies, which suppresses competition and makes pricing go up.  So let’s go ahead and do our best to ensure that we eliminate those antitrust exemptions in the health care industry.” 
Brooks concluded, “Then finally my position is, once we’ve got the repeal and we have interjected competition into the marketplace with all the benefits that comes from that, with price suppression, better quality of service, let’s turn this over to the states in the form of block grants and let the 50 states handle this health care issue.”


Rep. Palmer issued below statement on March 16th.
“We have one opportunity to answer the healthcare crisis the American people are facing. In my opinion, the current bill does not answer this crisis. I voted against the American Health Care Act in the Budget Committee because the promises of changes in the future are insufficient. Now that the bill has been reported out of committee, I will continue to work for the changes that are necessary to ensure Medicaid is a viable and affordable program to provide healthcare to the people who need it most. In that regard, I believe block granting Medicaid to the states and requiring work for able-bodied working age adults are essential to achieving this objective. I look forward to working with my colleagues to make these and other improvements to this bill.”

Rep. Sewell has three press releases

Rep. Sewell Statement on GOP Health Bill

Mar 7, 2017 
Press Release
The GOP health bill would make large cuts to Medicaid, destabilize Medicare by reducing funding for the Medicare trust fund, and increase health costs for working and low-income families.
Washington, D.C. – On Monday, Republicans in Congress released legislation to replace the Affordable Care Act. The GOP health bill would make large cuts to Medicaid, destabilize Medicare by reducing funding for the Medicare trust fund, and increase health costs for working and low-income families. Estimates suggest that 357,000 Alabamians are at risk of losing their coverage if the Affordable Care Act (ACA) is repealed.
“For my constituents, access to healthcare is a life or death issue,” said Rep. Terri Sewell (D-AL). “After seven years of calling for the Affordable Care Act’s repeal, it is unconscionable that the best Republican leadership has to offer is a plan that cuts Medicaid, destabilizes Medicare, and takes insurance away from millions of hardworking Americans. In fact, estimates suggest that 357,000 Alabamians are at risk of losing their coverage if we repeal the ACA. Our access to care is a fundamental right, not a privilege. Protecting care for seniors, disabled Americans, and working and low-income families goes to the heart of who we are as a country. We cannot settle for a health plan that leaves millions of Americans without the coverage they need.”
Studies show that the GOP health plan would increase costs for the average enrollee by $1,542 if the bill were in effect today. At the same time, the proposed bill eliminates requirements for insurance companies to cover preventative care, and makes it possible for insurers to discriminate against seniors. By cutting Medicaid and reducing health assistance to low-income families, the health bill would reduce revenue for rural hospitals,700 of which nationwide have been labeled as financially at risk.
Patients across Alabama’s 7th District would lose assistance under the GOP health plan. In Jefferson County, residents’ health coverage tax credits will be 33% lower than they were under the ACA.
Despite concerns raised by both Republicans and Democrats, House Republicans plan to move forward with consideration of the health bill in the Ways and Means Committee and Energy and Commerce Committee on Wednesday, March 8. Rep. Sewell is a member of the Ways and Means Committee and will participate in tomorrow’s markup of the GOP health bill.

Rep. Sewell Votes Against GOP Repeal Bill

Mar 9, 2017 
Press Release
The House Ways & Means Committee voted to advance the bill in Congress, despite not yet having any estimate for the bill’s cost or impact from the Congressional Budget Office
Washington, D.C. – On Thursday, the House Ways & Means Committee considered amendments to the Republican health plan and voted to advance the bill in Congress, despite not yet having any estimate for the bill’s cost or impact from the Congressional Budget Office (CBO). Congresswoman Terri A. Sewell (AL-D) offered amendments to the bill that would prohibit increases in taxes and medical costs for rural farmers and prevent rural hospital closures. The amendments offered by Rep. Sewell were defeated in party-line votes. Rep. Sewell opposed the Republican repeal bill when the Committee voted to advance the bill.
“I voted against today’s GOP repeal bill for one simple reason: it would raise health costs for working families and struggling Americans while decreasing their quality of coverage,” said Rep. Terri Sewell. “My constituents work hard to provide for their families, and additional health costs jeopardize their access to care. The Republican health bill would bankrupt low-income families and the rural hospitals that depend on their access to care by eliminating income-based support for health coverage, slashing Medicaid, and erasing preventative care coverage. The amendments I offered today would have protected rural Americans from increased health costs and growing health disparities. Without those safeguards for working families, and with no estimate yet for this bill’s cost, I could not in good conscience vote for this legislation.”
Among the amendments offered by Rep. Sewell was a measure that would prohibit the Republican health bill from increasing taxes or medical costs for rural farmers and farmers with disabilities. Rep. Sewell drew inspiration for the amendment from a rural farmer in Alabama whose access to health insurance through the Affordable Care Act saved him from financial disaster.
Rep. Sewell also spoke at the hearing about the need to protect against increased health disparities for minority populations. For a wide range of diseases today, the mortality rate for African Americans is much higher than that for other populations. With cancer, for instance, the mortality rate among African Americans is 20 percent higher than it is for white populations.
Rep. Sewell voted against the Republican repeal bill when it passed the Ways & Means Committee early Thursday morning in a party-line vote.

Rep. Sewell Statement on CBO Analysis of GOP Repeal Bill

Mar 13, 2017 
Press Release
The nonpartisan CBO releases projections of how many Americans would gain or lose insurance under the Republican proposal to repeal the Affordable Care Act
Washington, D.C. – Today, the nonpartisan Congressional Budget Office (CBO) released projections of how many Americans would gain or lose insurance under the Republican proposal to repeal the Affordable Care Act as well as cost projections for the proposed bill. The CBO analysis comes nearly a week after the Ways & Means Committee considered and voted to advance the Republican repeal bill. Congresswoman Terri A. Sewell voted against the repeal bill in committee.
“The CBO report released today makes one thing clear: the Republican repeal bill will cost American lives and leave millions uninsured,” said Rep. Terri Sewell. “Under this bill, 14 million Americans would lose their insurance within the next year. Over the next decade, that number would rise to an unsustainable 24 million uninsured Americans. Our healthcare infrastructure, from our rural hospitals to our network of family physicians, cannot withstand that kind of blow to health coverage. I believe that all Americans have a right to affordable healthcare, but this legislation turns healthcare into a privilege. For families in my district, the Republican repeal bill means more expensive coverage with fewer protections. We cannot ask working Americans to go broke, bankrupt, or do without healthcare.”
Today’s report from the CBO and Joint Committee on Taxation shows that by 2018, five million fewer people would be covered under Medicaid, six million fewer Americans would be covered in the individual market, and a total of 14 million more Americans would be without insurance. The CBO report estimates that in 2018 and 2019, average premiums for single policyholders in the non-group market would rise 15 to 20 percent under the GOP repeal bill.
In addition, the report shows that low-income seniors will see premium increases of $12,900, while the average 40 year old will see an average premium increase of $700. CBO projects that the actuarial value of all plans will decrease under the AHCA.
On March 9, Rep. Sewell voted against the Republican repeal bill when it passed the Ways & Means Committee in a party-line vote. Rep. Sewell’s remarks during the committee hearing are available here.
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Thursday, March 16, 2017

Alabama expertise re health care

[11/26/19 - The business and governmental structures for the delivery and financing of healthcare in the United States are monumentally complex and are in need of substantial improvements. It is doubtful that average lawmakers and the public are able to have an adequate understanding of the same in order to agree on how to make improvements and to make improvements. To get a sense of this, read  There Is Never A 'Free Market' In Health Care and
MAKING HEALTH CARE MARKETS WORK:COMPETITION POLICY FOR HEALTH CARE. I predict there will not be significant improvements during the next two years.]

[4/6/19 - addendum added below re "markets and competition in healthcare"]


I am not aware of any reply from the Alabama legislative delegation to my solicitation of their views related to the American Health Care Act, particularly concerning coverage and affordability (and other matters I inquired about in Health care and Letter to Rep. Sewell).

In the clash of advocacy in Washington DC, the sides mainly argue in favor of what they want, and they prevaricate and avoid that which does not support what they want. This methodology is not optimal for helping voters get an accurate picture of what the American Health Care Act  will or will not achieve.

The Alabama legislative delegation, to the extent they say anything, are likely to echo what their side says in Washington DC. That, as stated, is not optimally helpful to voters.

Maybe, in the face of what the politicians serve up to the voters, it is a pointless exercise for Alabamians to strive to get an accurate picture related to the American Health Care Act.

Be that as it may, there is expertise and knowledge in Alabama which could helpful in a voter quest to get a more accurate picture than they can get from the politicians.

I will try to solicit views and information from these resources in Alabama.

One good resource are academics. For example, UAB has a Department of Health Care Organization and Policy, which has more than 20 professors. Professors in that department, as well as other professors and departments have relevant expertise which may be drawn upon..

Health insurance companies, hospitals and doctors should be well informed about how Obamacare is working and its attendant problems, and how it can be expected that  the American Health Care Act would perform. 

Personnel who work in the Alabama Medicaid program should be able to shed useful light on how it can be expected that  the American Health Care Act will affect Medicaid in Alabama. 

Alabama newspapers, TV stations, and radio programs should have an interest in obtaining and purveying relevant information, and they may be of help for voters to get  an accurate picture related to the American Health Care Act

Business chambers of commerce have an interest in the health care bill from the perspective of business.

I will endeavor to solicit views from the above parties.

There is likely going to be a variety of opinions that may be proffered, and there also may be significant bias in the views expressed. 

Short statements from responders that would lend themselves to comparison would seem best for the purpose of trying to get an accurate picture of what the American Health Care Act will do. If responders provide statements, the responders should try to set aside their own biases and agenda and think only from the perspective of Alabamians generally.

I will endeavor to post responses I receive.

For what it is worth I set forth below my own layman's statement about the American Health Care Act.

[Edit: After My statement below, I will append the contacts I am making to solicit statements. I am posting statements I receive and relevant information at Statements re health care.]

My statement
The provision of health care in the United States is a monstrously difficult problem.

The existing system is badly fragmented, and that contributes greatly to difficulty in solving the country's health care problem. Obamacare has done little for lessening the fragmentation. The American Health Care Act is not going to do much either.

The United States system is hugely expensive compared to what other countries pay for their health care. In the United States, health care is in the range of 20% of the total economy, whereas other countries do with much less, in the range of 9% to 14%. This disparity in national health care costs is in dire need of attention and is a large component of the difficult problem the United States faces regarding its health care.

Cost is not the sole consideration, but getting health care for less cost should be in the fore of what Congress is doing. In reducing cost, attention should still be paid to what is needed to provide adequate health care. With that in mind, consider the following:

A. Things that can reduce cost

1. If medical malpractice is reformed, and defensive medicine is reduced, that will help reduce the country's health care costs. An estimate of the amount of reduction is something that responders can usefully inform Alabama voters about.

2. The government can play a role in reducing health care costs by exerting control over prices. The biggest impact could be regarding drug prices, which might start with Medicare negotiating drug prices with the pharmaceutical companies. This is  a controversial step, which may be part of steps 2 or 3 of the Republican plan. Any such control will have ramifications, including reducing availability of some drugs and lessening the development of new drugs.

3. If there is a reduction in total demand for health care, prices will fall and premiums and deductibles should fall. The American Health Care Act will reduce government funds for health care by means Medicaid cutbacks and replacing higher subsidies with lower tax credits, and this will translate to a reduction of demand. Under principles of supply and demand, the reduced demand should result a reduction of prices but the amount of such reduction is very problematic and may be negligible. It is probably the wildest of imagining by the Trump team that this reduction in demand by cutting back Medicaid and people dropping coverage will result in more than a small fraction of what is in their minds for reduced premiums and deductibles. Further the reduction in prices, premiums and deductible is not due to increased plan choice, but due reduced spending and reduced health services, drugs and medical equipment being obtained.

B. Increasing plan choice is chimera for reducing cost

If there is more choice in insurance plans, people may plan they don't want certain services, drugs and equipment to be covered under their plan. and that can allow the insurance company to charge them less in premiums and deductibles.

That creates a problem, however, that, if those people are allowed to do that, the people who need the services, drugs and equipment that the first set of people forego will have to pay higher premiums and deductibles to have the services, drugs and equipment covered by their plan. In other words, plan choice can reduce premiums and deductibles for some people but increase them for other people.

The same applies as regards the Obamacare mandate and what happens if it is eliminated.The elimination of the mandate will reduce premiums for those who choose not to have insurance coverage. As is well known, under Obamacare, the mandate results in healthier people having to buy insurance and pay premiums. If healthier people do not buy insurance, that will result in higher premiums and deductibles for the unhealthier people who buy insurance.

It should also be pointed out that consumers are unaware of the substance of their plan choice and and ostensible competition in premiums and deductibles. Under Obamacare, where there are standard benefits, insurance companies have competed on premiums and deductibles by reducing their "networks." Consumers cannot make a meaningful comparison of slightly higher or lower premiums compared to the "value" of a larger or smaller network. If there is more plan choice, comparison of premiums and deductibles will prevent genuine competition from happening.

[Ed. 6/5/17 For further discussion of the "chimera" of increased plan choice, see Maine and this discussion:
There is an argument to be put forth that Rep. Palmer's proposal will result in increased plan choice and increased competition among plans, and that such increased competition will get translated into reduced provider charges.
It is submitted that this is a chimera, and the insurance companies best understand why it is a chimera. The insurance companies are most informed about provider charges, and the contracts they negotiate with providers about charges, and consumers are without information or ability to make meaningful marketplace choices about insurance plans that will filter through to impacting provider charges. Further, insurance companies are practiced in navigating the provider marketplace, out of sight of consumers, with a view to higher insurer profitability, and with little concern about consumer plan choice translating into reduced charges.]

C. My picture for Alabama voters to think about

The picture I would offer to Alabamians is that the country has spent six wrenching and expensive years endeavoring to implement Obamacare, and the result has been very inadequate in addressing the country's immense difficulties in providing health care.

The American Health Care Act is going to wrench the country for more years to come. It is not going to do much to solve the long term problem of providing health care in the United States. The country is going to be beset by great problems for many years to come.

The American Health Care Act will achieve a reduction of health care spending and a reduction of health care received by millions of Americans, but that is not a viable long term solution to the problem.

Medical malpractice reform and government control of health care prices offer meaningful ways to reduce health care costs and need to be pursued. The are steps in the right direction, but more is needed to tackle total health care costs in the United States (to bring them in line with what other countries are able to do). This includes reforming the countries fragmented health care system, which should help significantly in reducing cost.

Edit 3/23
Press releases and other statement of Alabama's seven members of Congress are posted at Statements re health care. Those are not helpful for Alabamians to understand what they should want to understand. Here are some things Alabamians should understand:
The country's health care costs (i.e., total spending on health care) are subject to being reduced if less health care is consumed (which can translate into reduced premiums and deductibles). As an example, if maternity care, mental health services and substance abuse treatment are eliminated as essential health care benefits in health insurance, insurance premiums and deductibles can get reduced, and either there will be less of those services consumed (which will reduce total health care spending), or, to the extent people obtain those services outside their insurance, there will not be reduced health care cost.
The matter of increased plan choice is unclear for now as to how it will fit with required essential health benefits, and that may not get pinned down for some time. To the extent increased plan choice allows people to decide they want less covered by their insurance, or not to have insurance at all, those persons may slide back towards the pre-Obamacare situation of cut rate "skinny" insurance or no insurance sending them to emergency rooms, and further premiums and deductibles for other people who need and choose fuller coverage will rise.
Amounts of subsidies (or tax credits in lieu of subsidies) are subject to alterations, with corresponding impact on health care that will be received. As an example, it is being put out that Medicaid may be replaced by a refundable tax credit to be used to buy insurance in lieu of Medicaid. These are largely fungible dollars ultimately being spent on health care. If the aggregate of these refundable tax credits are less than the aggregate amount of the Medicaid dollars they are replacing, there will be less health care  that will be provided to to those persons.
It is being suggested that people in the 50 to 65 age group will be given bigger tax credits than originally provided because those persons will have larger premiums and deductibles if younger, healthier people forego insurance.
The crux of the debate and negotiating that is going on is essentially how far health care is to be pushed back to pre-Obamacare days versus the extent to which is essentially another form of Obamacare.
Further see Does politics make us idiots?.






Addendum 4/6/19 - markets and competition in healthcare
Healthcare costs nearly twice as much in the United States as in other countries. Congress needs to analyze why this is, and what can be done to lessen the cost of health care in the United States.

One possible factor causing health care to cost so much more in the United States is that the United States has a less healthy population than other countries, and thus more has to be spent on healthcare.

Another possible factor causing healthcare to cost more in the United States is that more and better health care is provided in the United States.

A third possible factor is that there is a lot of waste and misallocation of economic resources that are expended on healthcare, and that such waste and misallocation must be reduced.

This discussion will address waste and misallocation.

"Waste and misallocation" of economic resources needs a standard for gauging what is "waste and misallocation."

Markets and competition are supposed to be a mechanism for gauging and limiting "waste and misallocation."  This is by means of consumers making informed decisions about products and services offered to them, which decisions take into account the prices for the products and services of the providers, comparing prices, and assessing the value of the product or service to the consumer as determined by the consumer. In this model, there is not waste and misallocation of resources because consumers get what they want for the price they decide to pay. If a provider is inefficient and wastes money in manufacturing or providing products and services, and charges higher prices as a result, the consumer will choose not to pay the higher price.

The foregoing concerning markets and competition has significant failure in how it works in healthcare where the health care is obtained pursuant to insurance. The consumer, in choosing a health insurance policy, knows little or nothing about the contracts that the insurer has with providers and how much is payable to a provider for a product or service the insured consumer obtains or will obtain. The insured consumer, at the time of getting the policy, does not even know exactly what products and services the consumer will need under the policy, let alone what the prices are that the insurer will pay.

After the insured consumer obtains the insurance policy, and when a product or service is needed or desired, the additional cost the consumer is required to pay may be nothing or a small fraction of the total cost payable for the cost or service, and frequently the product or service is obtained by the consumer without knowing what the full price is.

Further, products and services related life or death, and fixing health problems, are frequently of incalculable worth to the consumer, and no price is too high, which is different compared to other products and services a consumer purchases.

From the consumer's perspective, "markets and competition" basically operate only through comparing amounts of premiums, deductibles, co-pays, covered services and the network. The question then becomes how consumer decisions about which insurance policy to obtain affects prices that are charged by providers, and paid by the insurers, under insurance contracts.

The insurers are in the best position to know about providers, their products and services, the prices they seek to obtain for their products and services, and what prices the insurer is able to get in the contracts with the providers.

From the insurer's perspective, an overriding consideration is profitability for shareholders and paying salaries of executives. An insurer has a number of ways to achieve a profitability target, including negotiating for lesser provider prices, limiting the available "network" under the insurance policy, and limiting covered services,

Insurers are constrained by the consumer impetus that "no price is too high" and that no product or service shall not be covered if it will help, or may, help the insured with the insured's medical condition. All insurers are subject to that consumer impetus, and an evaluation could be made that they all accommodate that impetus.

It is submitted that the combination of the foregoing factors yields a situation in healthcare markets and competition exert insufficient downward pressure on prices and much pushes or pulls the prices up.

The insurers probably have the best sense of the foregoing. Given their economic interest in maintaining the status quo, it is uncertain how forthcoming the insurers will be explaining how well or how poorly markets and competition work in healthcare.

It is further submitted that a main explanation of why healthcare costs are so much lower in other countries is that, directly or indirectly, there is much greater governmental control over prices for healthcare services and products, and there is effectively a national budgeting process for healthcare.

If you do an internet search of "how well do markets and competition work in healthcare," you will find numerous articles. If you find an article that you consider especially informative and persuasive about the question, please tweet me a link. Thanks.

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Tuesday, March 14, 2017

Letter to Rep. Sewell

[Letter sent by email to Rep. Terri Sewell (D), AL 7th Congressional district]

From: Rob Shattuck <rdshattuck@gmail.com>
Date: Tue, Mar 14, 2017 at 12:38 PM
Subject: Re: I want to hear from you
To: Representative Terri Sewell <AL07TSIMA@mail.house.gov>

Dear Representative Sewell,
With the CBO report out, it is increasingly clear that the Republican bill mainly effectuates reduced health care spending (and comcomitant reduced health care) by means of Medicaid cutbacks and replacing the subsidies with lower tax credits resulting in less insurance coverage.
The Republicans and the Trump team are endeavoring mightily to avoid the stark reality of the bill.
They are rejecting the CBO report's conclusions, but the Republicans and the Trump team offer no substantive counter-report that sets forth different conclusions to rebut the CBO's conclusions.
They seek to change the subject from "coverage" (by asserting coverage does not result in care being received), to focusing on actual receipt of care.
No doubt high deductibles and other factors are currently resulting in patients choosing not to receive care or otherwise not receiving desired care.
Whatever the amount of desired care that is not currently being received, the Republicans and the Trump team don't provide a credible basis for how their bill will result in actual care being received that is not being received currently.
The main thing the Republicans and the Trump team assert is that increased plan choice and "competition" will result in lower premiums and lower deductibles, and that will result in more insurance coverage and more health care being received.
This is a chimera.
Whatever lower premiums and deductibles result for people who choose not to have coverage or who choose reduced coverage under more plan choices, that will result in higher premiums and higher deductibles for other people. The CBO report fairly well lays this out, reporting that premiums will increase by 15% to 20% through 2020 and then decrease by 10% in 2026.
Further, a 10% decrease by 2026 is hardly increasing the affordability of health care anywhere close to what the Republicans and the Trump team are trying to lead Americans to believe will happen under the Republican plan.
To repeat, the Republicans and the Trump team have no credible counter-report to rebut the CBO's conclusions, and they are only making assertions that are not supported by anything meaningful.
The CBO's full report can be read by download by clicking here.
I believe that Alabamians need to be informed of the foregoing stark realities about the health bill. I am endeavoring to do that in the limited ways that are available to me. I am sure you want to inform Alabamians of such stark realities, and I hope you and your supporters can contribute to that being done.
Thank you.



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Saturday, March 11, 2017

Health care

[Update 4/13: Rep. Palmer is holding a town hall on Tuesday, April 18th. President Trump now appears to be reactivating on health care reform, and, to force Congressional action, he is threatening to cut off Obamacare subsidy payments that are used to pay health insurance premiums for lower income persons. This blog entry, and also Alabama expertise re health care, Statements re health care and Does politics make us idiots, will be added to before Tuesday in order to contribute to calling out Rep. Palmer on health care.] [See Health care II, Maine, Can Rep. Palmer defend himself, Tom Price,  Shelby County GOP, and Calhoun County which have been added. (NB:Alabama expertise re health care, Statements re health care contains the most extensive statement of my own views.)]

[Update 5/27: The special election to fill Jeff Sessions' seat in the U.S. Senate is underway, and health care should be a central issue in the election. I am picking up on this, starting with Health care III.]

To Rep. Gary Palmer, AL 6th Congressional district
The country is once again confronting overhauling its health care system.

Health, and how health care is obtained, are of huge concern to just about everyone.

The implementation of Obamacare during the past seven years has been wrenching and expensive for patients, providers and insurance companies. There have been defects and failures in the country's health care system for 25 years. One can well be dubious of Congress acting again on this subject, and whether our country's tortured experience in health care will continue for many more years to come regardless of what Congress does.

Under the circumstances, I think you owe it to your 6th district constituents to make a comprehensive exposition of your views about the following:

1. What do you think would be the best thing for Congress to do from the point of view of Alabamians (which hopefully would be applicable for all Americans)?

2. Assuming it is not realistic that Congress will do what you think best, and Congress is considering various things, what are the particular aspects, in order of their priority in your mind for Alabamians, that you will advocate for as the legislative process proceeds? (Possibly, you consider yourself as having little or no influence regarding the legislation, in which case just respond to the question by informing Alabamians of what you think Alabamians should consider important in the legislation and what Alabamians should try to find ways to push for in the legislation.)

Update 3/12
On this morning's Sunday talk shows, Trump spokespersons on behalf of the Medicaid spending cutbacks in the health care bill made the contention that allowing States more control over how Medicaid funds are spent would result in more and better health care being provided with fewer funds. It is requested of Rep. Palmer whether he believes Alabama would be able to provide more and better health care to those being served by Medicaid with fewer funds, provided the state had more control over the funds. If Rep. Palmer's answer is yes, particular information is requested about particular expenditures that are currently being wasted or spent inefficiently in the Medicaid program, which information would show how Alabama would do better with lesser funds if the state has control of the funds. Also, it would be appreciated if Rep. Palmer could give names of Alabama personnel in the Alabama Medicaid program who could vouch for what Rep. Palmer says.


A chimera of expanded plan choice reducing premiums and deductibles
The Trump team is touting that their plan will make health care more affordable by reducing premiums and decreasing deductibles, which will come about by increasing plan choice and increasing competition among plans, including across state lines.
In insurance, all premiums and deductibles go to pay for health care services, drugs and medical equipment plus insurance company overhead and profit.
Ultimately premiums and deductibles can be reduced only if prices for the health care services, drugs and medical equipment are reduced and/or less health care services, drugs and medical equipment are obtained.

1. Reductions not due to increased plan choice
a. If prices are controlled by the government, the government can reduce prices by fiat. The controlling of prices will result in less services, drugs or equipment being provided. The reduction of prices cannot be considered a result of competition.
b. If there is medical malpractice reform, and premiums for medical malpractice and amount of "defensive medicine" are reduced, that should result in reduced premiums and deductibles. This reduction is not a result, however, of more plan choice and more competition in plans.
c. If there is a reduction in demand, prices will fall and premiums and deductibles should fall. The health bill will result in a large reduction in demand by reason of Medicaid cutbacks and people dropping insurance because higher subsidies are replaced with lower tax credits.  Under principles of supply and demand, the reduced demand should result a reduction of prices but the amount of such reduction is highly unquantifiable and may be negligible. It is probably the wildest of imagining by the Trump team that this reduction by cutting back Medicaid and people dropping coverage will result in more than a small fraction of what is in their minds for reduced premiums and deductibles. Further the reduction in prices, premiums and deductible is not due to increased plan choice, but due reduced spending and reduced health services, drugs and medical equipment being obtained.

2. Reductions due to increased plan choice are highly dubious
If there is more choice in insurance plans, people may plan they don't want certain services, drugs and equipment to be covered under their plan. and that can allow the insurance company to charge them less in premiums and deductibles.
That creates a problem, however, that, if those people are allowed to do that, the people who need the services, drugs and equipment that the first set of people forego will have to pay higher premiums and deductibles to have the services, drugs and equipment covered by their plan. In other words, plan choice can reduce premiums and deductibles for some people but increase them for other people.
The same applies as regards the Obamacare mandate and what happens if it is eliminated.The elimination of the mandate will reduce premiums for those who choose not to have insurance coverage. As is well known, under Obamacare, the mandate results in healthier people having to buy insurance and pay premiums. If healthier people do not buy insurance, that will result in higher premiums and deductibles for the unhealthier people who buy insurance.
It should also be pointed out that consumers are unaware of the substance of their plan choice and and ostensible competition in premiums and deductibles. Under Obamacare, where there are standard benefits, insurance companies have competed on premiums and deductibles by reducing their "networks." Consumers cannot make a meaningful comparison of slightly higher or lower premiums compared to the "value" of a larger or smaller network. If there is more plan choice, comparison of premiums and deductibles will prevent genuine competition from happening.
Alabamians at mercy of chimeras on high
Rep. Palmer is asked above to speak about health care to his constituents. The extent to which he will oblige remains to be seen.
The extent to which Senators Shelby and Strange and Representatives Byrne, Roby, Rogers, Aderholt, Brooks, and Sewell will or can articulate for the benefit of Alabamians what has been asked of Rep. Palmer is dubious. It is also dubious the extent to which any of them will have meaningful input in the shaping of whatever legislation results.
Alabamians can watch daily the forces clashing high above. Not only can Alabamians do little to affect the out come high, they are being served up chimearas.
The Trump team is ready to reject whatever the Congressional Budget Office projects about reduced coverage, increased or decreased premiums and deductibles, particularly for those less able to afford greater financial burden or having greater needs.In rejecting CBO scoring, the Trump team does not appear of have substitute projections for Alabamians to have a sense of what is going to happen to their health care. The Trump team is making chimerical assertions about large reductions in premiums and deductibles that is going to save the country from the Obamacare "disaster."
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Monday, March 6, 2017

Reducing taxpayer cost of maintaining Trump family

To Senators Shelby and Strange and Representatives Byrne, Roby, Rogers, Aderholt, Brooks, Palmer and Sewell

Can Congress do anything to reduce the taxpayer cost of maintaining President Trump and his family?

Just how much is too much for the taxpayers to be called on to pay?

Is the situation that of President Trump practicing his "art of the deal" prowess on the American people, in which Congress needs to negotiate on behalf of the American people against President Trump?

Costs of President Trump's family living arrangements
One current estimate is that Melania and Barron's living in New York is costing New York about $150,000 a day, and New York is seeking reimbursement from the Federal government and the American taxpayers of these costs..

The Hill estimates that the cost of a President Trump weekend  at Mar-a-Lago (now up to four weekends) is $3,000,000 per weekend

This is while the membership fee at Mar-a-Lago (owned by the Trump organization) was recently doubled from $100,000 to $200,000.

Many people want access to President Trump, and profits will accrue to Mar-a-Lago from people who want to "pay to play" or augment their social profile by hobknobbing with President Trump.

Besides the costs to taxpayers, these opulent living arrangements for President Trump and his family are imposing significant business costs on other people. This is being reported currently in the Mar-a-Lago area. Businesses in the Trump Tower area suffered significant costs before January 20th. The situation currently is not clear.

Taxpayers paying for Trump business
President Trump is giving every indication that he seeks to increase his wealth as much as possible while he is President, and he will exploit the Presidency to benefit the Trump family business. Moreover, taxpayers are going to pay costs in support of the Trump profit making enterprise.

In January, Eric Trump made a Trump organization promotional trip to Uruguay, and the United States taxpayers will foot a bill of about $100,000.

. As the news article reporting on the Uruguayan trip says:
The Uruguayan trip shows how the government is unavoidably entangled with the Trump company as a result of the president's refusal to divest his ownership stake. In this case, government agencies are forced to pay to support business operations that ultimately help to enrich the president himself. Though the Trumps have pledged a division of business and government, they will nevertheless depend on the publicly funded protection granted to the first family as they travel the globe promoting their brand.
Only time will tell how much money the Trump organization will make off the Trump Presidency, and how much taxpayers will pay in support of the Trump family business.

Trump's "art of the deal" with the American people
One can only marvel at President Trump's deal making prowess in the above deal he is (unilaterally) sticking the American people with, including taxpayer support of the lavish living style of President Trump and his family, exploiting the Presidency to increase his family wealth and making the Trump businesses more profitable, and getting taxpayers to pay costs in support of the Trump business enterprise.

Many people were dubious about President Trump's character and motivations in running for President and thought he ultimately would be seeking his own glorification and did not care very much about helping the American people. The "art of the deal" President Trump is practicing on the American people will only be validation for the skepticism of these people about President Trump.

Those who are ardent Trump supporters may begin to have doubts about President Trump's character and motivations in considering the above deal President Trump is trying to stick the American people with.

Those supporters may start to find some hollowness in the President words in his inauguration address. As President Trump lives his opulent life style at taxpayer expense and as he exploits the Presidency to increase the Trump family wealth, supporters may wonder how genuine President Trust was in saying things such as
The forgotten men and women of our country will be forgotten no longer.
and 
But for too many of our citizens, a different reality exists: Mothers and children trapped in poverty in our inner cities; rusted-out factories scattered like tombstones across the landscape of our nation; an education system, flush with cash, but which leaves our young and beautiful students deprived of knowledge; and the crime and gangs and drugs that have stolen too many lives and robbed our country of so much unrealized potential.
Congress needed to represent American people in the deal
In this unilateral deal that President Trump is trying to stick the American people with, Congress needs to step forward and represent the American people.

The below Feb. 22nd op/ed piece in The Wall Street Journal makes a good suggestion that Congress ought to put forth on behalf of the American people for their deal with President Trump. The idea is basically to put the Trump business in a public trust while President Trump is in office, with profits to flow to the Federal government while President Trump is in office and those profits can be used to pay for both the lavish lifestyle of President Trump and his family and also to support the conduct of the Trump business.

Congress may come up with other ideas in negotiating for the American people against President Trump.



A Real Fix for Trump’s Conflicts of Interest

Congress should establish a public trust to oversee his company.


BY GEORGE M. COHEN



Shortly before becoming president, Donald Trump announced that his business empire would be placed into a trust overseen by his two eldest sons. All profits generated by foreign governments at his hotels will be transferred to the U.S. Treasury. The plan represents a step in the right direction, but it isn’t enough to settle doubts about conflicts of interest in the Trump administration.
Congress and the president should instead work together to establish a public trust that oversees the Trump Organization throughout Mr. Trump’s presidency. All profits from the business would be paid directly to the U.S. government. His family could still be involved in the business, but ultimate authority would go to a congressionally appointed independent government trustee or board.
The profits could be used, among other things, to offset the cost of Mr. Trump’s weekend trips to Mar-a-Lago or the extra security required for his family at Trump Tower in New York. Since the government would have ultimate control over the business, it would have an incentive to align the interests of the business with those of the country. If a particular deal is good for the Trump Organization but bad for the U.S., the company would side with what’s best for America.
The president in West Palm Beach, Fla., Feb. 17.
The president in West Palm Beach, Fla., Feb. 17.PHOTO: GETTY IMAGES
This solution is not without difficulties. As head of the executive branch of government, Mr. Trump could define the “national interest” in ways that unduly favor his business interests. The Trump children and other employees of the Trump Organization, who know better than any government overseer, could manipulate “profits” and investments to postpone revenues and reduce the amounts to be paid to the government.
Nevertheless, government ownership and control may be the best of many imperfect options. It would provide greater transparency about exactly what the Trump Organization’s interests, assets and liabilities are. This could facilitate more-open debate on how conflicts of interest should be resolved. Ambiguity only encourages unfounded speculation and conspiracy theories.
Congress could try to go it alone and pass such a plan with veto-proof majorities, though it would be standing on shaky legal ground because of the Fifth Amendment’s prohibition on the taking of private property for public use without just compensation. But Mr. Trump should realize that such a proposal is in his best interest. This setup would severely undercut any argument that he is working in his company’s interest, not the country’s. As soon as he leaves office, his family will likely inherit a strong and untainted business.
If Mr. Trump continues his current strategy, he can expect an endless stream of lawsuits, boycotts, political criticism and second-guessing of his motivations. Handing off the company would stop much of that immediately. And if he does well as president, his business will prosper. Joining these public and private interests would be exactly the kind of innovative solution that Mr. Trump applauded as a businessman.
Mr. Cohen is a professor of law at the University of Virginia.
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Saturday, March 4, 2017

Crisis

To Senators Shelby and Strange and Representatives Byrne, Roby, Rogers, Aderholt, Brooks, Palmer and Sewell

President Trump's new charges that President Obama wiretapped the candidate's Trump Tower offices during the campaign is potentially plunging the country into crisis.

I think Congress needs to go into its own crisis mode. I don't know exactly what the form of such a crisis mode should be.

Please speak to your Alabama constituents about this.

Thank you.
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