HEALTH CARE

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IS THIS WHAT DEMOCRACY LOOKS LIKE?

27 MILLION

Over 27 million people are uninsured in America.

COST

Cost is the number one barrier to coverage for the uninsured.

FULL TIME WORKER

A majority of the uninsured have at least one full time worker in their family.

400%

Families with incomes below 400% of poverty are at highest risk of being uninsured.

PREVENTION

The uninsured delay care and receive less preventive care.

MEDICAL BILLS

Medical bills can threaten the financial well-being of the uninsured.
LEAGUE REFERENCES
  • LEAGUE REFERENCES
  • 2018 Healthcare Caucus Intro

    First, a thank you to our sponsoring leagues: Our state leagues of Arizona; Oregon; Vermont; Massachusetts; and Louisiana. Also our local leagues of: Metropolitan Phoenix, AZ; Northwest Maricopa County, AZ; Amherst, MA; Charlotte-Mecklenburg (NC); Piedmont Triad NC; Los Angeles, CA; Ann Arbor Area, MI; and Harvard, MA.

    Health care remains an important topic for the League. And we are not alone. In a new Reuters/Ipsos poll in June 2018, health care was cited as the most important problem facing the US today. As such, let us discuss where the League stands. The League’s Statement of Position on Health Care dates back to its announcement by the National Board in April 1993 and was supplemented by concurrence recently in June 2016. The position is quite lengthy but to sum up the key elements, the League believes that a basic level of quality health care at an affordable cost should be available to all U.S. residents. Every U.S. resident should have access to a basic level of care that includes:
    · The prevention of disease
    · Health promotion and education
    · Primary care (including prenatal and reproductive health)
    · Acute care
    · Long-term care and
    · Mental health care
    The League favors a national health insurance plan financed through general taxes in place of individual insurance premiums, commonly known as the “single-payer” approach. The League believes that the ability of a patient to pay for services should not be a consideration in the allocation of health care resources. At the last convention in 2016, a position on behavioral health was adopted by concurrence. The key points are that all people need access to affordable, quality inpatient and outpatient behavioral health care, including needed medications and supportive services and that behavioral health care must be integrated with and achieve parity with physical health care.

    In 2010, after two decades of League work to ensure access to affordable, quality health care for all Americans and protect patients’ rights, the Affordable Care Act (ACA) was signed into law. The League supports the implementation of the ACA and remains vigilant in light of the current efforts to repeal or diminish the law in Congress and the courts. According to the 2017 Kaiser Women’s Health Survey, seven years after the passage of the ACA in 2010, nine in ten women now have health insurance coverage, more than ever before. In addition, the majority of women who use contraception have full coverage without cost sharing under the ACA’s preventive services requirement. But we still have a long way to go to achieve universal health care for all US residents. International human rights law recognizes one’s fundamental right to health care, yet the US stands alone among developed countries with millions left uninsured. In our complicated and fragmented health care system, large gaps in health equity still persist-by income, education, race, ethnicity, geography, gender identity and physical abilities among other factors. It is time to embrace the fact that health care is not a privilege for the few in America, but a human right for all. It is time to implement a socially just system of care in the form of national improved Medicare for all.

    Make no mistake, these are trying times for advocates of universal care. In the past year alone we faced multiple threats. We saw the Individual mandate penalty repealed, which the CBO predicts will cause 13M fewer Americans to be insured by 2027. We’ve seen states gain the power to impose work requirements on Medicaid enrollees. In Kentucky alone, 95,000 Medicaid enrollees are expected to lose coverage within five years. There are near weekly assaults on our reproductive freedoms in many states. Funding for the Children’s Health Insurance Program, on which almost 9M low income children depend, was in serious jeopardy, as were Federally Qualified Health Centers, those “safety-net” providers of comprehensive primary and preventive health care. In February, 20 states attorneys general led by Texas filed a suit to have the entire ACA declared unconstitutional-including coverage for pre-existing conditions. An Urban Institute June 2018 analysis shows that if the entire ACA were eliminated, the number of uninsured people would increase by 17.1 million in 2019. According to a 2016 Kaiser Family Foundation analysis, 52 million adults under age 65 have a pre-existing health condition that would likely render them uninsurable.

    In the face of all these challenges, it has never been more important for advocates of single-payer care to stand up and make ourselves heard. To tell us more about improved Medicare for all and what actions we can take, I am honored to present our invited speaker Dr Claudia Fegan.

    Dr. Fegan is chief medical officer for the Cook County Health and Hospital System and John H. Stroger Jr. Hospital of Cook County. She is also president of the Chicago-based Health and Medicine Policy Research Group. She received her undergraduate degree from Fisk University and her medical degree from the University of Illinois College of Medicine. Dr. Fegan is a fellow of the American College of Physicians, certified in health care quality and management, and a diplomate of the American Board of Quality Assurance and Utilization Review Physicians.

    Dr. Fegan is national coordinator of Physicians for a National Health Program. In her current and past leadership roles in PNHP she has appeared on national television and radio programs, and has testified before congressional committees on a wide range of health care issues. She has lectured extensively to both medical and community audiences on health care reform in the U.S. and Canada. She is a co-author of the book “Universal Healthcare: What the United States Can Learn from the Canadian Experience" and a contributor to "10 Excellent Reasons for National Health Care.” Welcome Dr Fegan!

  • HR 676 - A summary of the proposed Medicare For All Act.

    This bill establishes the Medicare for All Program to provide all individuals residing in the United States and U.S. territories with free health care that includes all medically necessary care, such as primary care and prevention, dietary and nutritional therapies, prescription drugs, emergency care, long-term care, mental health services, dental services, and vision care.

    Only public or nonprofit institutions may participate. Nonprofit health maintenance organizations (HMOs) that deliver care in their own facilities may participate.

    Patients may choose from participating physicians and institutions.

    Health insurers may not sell health insurance that duplicates the benefits provided under this bill. Insurers may sell benefits that are not medically necessary, such as cosmetic surgery benefits.

    The bill sets forth methods to pay institutional providers and health professionals for services. Financial incentives between HMOs and physicians based on utilization are prohibited.

    The program is funded: (1) from existing sources of government revenues for health care, (2) by increasing personal income taxes on the top 5% of income earners, (3) by instituting a progressive excise tax on payroll and self-employment income, (4) by instituting a tax on unearned income, and (5) by instituting a tax on stock and bond transactions. Amounts that would have been appropriated for federal public health care programs, including Medicare, Medicaid, and the Children's Health Insurance Program (CHIP), are transferred and appropriated to carry out this bill.

    The program must give employment transition benefits and first priority in retraining and job placement to individuals whose jobs are eliminated due to reduced clerical and administrative work under this bill.

    The Department of Health and Human Services must create a confidential electronic patient record system.

    The bill establishes a National Board of Universal Quality and Access to provide advice on quality, access, and affordability.

    The Indian Health Service must be integrated into the program after five years. Congress must evaluate the continued independence of Department of Veterans Affairs health programs.

  • Official League Stance on Healthcare

    LWVUS
    Health Care Statement


    In 1990, the LWVUS undertook a two-year study of the funding and delivery of health care in the United States. Phase 1 studied the delivery and policy goals of the U.S. health care system; Phase 2 focused on health care financing and administration. The LWVUS announced its initial health care position in April 1992 and the final position in April 1993.

    The health care position outlines the goals the LWVUS believes are fundamental for U.S. health care policy. These include policies that promote access to a basic level of quality care at an affordable cost for all U.S. residents and strong cost-control mechanisms to ensure the efficient and economical delivery of care. The Meeting Basic Human Needs position also addresses access to health care.

    The health care position enumerates services League members believe are of highest priority for a basic level of quality care: the prevention of disease, health promotion and education, primary care (including prenatal and reproductive health care), acute care, long-term care and mental health care. Dental, vision and hearing care are recognized as important services but of lower priority when measured against the added cost involved. Comments from numerous state and local Leagues, however, emphasized that these services are essential for children.

    To achieve more equitable distribution of services, the League endorses increasing the availability of resources in medically underserved areas, training providers in needed fields of care, standardizing the services provided under publicly funded health care programs and insurance reforms.

    The LWVUS health care position includes support for strong mechanisms to contain rising health care costs. Particular methods to promote the efficient and economical delivery of care in the United States include regional planning for the allocation of resources, reducing administrative costs, reforming the malpractice system, copayments and deductibles, and managed care. In accordance with the position’s call for health care at an affordable cost, copayments and deductibles are acceptable cost containment mechanisms only if they are based on an individual’s ability to pay. In addition, cost containment mechanisms should not interfere with the delivery of quality health care.

    The position calls for a national health insurance plan financed through general taxes, commonly known as the “single-payer” approach. The position also supports an employer-based system that provides universal access to health care as an important step toward a national health insurance plan. The League opposes a strictly private market-based model of financing the health care system. With regard to administration of the U.S. health care system, the League supports a combination of private and public sectors or a combination of federal, state and/ or regional agencies. The League supports a general income tax increase to finance national health care reform.

    The League strongly believes that should the allocation of resources become necessary to reform the U.S. health care system, the ability of a patient to pay for services should not be a consideration. In determining how health care resources should be allocated, the League emphasizes the consideration of the following factors, taken together: the urgency of the medical condition, the life expectancy of the patient, the expected outcome of the treatment, the cost of the procedure, the duration of care, the quality of life of the patient after the treatment, and the wishes of the patient and the family.

    As the LWVUS was completing Phase 2 of the study, the issue of health care reform was rising to the top of the country’s legislative agenda. In April 1993, as soon as the study results were announced, the LWVUS met with White House Health Care officials to present the results of the League’s position. Since then, the League has actively participated in the health care debate.

    The LWVUS testified in fall 1993 before the House Ways and Means Subcommittee on Health, the Energy and Commerce Committee and the Education and Labor Committee, calling for comprehensive health care reform based on the League position. The League joined two coalitions— one comprised of consumer, business, labor, provider and senior groups working for comprehensive health care reform, and the other comprised of groups supporting the single-payer approach to health care reform.

    Throughout 1994, the League actively lobbied in support of comprehensive reform, including universal coverage, cost containment, single-payer or employer mandate and a strong benefits package. The League emphasized LWVUS support for the inclusion of reproductive health care, including abortion, in any health benefits package.

    The LWVEF initiated community education efforts on health care issues with the Understanding Health Care Policy project in the early 1990s. The project provided training and resources for Leagues to conduct broad-based community outreach and education on health care policy issues with the goal of expanding community participation in the debate.

    In spring 1994, the LWVEF and the Kaiser Family Foundation (KFF) undertook a major citizen education effort, Citizen’s Voice for Citizen’s Choice: A Campaign for a Public Voice on Health Care Reform. The project delivered objective information on health care reform to millions of Americans across the country through local and state Leagues sponsored town meetings in major media markets nationwide, involving members of Congress and other leading policy makers and analysts in health care discussions with citizens. In September 1994, the LWVEF and KFF held a National Satellite Town Meeting on Health Care Reform, with 200 + downlink sites across the country. They also undertook a major television advertising promotion of public participation in the health care debate.

    In 1997, the LWVUS joined 100 national, state and local organizations in successfully urging Congress to pass strong bipartisan child health care legislation. In 1998, the LWVUS began working for a Patients’ Bill of Rights, aimed at giving Americans participating in managed care health plans greater access to specialists without going through a gatekeeper, the right to emergency room care using the “reasonably prudent person” standard, a speedy appeals process when there is a dispute with insurers and other rights.

    In 1998, the LWVEF again partnered with KFF and state and local Leagues on a citizen education project, this time focused on Medicare reform, patients’ bill of rights and other health care issues. In the first phase, more than 6,500 citizens participated in focus groups, community dialogues and public meetings. Their views were reflected in “How Americans Talk about Medicare Reform: The Public Voice,” presented to the National Bipartisan Commission on the Future of Medicare in March 1999. The report emphasized that people value Medicare but recognize its flaws. Fairness, responsibility, efficiency and access were identified as important values for any reforms of the Medicare system.

    In spring 2000, the LWVEF and KFF developed and distributed In spring 2000, the LWVEF and KFF developed and distributed two guides, Join the Debate: Your Guide to Health Issues in the 2000 Election and A Leader’s Handbook for Holding Community Dialogues. The project focused on five issues under debate in the election: the uninsured, managed care and patients’ rights, Medicare reform, prescription drug coverage and long-term care.

    In the late 90s, the LWVUS lobbied in support of a strong Patients’ Bill of Rights. Despite close votes in 2000, Senate opponents continued to block passage. At Convention 2000, League delegates lobbied their members of Congress to pass a strong, comprehensive Patients’ Bill of Rights, but it was shelved as Election 2000 drew near.

    In the 108th Congress, the League lobbied in support of the Health Care Access Resolution. In 2003, the League opposed the Medicare Prescription Drug bill, which the President signed into law, because of provisions that undermined universal coverage in Medicare.

    In May 2006, the League urged Senators to oppose the Health Insurance Marketplace Modernization and Affordability Act (HIMMA), which purported to expand healthcare coverage, while actually limiting critical consumer protections provided in many states.

    From 2007-2009, the League urged reauthorization of the State Children’s Health Insurance Program (SCHIP), which provided health care coverage in 2007 to six million low-income children; the efforts were rewarded with reauthorization in early 2009.

    In 2010, two decades of League work to ensure access to affordable, quality health care for all Americans and protect patients’ rights celebrated success when the Affordable Care Act (ACA) was signed into law. The League remains vigilant in light of current efforts to repeal or diminish the law in Congress and the courts.

    In the 112th Congress, the League continued to fight attempts to repeal the Affordable Care Act and to limit provisions that provide health and reproductive services for women. State Leagues began to work with their legislatures to implement the ACA and the LWVUS signed on to an amicus brief in the challenge to the Affordable Care Act, which was upheld by the Supreme Court.

    In 2013, as opposition to the ACA was raised in the legislative, regulatory and judicial processes, the LWVUS submitted comments opposing religious exemptions for contraceptive services. This debate continued in the courts and the League joined with other concerned organizations in opposing broad “religious exemptions” to the requirement that all insurance plans provide access to contraception as basic care in the 2014 Supreme Court case of Burwell v. Hobby Lobby Stores.

    Judicial action continued in 2015 as supporters, including the League, submitted an amicus brief in the case of Burwell v. King, which challenged the availability of tax subsidies for people who purchase health insurance on a marketplace administered by the federal government. The ACA gave states a choice not to administer its own marketplace. The brief outlined how tax subsidies are essential to women's health and critical to the ACA's continued viability.

    The League continued to support implementation of the ACA at the state level and expansion of the Medicaid program, as provided by the ACA. The League also continued its strong support for continued funding of the Children’s Health Insurance Program (CHIP).

    The League’s Position: The League of Women Voters believes that a basic level of quality health care at an affordable cost should be available to all U.S. residents. Other U.S. health care policy goals should include the equitable distribution of services, efficient and economical delivery of care, advancement of medical research and technology, and a reasonable total national expenditure level for health care.

    Basic Level of Quality Care: Every U.S. resident should have access to a basic level of care that includes:
    · The prevention of disease
    · Health promotion and education
    · Primary care (including prenatal and reproductive health)
    · Acute care
    · Long-term care
    · Mental health care

    Every U.S. resident should have access to affordable, quality in- and out-patient behavioral health care, including needed medications and supportive service that is integrated with, and achieves parity with, physical health care.

    Dental, vision and hearing care also are important but lower in priority. The League believes that under any system of health care reform, consumers/ patients should be permitted to purchase services or insurance coverage beyond the basic level.

    Financing and Administration: The League favors a national health insurance plan financed through general taxes in place of individual insurance premiums. As the United States moves toward a national health insurance plan, an employer-based system of health care reform that provides universal access is acceptable to the League. The League supports administration of the U.S. health care system either by a combination of the private and public sectors or by a combination of federal, state and/ or regional government agencies.

    The League is opposed to a strictly private market-based model of financing the health care system. The League also is opposed to the administration of the health care system solely by the private sector or the states.

    Taxes: The League supports increased taxes to finance a basic level of health care for all U.S. residents, provided health care reforms contain effective cost control strategies.

    Cost Control: The League believes that efficient and economical delivery of care can be enhanced by such cost control methods as:
    · The reduction of administrative costs
    · Regional planning for the allocation of personnel, facilities and equipment
    · The establishment of maximum levels of public reimbursement to providers
    · Malpractice reform
    · The use of managed care
    · Utilization review of treatment
    · Mandatory second opinions before surgery or extensive treatment
    · Consumer accountability through deductibles and copayments

    Equity Issues: The League believes that health care services could be more equitably distributed by:
    · Allocating medical resources to underserved areas
    · Providing for training health care professionals in needed fields of care
    · Standardizing basic levels of service for publicly funded health care programs
    · Requiring insurance plans to use community rating instead of experience rating
    · Establishing insurance pools for small businesses and organizations

    Allocation of Resources to Individuals: The League believes that the ability of a patient to pay for services should not be a consideration in the allocation of health care resources. Limited resources should be allocated based on the following criteria considered together:
    · The urgency of the medical condition
    · The life expectancy of the patient
    · The expected outcome of the treatment
    · The cost of the procedure
    · The duration of care
    · The wishes of the patient and the family

    Behavioral Health: The League of Women Voters supports:
    · Behavioral Health as the nationally accepted term that includes both mental illness and substance use disorder
    · Access for all people to affordable, quality in- and out-patient behavioral health care, including needed medications and supportive services
    · Behavioral Health care that is integrated with, and achieves parity with, physical health care
    · Early and affordable behavioral health diagnosis and treatment for children and youth from early childhood through adolescence
    · Early and appropriate diagnosis and treatment for children and adolescents that is family-focused and community-based
    · Access to safe and stable housing for people with behavioral health challenges, including those who are chronically homeless
    · Effective re-entry planning and follow-up for people released from both behavioral health hospitalization and the criminal justice system
    · Problem solving or specialty courts, including mental health and drug courts, in all judicial districts to provide needed treatment and avoid inappropriate entry into the criminal justice system
    · Health education from early childhood throughout life that integrates all aspects of social, emotional and physical health and wellness
    · Efforts to decrease the stigmatization of, and normalize, behavioral health problems and care

    Statement of Position on Health Care, as Announced by National Board, April 1993 and supplemented by concurrence, June 2016.


  • Healthcare OpEd by Dr. Michelle Dorsey

    On July 30th, the nation will celebrate the 52nd anniversary of the Medicare program, which serves 46 million seniors and 9 million disabled Americans. Prior to 1965 about half of all seniors lacked health insurance, while today nearly everyone over age 65 is covered. Medicare recipients enjoy excellent access to care, including to physicians, hospitals and other providers, with 96% reporting they have a usual source of care. For those who do not qualify for Medicare, the future is much less certain. Lack of health insurance results in a reduction in preventative care and screenings, and medical bills contribute to almost half of all bankruptcies. Currently, Congress is locked in a partisan standoff, with the health, well-being and very lives of millions of Americans on the line. It is time for truly bipartisan health care reform.

    The United States operates the most complicated and fragmented health care system in the world. There are many payment systems, payers, and fee schedules with a complex and redundant private insurance bureaucracy. Additionally, America is trailing many developed countries on key health care measures such as infant mortality, life expectancy, disease burden, hospital admissions for preventable disease, avoidable mortality and in preventative medicine. Yet we spend the most of any country on health care; nearly 18% of GDP. Administrative costs in U.S. health care are the highest in the developed world, accounting for over 8% of spending, while traditional Medicare is operating at 2% overhead. These administrative expenditures are crowding out investments in public health. Furthermore, there is no socially beneficial reason to operate health care as a for-profit enterprise.

    In addition to the financial considerations, the United States has an overriding moral and ethical obligation to provide basic health care to every citizen. Like so many countries before us, it is time to embrace the fact that health care is not a privilege for the few, but a right for all. In a recent Pew Research Center survey, 60% of Americans said it is the responsibility of the federal government to ensure health care coverage for all Americans. The U.S. is fortunate to be home to the world’s best training programs which graduate first-rate medical staff. We play a central role in innovation, including in research and advances in technology. A socially just system of care needs to be developed so that these resources can be provided to all, as a public service.

    The League of Women Voters, as a nonpartisan, progressive, political organization committed to helping create an informed and active electorate, has long supported access to a basic level of quality care at an affordable cost for all U.S. residents. Basic care should include the prevention of disease, health promotion and education, primary care (including prenatal and reproductive health), acute care, long-term care and behavioral/mental health care. The League favors an equitably distributed, efficient and economical national health insurance plan financed through general taxes in place of individual insurance premiums. As a result, the League opposes the American Health Care Act (AHCA) and the Better Care Reconciliation Act (BCRA) which would leave at least 23 million people, particularly minorities and underserved populations, uninsured. The AHCA and BCRA will reduce revenue to the Medicare Hospital Insurance (Part A), hastening its insolvency by 2-3 years. The BCRA will also increase the number of uninsured 50-64-year olds, which will result in new Medicare enrollees requiring more services due to delay in seeking care.

    As we approach the 52nd anniversary of the Medicare program, please consider calling your Senator today and urge them to protect Medicare by voting no on the BCRA. Join the League of Women Voters in supporting bipartisan reform that creates a fair and equitable health care system that is worthy of this great nation.

    Michelle Dorsey, MD
    President, League of Women Voters of Metropolitan Phoenix The United States operates the most complicated and fragmented health care system in the world. There are many payment systems, payers, and fee schedules with a complex and redundant private insurance bureaucracy. Additionally, America is trailing many developed countries on key health care measures such as infant mortality, life expectancy, disease burden, hospital admissions for preventable disease, avoidable mortality and in preventative medicine. Yet we spend the most of any country on health care; nearly 18% of GDP. Administrative costs in U.S. health care are the highest in the developed world, accounting for over 8% of spending, while traditional Medicare is operating at 2% overhead. These administrative expenditures are crowding out investments in public health. Furthermore, there is no socially beneficial reason to operate health care as a for-profit enterprise.

    In addition to the financial considerations, the United States has an overriding moral and ethical obligation to provide basic health care to every citizen. Like so many countries before us, it is time to embrace the fact that health care is not a privilege for the few, but a right for all. In a recent Pew Research Center survey, 60% of Americans said it is the responsibility of the federal government to ensure health care coverage for all Americans. The U.S. is fortunate to be home to the world’s best training programs which graduate first-rate medical staff. We play a central role in innovation, including in research and advances in technology. A socially just system of care needs to be developed so that these resources can be provided to all, as a public service.

    The League of Women Voters, as a nonpartisan, progressive, political organization committed to helping create an informed and active electorate, has long supported access to a basic level of quality care at an affordable cost for all U.S. residents. Basic care should include the prevention of disease, health promotion and education, primary care (including prenatal and reproductive health), acute care, long-term care and behavioral/mental health care. The League favors an equitably distributed, efficient and economical national health insurance plan financed through general taxes in place of individual insurance premiums. As a result, the League opposes the American Health Care Act (AHCA) and the Better Care Reconciliation Act (BCRA) which would leave at least 23 million people, particularly minorities and underserved populations, uninsured. The AHCA and BCRA will reduce revenue to the Medicare Hospital Insurance (Part A), hastening its insolvency by 2-3 years. The BCRA will also increase the number of uninsured 50-64-year olds, which will result in new Medicare enrollees requiring more services due to delay in seeking care.

    As we approach the 52nd anniversary of the Medicare program, please consider calling your Senator today and urge them to protect Medicare by voting no on the BCRA. Join the League of Women Voters in supporting bipartisan reform that creates a fair and equitable health care system that is worthy of this great nation.

    Michelle Dorsey, MD
    President, League of Women Voters of Metropolitan Phoenix

  • Too Big to Fail, Too Big to Know, and Too Big to Ignore

    Too Big To Fail, Too Big to Know, and Too Big to Ignore
    By: Jana Lynn Granillo

    How does ACA affect me and my community? Well, that is a big question with a big answer. The ACA is big. It is more than the marketplace and mandates - which is till the law. IT is a whole system of care, infrastructure and problem solving intended to make us healthier as a nation.

    When I think of the ACA, what churns to the top of my thoughts are vulnerable populations, my neighbors, my own insurance and where I live.

    When I hear students playing in the school yard, I know many are economically disadvantaged. We have a shockingly large percentage of
    students on the Free and Reduced Lunch program. How many of those children have AHCCS/Medicaid or participate in the ACA Marketplace?

    When I commute, I drive by community healthcare centers, also know as
    Federally Qualified Health Centers. The ACA funding impacts these clinics.

    When I shop for groceries, I see seniors counting their pennies with clipped coupons. How many seniors will endure a fall or become a victim to MRSA? How many of them are Medicare and Medicare dual eligibles?

    When I hear a first responder siren, I think about behavioral health. According to a
    recent report on the opioid crisis, my community is on a data map and it is colored red. Does the siren tell of another victim? Does that victim have behavioral health options or even a treatment bed for evaluation?

    When I choose doctors, I wonder if they were part of the
    National Service Corp.

    What about treatment options? Is there a new medication on the horizon for a chronic condition or disease by the National Institute of Health? Will my elderly relative have to travel to Phoenix to get treatment that is not available in rural areas?

    Will the county hospital financially be in the “green” this year or do we take a hit on our property taxes to support the district? Will the receive
    Disproportionate Share Payments for serving the underserved? What funding will be available?

    What about all those medically served by the fire department, especially those who don’t have a point of care? Who pays for that?

    Finally, I ponder, will our family (employer) insurance be there tomorrow? I can’t afford a premium without help.

    So, does the ACA affect me, my family and my community? YES!

    How do we proceed? We must include experts from multiple health disciplines to define reform around a common goal: affordable quality healthcare systems that is responsible, provides short term stabilization and long term solutions that protects all.

  • The ACA: Important information about ObamaCare

    THE AFFORDABLE CARE ACT
    By Lois Brechner, Second Vice President,
    LWV of Northwest Maricopa County

    The Affordable Care Act (ACA), commonly referred to as Obamacare, was enacted by Congress in 2010. How has it succeeded? How has it failed? What do we still not know? Can it be improved? The present law is broad and complex with many goals and even more provisions. This paper will deal with its major achievements, its biggest disappointments, questions not yet answered, and suggestions for making needed changes.

    SUCCESSES:
    According to the Census Bureau, over twenty million more people now have health insurance. Recently, the both the Census Bureau and a Gallop Poll reported that the number of uninsured Americans dropped from 13.3% of the population to 9.1%. (1) Many of these newly insured Americans could not have afforded insurance before the ACA or would have been refused insurance because of a preexisting health condition. Under the ACA, health insurance is subsidized for those with low and middle incomes. Young people up to age 26 became eligible to remain covered through their parents. In addition, states who opted for government subsidy to expand Medicaid coverage under the ACA, were able to provide health insurance for more people without additional costs.

    Studies have found that Americans have become less vulnerable to financial shocks related to health issues. Fewer people could not pay their medical bills or avoided getting medical care because of its cost. Medical debt and bills in collections have definitely declined. Prior to the ACA, a large percentage of bankruptcies were cause by catastrophic medical costs.

    The ACA required insurers to provide more comprehensive health coverage. Policies now cover services like maternity care and treatment for drug addiction with no annual cap in payments. Patients have increased access to mental health counseling, contraception, and cancer screenings.

    The ACA contains a mix of new spending and taxes, which, along with cuts to the federal Medicare program, should save us more than it costs. The Congressional Budget Office estimates that if the present law continues, it will save federal dollars, thus lowering the federal deficit, through at least 2025. Even with small changes to tax provisions under the law, an analysis by the Committee for a Responsible Federal Budget, ran the numbers and corroborated the Congressional
    Budget Office findings. (2)

    FAILURES:
    The insurance marketplaces and Medicaid expansion are a good deal for people near the poverty line. However, for many of those with higher earnings which make them ineligible for subsidies, premiums are high and can cause a financial hardship, and deductibles are often much higher than those seen in typical employer-provided health plans. Many healthy young Americans are paying fines instead of enrolling in the ACA. Without enough younger, more healthy enrollees, the pool opting for the ACA is older, sicker, and less predictable in regard to health care needs. Therefore, insurers say they are forced to raise costs significantly or pull out of the ACA market.

    Even though insurance through the ACA is easier to shop for than when it was first enacted, it still remains quite complicated. Selecting the right health plan is often frustrating or, in some cases, impossible for too many Americans who are unsure of their health needs and/or are unable to understand jargon, such as “out-of-pocket maximum” or “in-network provider.” Patients, once insured, still often struggle to use their policies and can be hit with surprise bills and long negotiations with their carriers. In addition, in some parts of the United States, enrollees have only one or very limited insurers. The remaining insurance companies have also been shifting around their offerings each year. The number of doctors or hospitals available through their plans are becoming more limited. Therefore, enrollees find it necessary to change health plans, doctors, hospitals, etc. annually in order to find an affordable policy. (2)

    QUESTIONS NOT YET ANSWERED:
    It would probably take many more years before we can determine if the ACA is making Americans healthier. There is some encouraging, but too early evidence, that low-income people in two states with expanded Medicaid have reported improving overall health compared with neighboring states that declined Medicaid expansion. Research has indicated that more low-income Americans have visited a doctor and received basic preventive health services, including prescription contraceptives and treatments for diabetes. Twenty million people, however, is a small fraction of the nation’s population, and it will most likely take years to determine measurable results.

    There is no truly definitive evidence that the ACA has been the reason for the slowing of health spending. It is hard to separate the effects of the health law from forces like the great recession, rising insurance deductibles, and a slowdown in the development of new medical technologies. That is another area that would most likely take years to determine.

    Did the health law make medical care safer and more evidence-based? Have hospitals improved the quality of care due to the ACA? The law has contained many provisions to improve care received in hospitals. Whereas the health system is still too often a dangerous place for patients, fewer patients are contacting infections in hospitals, and fewer patients are leaving the hospital only to be readmitted within a few weeks. There is not definitive proof that these improvements are directly related to the ACA. Some trends were beginning before the passage of the health care act and, possibly, might have happened anyway. Certainly, requiring safety improvements and more oversight should prove beneficial and bring about continued progress. (2)

    SUGGESTIONS FOR FIXING THE AFFORDABLE CARE ACT:
    The ACA marketplaces can only be successful if enough insurers participate. We must draw insurers into the markets, keep them there, and limit premium growth. One way that success can be achieved is by subsidizing plans more and by limiting their risk of loss. Medicare+Choice, now Medicare Advantage, in the early years went through similar problems to those being experienced by the ACA. The 2003 Medicare Modernization Act—passed by a Republican Congress and signed by President George W. Bush—drastically increased payments to plans, and insurers flooded the market. Although members of both parties were concerned that the plans were overpaid and wasting taxpayer resources, by 2007, every Medicare beneficiary had access to at least one plan and the market stabilized, enrollment continued to grow, costs were controlled, and one in three Medicare beneficiaries was enrolled in a private plan. Increasing the subsidization of the ACA plans similarly, might reduce costs to patients and bring in both more consumers and insurers. (3)

    Part D, the Medicare prescription drug program, also runs entirely through private plans. Large losses are cushioned by a risk corridor program, which allows plans to stay in the market if they miscalculated the needs of the patients they attracted. The program allows them to keep premiums lower because they do not need to hedge against the full cost of potential losses. The ACA included a risk management program and a risk corridor program for marketplace plans. However, the risk corridor program expired at the end of 2016, along with a reinsurance program that compensated insurers for unusually high-cost patients. If Congress follows the model of Part D and makes the risk corridor program and the reinsurance program permanent, it could help stabilize the market places. (4)

    The original ACA allowed for a public option—a public health insurance plan that would compete with private companies and that would work with the ACA. In fact, the non-partisan Congressional Budget Office concluded in 2013 that a “public option” would reduce the federal budget deficit by $158 billion through 2023. The option, however, was removed from the ACA to get private companies on board.

    Putting a public option back in the ACA could fix the program by offering more options to consumers and would possibly bring down the cost of the insurance. The only real stipulation would be to make sure that the public option does not affect what private insurers offer but is attractive enough to compete with them.

    There are two types of public options:
    1. Weak options that just cover low income citizens or certain groups in
    certain areas.
    2. Strong options that would roll in other subsidy programs, like Medicaid and Medicare. They could also include aspects of a voucher system and could replace a lot of the bureaucracy of assistance programs. They could also be structured to keep them attractive to businesses and upper income consumers. (1)

    Another suggestion would be to require insurers to participate in broad regions. This “fix” would limit the private insurers from selectively working in more profitable areas and shunning others like rural areas. (5)

    Expanding Medicaid has been working well in states that have opted for this coverage. Expanding it throughout the country might prove beneficial. (6)

    There have been suggestions to lower the age of enrollment in Medicare to 55. This change would remove the older, possibly sicker people from the ACA. Insurers would carry less risk and costs would go down. This suggestion might reduce the number of enrollees in the ACA; however, it might help stabilize Medicare. (5)

    Finally, the penalty for eschewing coverage by the ACA is so low that many people are paying the fine instead of enrolling in the federal health care program. Again, copying Medicare’s policy which not only includes significant penalties, but grows those penalties the longer one waits to enroll for coverage, might encourage early enrollment. (5)

    CONCLUSION:
    Americans have made it clear that they do not want to give up their health insurance. Republicans might gain a great deal of support if they followed actions taken by the Republican Congress and President George W. Bush in 2003 to fix problems with Medicare, and work with Democrats to fix problems with the Affordable Care Act, and in doing so make America proud while lowering the deficit and the overall exorbitant cost of health care in the United States.
    (1) May 15,2017, Money, What is the Public Option for Health Insurance, Alicia Adamczyk
    (2) February 5 2017, The New York Times, Grading Obamacare, Successes, Failures and Incompletes, Margaret Sanger-Katz
    (3) November 14, 2016, The New York Times, Politics Aside, We Know How to Fix Obamacare, Austin Frakt
    (4) August 17, 2016m Kaiser Family Foundation, Explaining Health Care Reform, Risk Adjustment, Reassurance and Risk Corridors, Cynthia Cox, Ashby Semonskee, Gary Clastor and Larry Levitt
    (5) October 26, 2016, The New Yorker, Three Ways to Fix Obamacare, John Cassidy
    (6) March 30, 2017, Brookings Institution, Want to Fix Obamacare, Henry J. Aaron

  • The Future of Healthcare for Women

    Due to the passage of the Affordable Care Act (ACA), the uninsured rates among all groups of women fell dramatically. Per the Kaiser Family Foundation (KFF), between 2013 and 2015 the uninsured rates for all women fell from 17% to 11%, with rates for women <200% of the Federal Poverty Level (FPL) falling from 31% to 22%, single mothers falling from 24% to 16% and Hispanics falling from 31% to 20%. The number of women who delayed care has also fallen among women ages 18-64, from 13% in 2011 to 9% in 2015 (KFF). Further, the number of women who did not get care due to costs has fallen, for example prescription drugs from 12% in 2011 to 8% in 2015 (KFF). Medicaid expansion under the ACA as well as federal tax credits and cost sharing subsidies played a pivotal role in the increase in health care coverage for women.

    Proposed changes to the ACA under the American Health Care Act (AHCA) have a disproportionate impact on the Medicaid population, by cutting $880B in funding. Women comprise the majority of Medicaid beneficiaries, as they are more likely than men to be low-income or poor due to the fact that they are more commonly head of a single parent household, work part-year or part-time, are paid less for similar work, or stay home to care for children or aging parents (KFF). Medicaid covers nearly 1 in 5 women (1 in 4 Latinas and African American women), pays for half of the births and . of all public family planning (KFF). In Arizona, 20-30% of women were on Medicaid in 2015 (KFF).

    Under the AHCA, the federal funds for the ACA’s Medicaid expansion are eliminated and a spending cap is instituted. 31 states and DC have expanded Medicaid under the ACA for those up to 138% FPL, with the federal government paying 95% of the cost (KFF). The AHCA would withdraw the enhanced federal funds for Medicaid expansion except for those enrolled as of 12/31/19 (grandfathered) who did not have a gap in eligibility for more than 1 month (KFF). As a result, the Congressional Budget Office (CBO) estimates that some states would not continue their expanded Medicaid coverage and that no new states would adopt the Medicaid expansion. The eligibility requirements would likely return to levels seen prior to the ACA, with many states income eligibility levels set significantly below the FPL (KFF). As discussed previously, due to the fact that women make up the majority of Medicaid enrollees, they will suffer the greatest impact by these cuts to Medicaid.

    Subsides and credits are currently provided by the ACA to those with low income, seniors, and to those in areas with more expensive coverage. Under the ACA, premium tax credits are granted to those with incomes between 100-400% FPL (81% of Marketplace beneficiaries) and cost sharing subsidies are given to eligible individuals between 100-250% FPL (KFF). The AHCA eliminates the cost-sharing subsidies as of 1/1/20 and provides a flat tax credit based only on age, up to an income of $75,000, which would decrease aid to older and low income

    Marketplace enrollees (KFF). Because women are more likely to be low income, they will be affected by these changes to a greater extent.

    Under the AHCA, federal Medicaid payments to Planned Parenthood (PP) would be prohibited for 1 year. A recent opinion poll shows that 75% of Americans favor continued federal funding for PP (KFF). Currently PP receives approximately $500M yearly in federal support by providing care to Medicaid patients as well as grant funds from the federal Title X family planning program. PP provides essential services to 2.5M patients each year, not only providing contraceptives but also sexually transmitted infection and cancer screenings. Under AHCA, defunding PP would result in almost 400,000 women losing access to preventative care and up to 650,000 having reduced preventative care according to an estimate from the Government Accountability Office (GAO). PP made up only 6% of the safety-net clinics providing family planning services in 2015, but served 32% of women who sought contraceptive care at those centers (KFF). This compares to federally qualified health centers which comprise 54% of clinics but saw only 30% of contraceptive clients (KFF). Community Health Centers would be given additional funds under the AHCA, but with no requirement to spend them on women’s services, and no current capacity to fill the gap left by PP (KFF). A study from the Washington University School of Medicine has shown that access to free birth control significantly lowers rates of unintended teen pregnancy and abortion.

    No cost contraceptive coverage is provided under the ACA to the majority of women with private insurance, including all FDA-approved contraceptive methods. Due to the ACA, the share of women paying any out-of-pocket cost on oral contraceptives fell from 20.9% in 2012 to 3% in 2015 (KFF). Currently “exemptions” to coverage are reserved for a house of worship only, in which case the employer is not required to cover contraceptives and employees and dependents do not have guaranteed coverage (KFF). “Accommodations” are granted to religiously affiliated nonprofit and closely held for-profit corporations where an employer must notify HHS, the insurer or third party administrator (TPA) of the religious objection to contraception (KFF). In these cases, the employer is not obligated to purchase contraceptive coverage, but the insurer or TPA must pay for coverage for workers or dependents. The AHCA does not specifically address contraceptive coverage, but President Trump’s Executive Order Promoting Free Speech and Religious Liberty called on the Secretaries of Labor, Treasury and Health and Human Services to amend regulations to protect conscience-based objections, with the goal of “exempting” (rather than “accommodating”) any employer with a religious or moral objection from the contraceptive coverage requirement (KFF). If this were to occur, contraceptive coverage would once again be decided by employers, insurance plans and state policy (KFF).

    One of the big successes of the ACA was prohibiting the ability of insurers to deny coverage based on pre-existing conditions (guaranteed issue). This is particularly important for women, as pre-existing conditions can include pregnancy, prior C-section, sexual assault, domestic violence, breast cancer, and postpartum depression. 32% of mothers have had a C-section, 1 in 6 women are victims of sexual assault, and 30% have experienced some form of domestic abuse (Farber). The AHCA maintains the ban but if there is a gap in coverage of 63 days or more in the preceding 12 months, the AHCA allows insurers to charge 30% higher premiums for 1 year or allows states to request a waiver to allow insurers to medically underwrite (charge a higher rate for pre-existing conditions) for 1 year (KFF). So, while insurers cannot deny coverage, they can raise rates so that individuals with pre-existing conditions can no longer afford coverage. The ACA requires all plans in the Marketplace as well as the Medicaid expansion programs to cover 10 categories of Essential Health Benefits (EHB’s). According to the Center on Budget and Policy Priorities, prior to the ACA, 62% of individual market consumers had plans that didn’t cover maternity care, 18% had plans that didn’t cover mental health treatment, 34% had plans that didn’t cover substance abuse treatment, and 9% had plans that didn’t cover prescription drugs. Particular victories of the ACA for women’s EHB’s were the inclusion of maternity and newborn care, preventive services, no-cost prenatal screening, breastfeeding supports, prescription drugs, and mental health. The AHCA repeals the EHB requirements for the Medicaid expansion programs, such that states could opt out of some of the EHB categories including substance abuse treatment and prescription drugs (KFF).

    The AHCA also allows states to apply for a waiver to define their own EHB’s for the individual and small group health insurance markets beginning in 2020 (the MacArthur Amendment). This would allow states to exclude any of the current EHB’s from coverage, potentially allowing states to remove or scale back maternity services (KFF). Larger employers with employees in multiple states could then choose to adopt the EHB definitions of a state that does not include maternity benefits as it’s EHB for employees in all states.

    An additional advantage of the ACA Medicaid expansion is that it currently provides a pathway to coverage for postpartum mothers. By defunding the Medicaid expansion, some postpartum mothers would lose coverage once the 60-day postpartum period ends and would become uninsured (Health Reform Tracker (HRT)). The Manager’s Amendment has a Medicaid work requirement which would allow states to revoke Medicaid coverage from new mothers who haven’t found a job within 2 months after giving birth (HRT).

    The ACA requires all private plans, Medicaid expansion programs and Medicare to cover preventive services without cost sharing, including all of the services recommended by the U.S. Preventive Services Task Force (USPSTF), immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) and services recommended by the Health Resources and Services Administration (KFF). Covered are such services as breast and cervical cancer screening, osteoporosis screening, pregnancy related services (breastfeeding counseling and equipment rental, folic acid supplements, tobacco cessation, alcohol misuse), well woman visits, contraception, interpersonal and domestic violence screening and counseling. The AHCA maintains the preventive services requirement for private plans but repeals them for the Medicaid expansion population (KFF). This allows states the option to eliminate these critical services for low income women.

    Both the ACA and the proposed AHCA will maintain dependent coverage up to age 26 and ban the practice of gender rating (charging women higher premiums than men).

    Despite the current Congressional agenda, there is majority support for the ACA’s women’s health provisions per a Kaiser Family Foundation poll in March of 2017. 95% believe private health insurance companies cannot be allowed to deny coverage to pregnant women. 95% believe private health plans must cover mammograms and cervical cancer screenings with no out-of-pocket costs. 93% believe private health insurance companies should not charge women more than men for the same policy. 78% believe private health plans must cover the costs of birth control with no out-of-pocket costs. 83% believe the federal government should provide funding for reproductive health services, such as birth control and family planning, for lower income women. While the ACA’s coverage isn’t perfect, it does a much better job of covering the scope and breadth women’s health needs than the proposed AHCA. Instituting the AHCA has the potential to seriously limit women’s care and roll back the positive gains achieved under the ACA.

    Sources:
    Kaiser Family Foundation “10 ways that the House AHCA could affect women” by U. Ranji, A.
    Salganicoff, L. Sobel, and C. Rosenzweig. May 8, 2017. **THIS IS AN EXCELLENT RESOURCE AND
    SHAPED MUCH OF THE CONTENT OF THIS SUMMARY**
    Kaiser Family Foundation “The future of Contraceptive Coverage” by L. Sobel, A. Salganicoff, C.
    Rosenzweig. Jan 9, 2017.
    Health Reform Tracker, A Project of the UCSF/UC Hastings Consortium on Law, Science and
    Health Policy “MacArthur Amendment to the AHCA: Executive Summary,” “Manager’s
    Amendment to the AHCA: Executive Summary,” “Executive Summary of AHCA.”
    XXFactor “The AHCA would force new moms on Medicaid to find work 60 days after labor” by
    C. Cauterucci, March 22, 2017.
    ThinkProgress “These are the people who will suffer under Trumpcare” C. Quinlan, March 7,
    2017.
    Fortune, “How the GOP Health Care Bill Hurts Moms, Rape Survivors, and Poor Women” by M.
    Farber, May 5, 2017
    The New York Times Editorial Board “The Health Care Bill’s Insults to Women” May 12, 2017.

  • Employer Sponsored Healthcare Information

    Who is covered as well as impact of the ACA and BCRA Sandra Collier, MA
    League of Women Voters of Northwest Maricopa County July 2017

    Unique among the industrialized countries, American access to private health care has historically been through employer sponsored insurance plans. Prior to the ACA (Affordable Care Act), employers were able to offer any type of plan, or none at all. The desire to recruit and retain the most qualified employees was a prime motivator for offering partially paid employer sponsored health insurance. Employee health insurance costs are tax deductible for the employer and tax free for the employee. The ACA expanded employer coverage by requiring most employers to offer health insurance benefits that included, among other items, the ten essential health benefits, no lifetime or annual heath care caps, and no discrimination for preexisting conditions.

    The ACA (often referred to as Obamacare) is under attack from Congress. Republicans have sponsored bills in both the House of Representatives and the Senate to dramatically change current health care legislation. The CBO’s (Congressional Budget Office) independent nonpartisan review of the proposed Senate plan highlights the $321 million in deficit reduction and the increase in the number of uninsured individuals in the U.S. to 49 million by 2026.
    Public discourse has been focused on the contraction of federally sponsored medical insurance for low income Americans and the elimination of the taxes imposed on high income Americans. But what about employees? What impact will the legislative changes have on the majority of working Americans?

    The discussion below is divided into three sections. First, we will look at who has employer sponsored health insurance today, followed by a brief review of the impact of the ACA on employer sponsored plans and then the potential impact of the Senate sponsored BCRA (Better Care Reconciliation Act). The discussion is not intended to encompass everything that impacts employee health care, but, rather, aims to highlight some of the items that I find most relevant to the conversation.

    Who has employer sponsored health insurance today?
    The US Department of Labor, at March 31, 2016, found that 49% of private industry workers and 73% of state and local government workers participated in employer-sponsored health care (average 52% for all civilian workers).

    Annually data is gathered from US employers for the National Compensation Survey conducted by the Department of Labor, Bureau of Labor Statistics. Excluded from this data are federal government workers, military, agricultural workers, private household workers and the self-employed. The 2016 survey represented 133 million workers in all industries and occupations.

    Employers sponsored health insurance is not the same across the United States. Coverage varies by employer size, industry, whether there is a union, and location. The selected statistics listed below are from the Department of Labor March 2016 Employee Benefits in the United States, News Release dated July 22, 2016. 2 Access to health insurance:

    For all workers

    Full time workers

    Part time workers

    70% have access, 52% participate

    88% have access, 66% participate

    19% have access, 12% participate

    Employer sponsored Health Care by Industry Type, Employer size and how workers in the highest wage rate quartile compare to the lowest rate quartile:

    Workers in goods-producing industries

    Workers in servicing providing industries

    Union workers

    Nonunion workers

    Workers in the lowest 25% wage rate

    Workers in the highest 25% wage rate

    Employers with 500 workers or more

    Employers with less than 50 workers

    84% access, 66% participate

    68% access, 50% participate

    94% access, 79% participate

    66% access, 48% participate

    36% access, 22% participate

    93% access, 74% participate

    89% access, 71% participate

    52% access, 37% participate

    Who pays the premium?
    Single coverage. For those employees in the lowest 25% wage level the employer pays 77% of the premium (employees pay 23%)while for the higher paid employees in the top 25% the employer pays 82% of the premium (employees pay 18%).

    Family coverage. For those employees in the lowest 25% wage level the employer pays 61% of the premium (employees pay 39%) while for the higher paid employees in the top 25% the employer pays 72% of the premium (employees pay 28%).

    For large companies employing more than 500 workers the employer pays 73% of the premium (employees pay 27%) and small companies employing less than 50 workers the employer pays 64% (employee pays 36%)

    What does it mean?

    Health Care is not offered to all employees. The lowest paid workers are less likely to be offered access to employer offered health care insurance, less likely to participate, and will pay a larger % of the actual premium costs. For the lowest paid workers, who pay a larger % of the actual premium, it follows that employee deductions for health care are a much larger share of their compensation compared to the higher paid workers. In our society, it is expected that most skilled or professional positions have fringe benefits that include health care and larger incomes allow employees to participate. No participation can be due to a variety of reasons: health care coverage may be obtained for the family by another employed member, coverage is through a government program such as Medicaid, or health care coverage is declined because of the cost to the employee. If a large percentage (30%) of working people don’t have access to employer sponsored health insurance what do they do? Most individuals, working or not, are required under the ACA to carry health care insurance. Family members may obtain employer sponsored health insurance through the employer of another family member. Individuals and families can buy health insurance on the ACA Exchange where they have access to income based credits to help pay for the cost of the plans. Most users of the exchange are eligible for credits to offset the cost of the insurance. Not everyone complies with the law. There are many reasons working individuals without employer sponsored health care chose not to use the ACA exchange.

    Individuals may still purchase private health care insurance through brokers or directly from the insurance companies. Policies purchased privately are still subject to compliance with the ACA. Individuals without employer sponsored health care may have to make the emergency room their primary care provider. They are subject to tax penalties. For one group the lack of insurance is due to a lack of understanding about the health insurance exchanges work and the credits available to make the insurance affordable. Another set of workers have political motivation and, in principal, refuse to participate in Obamacare.

    Finally, some workers choose to purchase ACA noncompliant insurance and pay the penalty tax. For them the decision is financial and they believe they are savings thousands of dollars by purchased catastrophic insurance and paying regular medical expenses out of pocket.

    The Affordable Care Act
    The ACA was signed into law by President Obama in March 2010. The ACA is comprehensive health care reform legislation intended to expand coverage, control health care costs and improve access through state exchanges.

    Under the ACA most citizens are required to have individual health insurance or pay a penalty which ranges between $695 and $2080 and is computed based on family income. There are a few exceptions where individuals can decline coverage such as for religious reasons or when the lowest priced policy exceeds 8% of an individual’s income.
    Employers with more than 50 employees are required to offer insurance or face a fine. Employers who offer insurance also face a penalty if they have employees who decline that insurance and purchase their own policies from the exchange and receive tax credits. Employees are eligible to decline
    employer coverage and use the exchange if the employee portion of the premium exceeds 9.5% of their income.

    Employers with more than 200 employees are required to automatically enroll employees into health insurance plans, but employees can opt out of the plan if they choose.
    Tax credits are available to small employers offset insurance costs and reinsurance reimbursement programs are offered to employers who offer health insurance to retirees over age 55.
    American Health Benefit Exchanges (for individuals and families) and SHOP (Small Business Health Options Program for employers with less than 100 people) programs were put into place. Coverage from Health insurance purchased on these exchanges is only available to US citizens or legal immigrants.
    States can also create a Basic Health Plan for low income individuals who would otherwise be eligible to
    receive premium subsidies.

    Age ratings for individual coverage is limited to 3:1 for age and 1.5:1 for tobacco use. The base age is 21, therefore, the highest policy price for older individuals is 3x the amount charged for the 21-year-old.
    For employees, the HSA (Health Savings Accounts, pretax employee wages set aside to pay for qualified medical expenses not reimbursed by insurance) annual contribution is limited to $2500 per year, and the threshold for itemized deductions of unreimbursed medical expenses increases from 7.5% to 10% of adjusted gross income and the tax on distribution of HSAs not used for medical expenses increases to
    20%.

    For employers who offer “Cadillac plans” there is an additional excise tax for policies that exceed target threshold value. 5 Cadillac plans annual premiums exceed $10,880 for an individual or $29,500 for a family. The excise tax is scheduled to start in 2020.

    The ACA created an “essential benefits package”; ten benefits that must be covered. These benefits include: outpatient care, hospitalization, emergency services, maternity, mental health, prescription drugs, rehabilitation services, laboratory services, preventive services, and pediatric services.

    Health insurance companies are required to rebate to their customers the excess of premiums over reimbursed costs when reimbursed costs are less than 80 -85% of the premium paid. The reimbursement percentage is based on company size.

    No lifetime limits or pre-existing condition exclusions are allowed, dependent coverage is extended to age 26, waiting periods are limited to 90 days and a website was established to help individuals compare different policy options.
    The Medicare payroll tax deduction increases from 1.45% to 2.35% for those employees with earnings over $200,000 and $250,000 for married couples filing jointly. The ACA also imposes a 3.8% tax on unearned income for higher income taxpayers.
    Proposed Changes to the ACA by the Senate’s (BCRA) Better Care Reconciliation Act (as of July 11, 2017) that will have a direct impact on employers and employees. The BCRA will repeal the ACA compliant health insurance mandate (and the tax penalty) for citizens and legal immigrants.
    The Medicare payroll tax deduction increase for high earners and the tax imposed on pharmaceutical and the health insurance companies will be repealed. It will also repeal the Cadillac tax

    Waiting periods will increase to 6 months for those individuals who haven’t had continual coverage. Short term nonrenewable policies, which can be priced based on health status, can be sold to cover this period.
    The CBCRA allows for a new small business health plan where the essential health benefit requirement is not applicable.
    The plan retains the 10 essential health benefits requirements, but makes it easier for state to waive those requirements.
    The limits on consumer HSA accounts are increased and the tax penalty for non-medical expense
    reimbursement withdrawal is decreased to 10%.

    Maximum out of pocket limits remain but states can apply for waivers to increase those amounts. The same waiver process applies to lifetime limits.
    Change the maximum age rating limit from 3:1 to 5:1. This potentially increases the premiums for older individuals not yet eligible for Medicare by 67%.
    The ACA income based tax credits will remain in place through 2019. Beginning in 2020 the credits will be reduced and the tax credits are disallowed for anyone who is offered an employer sponsored health plan (whether they can afford the plan or not). In addition, the eligibility for credits contracts from “individuals in the US legally” to “qualified aliens” only. This will exclude worker visas and student visas.

    In summary
    Most Americans access health care through employer sponsored health insurance. We are the sole remaining industrialized nation that doesn’t guarantee health care for the majority of their citizens. Several proposals over the decades have tried to move the US closer to a national health care system; none were successful.
    The ACA was signed into law March 23, 2010 in an attempt to make good health care insurance affordable and available to all US citizens and legal residents. Millions more Americans now have access to affordable health care. But medical costs have continued to rise and the ACA has not been popular with large swaths of the American population. One of the campaign promises made by President Trump was to repeal and replace the ACA; replace it with something that offered better care at less cost.
    The BCRA of 2017 is the current Senate proposal. The bill promises large tax cuts and decreased government spending. I hope that I have been able to demonstrate how the proposed BRCA could negatively impact the average employed American whether they have employer sponsored health care insurance or they purchase individual insurance policies through the exchanges.
    Missing from the public dialog is discussion of the impact the proposed changes could have on working middle class families. Proposed changes that include no longer requiring employers to offer health insurance, increased premiums for older Americans, and the individual state option to request waivers of the essential benefits, out of pocket limits, or the lifetime exclusion.
    And finally, although the majority of individuals received their health care insurance via employer sponsored plans there are still millions of people who do not have access to employer provided health care. Access to good health care should be available to all Americans.

    References
    CBO, Congressional Budget Office Cost Estimate, H.R. 1628 Better Care Reconciliation Act of
    2017, CBO, Washington D.C. released June 26, 2017, accessed through CBO.gov. Last accessed
    7/10/17
    Bureau of Labor Statistics, U.S. Department of Labor, Employment Benefits in the United States –
    March 2016, USDL-16-1493; News Release, Washington D.C., July 22, 2016. Accessed through
    the Social Security website www.ssa.gov
    The Henry J. Kaiser Family Foundation, Focus on Health Care Reform, Summary of the Affordable
    Care Act, Palo Alto, CA, modified April 23, 2015. Last accessed through the Kaiser Family
    Foundation website on June 27, 2016
    The Henry J. Kaiser Family Foundation, Compare Proposals to Replace the Affordable Care Act,
    Palo Alto, CA. Last accessed through the Kaiser Family Foundation website on July 10, 2017
    Field MJ, Shapiro HT, editors, Institute of Medicine (US) Committee on Employment Based
    Health Benefits, Employment and Health Benefits: A connection at Risk. Chapter 2. Origins and
    Evolution of Employment Based Health Benefits, Washington DC: National Academies Press
    (US); 1993. Accessed through the www.ssa.gov website)
    Reed LS, Private Health Insurance in the United States: An Overview, December 1965;
    Washington DC; 1965. Accessed through www.ssa.gov/policy/docs/ssb/v28n12p3.pdf

  • Prevention: Health Means More than Healthcare

    What Prevention Elements are Necessary for a complete Arizona Health Care Plan
    Mary Ellen Cunningham MPA, RN
    Arizona League of Women Voters-Metro Phoenix
    June 2017

    As Congress examines and modifies health care insurance, it is important to understand that the desired outcome of these strategies and policies is health for the Nation. According to the World Health Organization, health is ‘not just the absence of illness but mental, social and physical well being’.1 Optimal health requires preventive efforts, not solely acute care.

    The nation’s public health agencies; national, statewide or local, work to prevent population level disease outbreaks including Zika or measles as well as supporting individual prevention efforts which could include obesity or unplanned teen pregnancies. Congress has long funded public health prevention efforts. Many of these efforts were folded into the Prevention and Public Health Prevention Fund (PPHF), which later became a part of the Affordable Care Act. In Arizona, this funding is used to help support immunizations for children, infectious disease prevention and control programs and projects, Arizona’s public health lab, childhood lead poisoning prevention and programs for prevention of chronic diseases, such as obesity, diabetes, heart disease and smoking.

    The Affordable Care Act also recognized the importance of wellness by including the requirement that Essential Health Benefits are included in policies. By including these elements in every health plan, families or individuals would not have to make hard choices because of cost when they selected insurance plans, for instance having to elect to not include maternity care or behavioral health services. The essential benefits captured the services that families needed to be able to access care and at the same time stay solvent if and when they were faced with a life event like a pregnancy or an injury that required rehabilitative services. Many people do not consider, especially in their youth, that they will ever be faced with a catastrophic injury or illness.

    States were given the freedom to select their package of required benefits. Arizona chose to use the state employee health plans as a model. The mandated Essential Health Benefits include (1) ambulatory patient services; (2) emergency services (3) hospitalization; (4) maternity and newborn care; (5) mental health and substance use disorder services including behavioral health treatment; (6) prescription drugs; (7) rehabilitative and habilitative services and devices; (8) laboratory services; (9) preventive and wellness services and chronic disease management; and (10) pediatric services, including oral and vision care. 21 Preamble to the Constitution of WHO as adopted by the International Health Conference, New York, 19

    The Center for Consumer Information & Insurance Oversight, Information on Essential Health Benefits (EHB) Benchmark Plans. Retrieved from: https://www.cms.gov/cciio/resources/data-resources/ehb.html

    Beyond the risk of loss of the Essential Health Benefits, both of the newest health care proposals from the US House and Senate also completely eliminate the Prevention and Public Health Fund (PPHF). It is important to know that some of these funds date from the late 1980’s. The nature of a block grant means states choose their own priorities based on the data and direct funding and programs towards those priorities. It would be fair at this point to ask why is this important? Why should we care? That may be more clear after we look at some of the leading causes of death and disability in Arizona and where some of these essential health benefits and prevention efforts would make a difference. The following is a short description of some of the health statistics for Arizona including teen birth, infant mortality and the leading causes of death for major age groups. According to Arizona Department of Health Services, Teenage Pregnancy Arizona Report 2015, Arizona’s teen pregnancy rate decreased from 32.7 in 2005 to 15.9 in 2015, a decrease of 51.3 percent. The pregnancy rate for the youngest teen, from 15-17, decreased from 39 in 2005 to 14.1 in 2015, a decrease of 63.9 percent. That means a decrease of 4,790 to 1,887 pregnancies of teens between 15-17 years of age in that decade. 3

    There are several factors attributed to the decrease in teen pregnancies from the downturn in the economy to the effects of prevention programs and the availability of Long Acting Reversible Contraceptives (LARC), accessible during a preventive health visit. 4

    Access to reproductive health planning and in fact access to preventive health visits (Ambulatory services) afford care providers the opportunity to discuss a woman’s reproductive plans and address any chronic health issues.5 Discussing a woman’s health before she becomes pregnant is referred to as preconception or interconception health. Almost half of all pregnancies in the United States are unplanned. When a woman becomes pregnant without planning she can start that pregnancy with undiagnosed or unmanaged diabetes or STDs for example. Unplanned pregnancies are at greater risk of delivering preterm or low birth weight babies. 6 Prevention funds in the ACA have also supported Teen Pregnancy Prevention programs in Arizona and nationally. 3 Teenage Pregnancy Arizona 2005-2015, Arizona Department of Health Services.
    Retrieved from: http://pub.azdhs.gov/health-stats/report/tp/2015/tp2015.pdf
    4 Patten, E., Livingston, G. (2016, April 29). Why is the teen birth rate falling? . Retrieved from: http://www.pewresearch.org/fact-tank/2016/04/29/why-is-the-teen-birth-ratefalling/
    5 Women’s Health.gov. Preconception health. Retrieved from:
    https://www.womenshealth.gov/pregnancy/you-get-pregnant/preconception-health
    6 Dean,S. , Elizabeth Mary Mason, Christopher P Howson, Zohra S Lassi, Ayesha M Imam, and Zulfiqar A Bhutta. Reprod Health. 2013; 10(Suppl 1): S3. Published online 2013 Nov 15. doi: 10.1186/1742-4755-10-S1-S3PMCID: PMC3828587Born Too Soon: Care before and between pregnancy to prevent preterm births: from evidence to action. Retrieved In 2015, Arizona’s infant mortality rate was 5.6, a decrease of 9.9 percent from 6.2 in 2014.7 According to the Arizona Health Status and Vital Statistics 2015 Annual Report, the leading causes of death to Arizona’s infants were congenital malformation and prematurity, followed by suffocation, often related to an unsafe sleep environment.8 Arizona’s Safe Sleep program helped reduce the rate of unsafe sleep-related deaths ten percent from 82 deaths in 2014 to 74 deaths in 2015. 9 These efforts included a media campaign and the concerted efforts of physicians, nurses, home visitors and care providers to educate families about safe sleep practices. Arizona’s prematurity rate decreased from 10.8 in 2005 to 9.0 in 2015, below the Healthy People 2020 goal. 10 Maternity care allows pregnant women to access the services they need to support a healthy pregnancy, which increase the chances of a healthy baby. Time with a care provider also allows for education of critical newborn care including safe sleep practices. This education is also reiterated during newborn care visits. The Arizona Health Status and Vital Statistics 2015 Annual Report tells us that the five leading causes of death for children from 1-14 from 2005-2015 were accidents or unintentional injuries including motor vehicle accidents and drowning, cancer, congenital malformations, homicide, and suicide. 11 The five causes of deaths among adolescents aged 15-19 over the same decade were unintentional injuries including motor vehicle accidents, intentional self harm also referred
    to as suicide, homicide, cancer and heart disease. 12 from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3828587/
    7Arizona Health Status and Vital Statistics 2015 Annual Report. Retrieved from:
    http://pub.azdhs.gov/health-stats/report/ahs/ahs2015/pdf/chptr2a_2d.pdf
    8 ibid
    9 Arizona Child Fatality Review Program Twenty Third Annual Report, November 15, 2016. Retrieved from: http://www.azdhs.gov/documents/prevention/womens-childrenshealth/
    reports-fact-sheets/child-fatality-review-annual-reports/cfr-annual-report-
    2016.pdf
    10 Healthy People 2010 MICH-9.1 Reduce total preterm births Target 11.4 Retrieved from:
    https://www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-childhealth/
    objectives
    11 Arizona Health Status and Vital Statistics 2015 Annual Report. Retrieved from:
    http://pub.azdhs.gov/health-stats/report/ahs/ahs2015/pdf/text_children.pdf.
    12 Arizona Health Status and Vital Statistics 2015 Annual Report. Retrieved from:
    http://pub.azdhs.gov/health-stats/report/ahs/ahs2015/pdf/2c11.pdf.

    In 2015, 768 children under 18 years of age died in Arizona. Arizona has had a Child Fatality Review program in existence for over 20 years. By statute, the death of every child from birth to age 18 is reviewed by multidisciplinary teams to identify trends in preventable child deaths. According to the Twenty Third Annual Report,13 almost 40 percent of these deaths were preventable. The leading causes of preventable deaths were prematurity, suffocation, generally related to unsafe sleep for infants, drownings, motor vehicle crashes and firearm injury. Early childhood home visiting programs, funded through the ACA, provide education and support to young families not only about early brain development but also about home safety including drowning prevention, automobile safety and gun safety. Again, when these trends are identified pediatricians and primary care providers also educate and reinforce messaging about what families can do to prevent avoidable child deaths. The leading causes of death among our young adults, aged 20-44 included accidents, suicide, cancer, heart disease and assault or homicide. 14 For middle aged adults, aged 45-64, the leading causes of death were cancer, heart disease, accidents, chronic liver disease and chronic lower respiratory disease.15 Finally, the leading causes of death for Arizona’s elderly, aged 65 and older included heart disease, cancer, chronic lower respiratory diseases, Alzheimer’s disease and cardiovascular disease. 16
    The preponderance of these leading causes of death, except for accidents, homicide and suicide, can be considered chronic disease and can be manageable. Preventive and wellness services and chronic disease management and Prescription drugs are included in the Essential Health Benefits and the Prevention and Public Health Prevention Fund supports programs to address chronic diseases. Arguably Mental health services and addiction treatment, a part of the essential health benefits at risk, would affect the loss of life or injury due to accidents, homicide and suicide. Loss of these services will leave more of our families either without access to care or exposed to catastrophic bills.

    Finally, in 2016, the death of 790 people in Arizona was a direct result of opioids. There has been a 74% increase in deaths attributed to opioids in Arizona since 2012. 17
    According to the Substance Abuse and Mental Health Services Administration (SAMHSA), in 13 Arizona Child Fatality Review Program Twenty Third Annual Report, November 15, 2016. http://www.azdhs.gov/documents/prevention/womens-childrens-health/reportsfact-
    sheets/child-fatality-review-annual-reports/cfr-annual-report-2016.pdf
    14 Arizona Health Status and Vital Statistics 2015 Annual Report. Retrieved from:
    http://pub.azdhs.gov/health-stats/report/ahs/ahs2015/pdf/2c15.pdf .
    15 Arizona Health Status and Vital Statistics 2015 Annual Report. Retrieved from:
    http://pub.azdhs.gov/health-stats/report/ahs/ahs2015/pdf/2c19.pdf.
    16Arizona Health Status and Vital Statistics 2015 Annual Report. Retrieved from:
    http://pub.azdhs.gov/health-stats/report/ahs/ahs2015/pdf/2c23.pdf
    17 2016 Arizona Opioid Report. Retrieved from:
    http://www.azdhs.gov/documents/audiences/clinicians/clinical-guidelinesrecommendations/
    prescribing-guidelines/arizona-opioid-report.pdf
    2014, while 15.7 million adults reported having a major depressive episode within the past year, almost one third did not seek professional care. National Survey on Drug Use and Health (SNSDUH) data also shows that of the over 21 million people over age 21 who needed treatment for a drug or alcohol problem, only about 2.5 million people received this treatment. 18
    The Institute of Medicine and National Research Council’s 2009 report Preventing Mental, Emotional, and Behavioral Disorders Among Young People which is referred to in the SAMHSA.gov/prevention web page tells us that for every $1 we spend on prevention of substance abuse and mental illness we could save $2 to $10 on treatment. 19 A poignant reminder from the report introduction reads: “As a society, we suffer from a collective health care myopia: we have not figured out how to balance rescue ___which is after-the fact treatment___ with the less dramatic but often far more cost-effective and socially desirable prevention of a problem.” 20
    After reviewing the causes of death and disability for Arizonans, it is clear that ensuring access to care, which includes the elements of the Essential Health Benefits and prevention funding can ensure more general wellness for our families; helping to reduce premature birth and death or disability from a treatable chronic disease. This will lead mental, social and physical well being for all Arizonans.
    18 SAMHSA Behavioral Health Treatments and Services. Retrieved from:
    https://www.samhsa.gov/treatment
    19Prevention of Substance Abuse and Mental Illness. Retrieved from:
    https://www.samhsa.gov/prevention
    20 O’Connell, M.E., Thomas Boat, and Kenneth Werner, Editors. Preventing Mental, Emotional and Behavioral Disorders among Young People: Progress and Possibilities. Committee on the Prevention of Mental Disorders and Substance Abuse among Children, Youth, and Young Adults: Research Advances and Promising Interventions. National Research Council and Institute of Medicine. (2009). Retrieved from:
    https://www.nap.edu/read/12480/Chapter/1

  • Medicaid: The history of Medicaid and how the ACA affects it.

    MEDICAID
    By Marjorie Dion, M.A., LWVNWV, June, 2017

    Prior to the Industrialized Age, people who were ill were treated by family members, itinerant doctors, or just plain quacks. Although there were hospitals, these institutions were regarded as places to go to die. Medical treatments were cheap and mostly ineffective. As America industrialized, charities, often religiously based, began to offer health care to ill or injured workers paid for by donations and employers. These charities often helped the less fortunate as well.

    Some early forms of health insurance were introduced during the 1930’s responding to more expansive and improved medical training, and care as well as hospitalization. Most healthcare was still provided by charities.

    During and after WWII, there were dramatic improvements in both healthcare and medications. Western Europe, recovering from the devastation of war, chose to use government to help provide healthcare to their people. This resulted in various forms of socialized medicine. The U.S. chose not to go this route, fearing socialism which might lead to communism. Both political parties were in agreement with this position.

    During WWII, the foundation of our present system of employer based insurance coverage arose out of the National War Labor Boards freezing of wages and salaries. This occurred at a time of robust economic growth. Since companies could not entice new workers with better wages, they found that health insurance benefits were a highly-prized benefit. Congress soon allowed companies to deduct the cost of provided health insurance from their taxes. Between 1940 and 1955, insured employees increased from 10% to 60%. To provide this service, insurance carriers needed to make a profit. This employer based, profit motivated insurance provided the foundation of our present healthcare system.
    • The development of present-day Medicaid, occurred in 1965 when both Medicare and Medicaid were introduced through an amendment to Social Security under Democratic President Lyndon Johnson. Most Republicans and virtually all Southern Democrats opposed this change. Medicare is a federally funded program offering healthcare to citizens 65 or older. Medicaid is a program jointly funded by the federal and state governments. It was originally designed to help low income children, pregnant women and individuals with disabilities. Although initially opposed by Republicans, the Party supported this program as well as Medicare allowing both programs critical modifications over time. (An American Sickness), Elisabeth Rosenthal, Penguin Press, 2017

    MEDICAID AND THE AFFORDABLE CARE ACT (ACA) 2010
    In 2010, 48 million Americans were not covered with health insurance. Within a few years after the passage of the ACA, the uninsured number fell to 28.6 million. Today, Medicaid covers 74.6 million American adults and children. Children are covered by CHIP (Children’s Health Insurance Program). Nearly 1 in 5 Americans are covered through Medicaid: 33 million children, 10 million elderly and disabled and over 4 million in long-term care. These categories comprise a large proportion of Medicaid recipients. The program provides care for maternity and pediatric care, assistance for disabled adults and children, nursing home care as well as support services covering mental illness and addiction disorders. (http://www.kff.org/health-reform/issue-brief/medicaidmoving-forward/)

    Medicaid is funded jointly by the federal and state governments. It comprises 17% of all state budgets and 9% of all federal spending. Federal monies are received from taxes on individuals at the top percentile of American income. Additional revenues come through taxes on health insurers, pharmaceutical companies and manufacturers of medical devices. The rest of the funding is derived from state taxes. Because of their contributions, states are given wide leeway in establishing installment and administrative procedures.
    (http://www.cbpp.org/research/state-budget-and-tax/policy-basics-where-do-our-state-tax-dollars-go)

    What benefits are covered for Medicaid beneficiaries through the ACA?
    • Essential Benefits: These include coverage for maternity, emergency services, hospitalization, and include insurance for disabled children and adults as well as mental and addiction services. For (https://en.m.wikipedia.org/wiki/Essential_health_benefits) Medicaid pays for nearly half of all childbirths in America as well as 2/3rds of the care of nursing home patients. (https//: www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/nursinghome-beneficiary-factsheet.pdf )
    • Individual Mandate: All citizens must have health insurance.
    • Community Rating: People with pre-existing conditions would not pay more for insurance than those without these conditions.
    • Among many other benefits, there is an emphasis on prevention and public health support at the local, state and federal levels. Hospitals in areas with large Medicaid populations, often in rural areas, also receive additional financial support.

    The ACA expanded Medicaid coverage to childless adults with incomes up to 138% of the FPL (Federal Poverty Level). This includes individuals making $15,417 or a family of 3 making $26,347 annually. ( https://www.americanprogress.org/issues/healthcare/news/2013/04/02/58922/10-frequently-asked-questions- n/about-medicaid-expansion/ ) Thirty- two states, including D.C. joined
    increasing coverage to an additional 11million people.

    In NFIB vs. Sibelius, 2012, the Supreme Court ruled that the although the ACA was constitutional, mandatory expansion was not since it was deemed coercive. However, if states wished to join the expansion they were free to do so.

    Ninety -one percent of states that did not expand coverage are located in the South. Those not covered are: White (43%), Black (30%) and Hispanic (22%). (http://www.kff.org/disparitiespolicy/issue-brief/the-impact-of-the-cvoverage-gap-in-states-not-expanding-medicaid-by-race-and-ethnicity/ )

    The effects of passage of the ACA and its expansion are significant in terms of positive health results. For example, The New England Journal of Medicine’s 2012 study shows that for every Four-hundred and forty-seven people covered by insurance, one life is saved. With 74.5 million Medicaid citizens covered, this means tens of thousands of lives were saved.
    (https://www.washingtonpost.com/posteverything/wp/2017/01/23/repealing-the-affordable-care-act-will-killmore-than-43000-people-annually/?utm_term+.21a27fb4383e ) Those not covered under expansion would suffer as a result. American productivity could only improve with a healthier population.

    THE HOUSE OF REPRESENTATIVES PROPOSED AFFORDABLE HEALTHCARE ACT (AHCA) 2017 AND ITS EFFECT UPON THE ACA AND MEDICAID
    The AHCA Act ( https://www.vox.com/policy-and-politics/2017/5/3/15531494/american-health-care-actexplained passed by the House of Representatives in 2017 fulfilled a nearly decade old promise of Republicans to their constituents to repeal and replace the ACA. The party also wanted to eliminate, among other things, the tax liability of affluent Americans as well as insurance companies and corporations. If this bill passes in its current form, these groups would see a trillion dollar decrease in taxation over a 10-year period. The Senate version recently made some modifications allowing some taxation on the wealthy to help fund their bill, but permits tax exemptions for other entities.

    The ACA’s portion on Medicaid is costly. The AHCA would cut up to $883 billion of this cost over a 10 -year period. Supporters of the bill would also like to see the deficit cut by $137 billion over that same 10 -year period.

    Republicans would also like to increase access and secure lower premiums by allowing people to choose what health care they do or do not want. Supporters want citizens to take responsibility for their own healthcare rather than relying upon the government.

    Financial funding of the AHCA: Since federal funding would not come from taxation, financing could come through per capita caps. Starting in 2020, the federal government would provide states with a flat capped rate of funding for each person enrolled in Medicaid. This would be based upon past state history but with a lower growth metric than the actual annual consumer price index. Or states could choose a block grant from the federal government. Very basic Medicaid coverage would need to come out of the grant, but remainder monies could be used by the states for any reason. Since states have to balance their budgets annually, there could be the temptation to the use the excess to help pay for deficits. If block grants are chosen, the state has to keep them for 10 years and would be prohibited from using the money for family planning.

    Medicaid recipients covered under expansion could keep their coverage unless they drop out for 30-60 days. They could rejoin later but with a serious financial penalty.

    Insurance for these plans would wind down by 2020 with the federal government no longer funding the program. Expansion states could continue coverage, but would have to pay for it out of state funds.

    To help the neediest Medicaid recipients such as nursing home residents or disabled children and adults, federal pools would be set up. Under the AHCA a $100 billion fund for 10 years would be available. There is a general feeling by legislators that more money would be needed.

    Other AHCA changes to the ACA impacting on Medicaid:
    • The Individual Mandate requires all Americans to have health insurance would be abolished. Pre-existing conditions under Community Rating could be offered, though states would be allowed to waive out of the insurance. This omission would allow insurers to increase premiums for people with pre-existing conditions.
    • Pre-existing conditions under Community Rating could be offered, though state have the option to waive of this coverage. This omission would allow insurers to increase premiums for people with pre-existing conditions.
    Essential Benefits would be covered unless a state wishes to waive coverage. If waived, maternity and newborn care as well as mental health would no longer be covered. Substance abuse disorders, including opioid addiction which alone killed 59,000
    Americans in 2016, would be eliminated.(https://www.nytimes.com/interactive/2017/06/05/upshot/opioid-epidemic-drugoverdose-
    deaths-are-rising-faster-than-ever.html ) The result of not having this coverage would be deadly. Additionally, Medicaid recipients would be unable for one year to use Planned Parenthood which provides health services in hundreds of communities, including rural areas, around the country. Decades ago, the Hyde Amendment disallowed federal funds for abortions, so this is not the reason why Planned Parenthood was prohibited. (https://peltiertech.com/chart-busters-what-plannedparenthood-
    actually-does/)

    • Older Americans could be charged more than 5 times more than a younger person for healthcare. For example, a 64-year-old man making $26,500 would pay $1,700 for coverage under the ACA due to subsidies. Under the AHCA, his annual premium would be $14,600.
    (http://money.cnn.com/2017/03/13/news/economy/cbo-premiums-republican-health-careplan/
    index.html)
    • Work Requirements: With certain exemptions (children, the elderly, disabled and pregnant women), all Medicaid recipients would be required to get a job. This requirement appears to pre-suppose that Medicaid is a welfare program, not a form of social insurance. There is a clear implication that recipients do not work or may not be willing to work. However, over 60% of non -disabled adults do work. Their jobs are low paying and do not offer health insurance or, if offered, is too expensive for these workers to purchase. Those who don’t work often face significant roadblocks, lacking reliable transportation or child care. Others may be caring for ill or elderly family members. Some may have criminal records making it difficult to get work. ( https://www.nytimes,com/2017/02/25/health/medicaidwork-
    requirement.html) Administration of these work requirements would be costly.

    CBO REPORT ON THE AHCA:
    In 2018 14 million more people will be uninsured under the AHCA than the ACA due to projected higher premiums and repeal of penalties associated with the Individual Mandate. In 2026 that number will rise to 23 million people uninsured. Bottom line: In 2026, an estimated 51 million people would be uninsured compared with the 28 million who would lack insurance that year under the ACA.

    OBSERVATIONS:
    Popular attitudes towards continuing funding Medicaid are very positive across the country. Governors from both parties, the AMA, hospitals and patient advocacy groups are all in favor of securing some form of Medicaid similar to the ACA. (http://www.kff.org/health-costs/report/kaiserhealth-tracking-poll-may-2017-the-ahcas-proposed-changes-to-health-care/)
    Uninsured people, with few other places to go, would increase the usage of emergency rooms for their health care. There would be little or no follow-up care. In 2006, before the ACA, approximately 120 million Americans sought help in emergency rooms each year. Almost 400,000 waited 24 hours or more. ( http://abcnews.go.com/Health/story?id=5884487&page=1) Similar numbers could be expected with the AHCA.

    Governors of both parties are requesting the Senate to reconsider what would happen to people currently on Medicaid under the House or Senate proposals and the ensuring higher premiums projected by the AHCA CBO report. The attached charts illustrate what could happen to recipients by age and state. (http://www.huffingtonpost.com/entry/democratic-and-gop-governors-urgesenate-to-rethink-healthcare-bill_us_59442a7ee4b01eab7a2d8cb9)

    Rural and small-town Americans would be hit the hardest by the AHCA. Arizona, for example, has about 20% of rural adults on Medicaid as well as 34% of its entire population on Medicaid. That population includes 45% of children. “…rural counties make up Medicaid Country”
    (http://khn.org/news/gop-medicaid-cuts-hit-rural-america-hardest-report-finds/)

    American healthcare is the most expensive in the world with results that do not compare well with other Western healthcare systems. Neither the ACA or the AHCA addressed this crucial issue. The U.S., alone among developed countries, has no mechanism to explain prices for medical procedures. Most institutions involved, including insurance carriers, hospitals, pharmaceutical companies and device manufacturers, establish their own prices. The goal of these costs is to make a profit. Why does one person’s Echocardiogram cost $1,714. In Massachusetts, $5,435 in New Jersey and less than $100 in Japan? Another example is in skyrocketing drug costs. “Approved in 1996, Avonex was expensive, about $9,000. a year. Today, two decades later, it is no longer the latest thing—but its annual price tag is over $62,000.” (http://www.cnn.com/2017/06/26/opinions/us-health- prices-rosenthtal-opinion/index.html ) Who can even decipher a hospital bill? Patients with insurance are often unaware of what procedures cost and do not have the wherewithal to do comparison shopping.

    American health care is expensive, but are outcomes worth the price? In this year’s survey, the Commonwealth Fund ranked the U.S. dead last compared with 10 other Western Countries on many outcomes. For one thing, there are few uninsured in Europe, while millions in the U.S. lack access to care due to the cost of premiums. In fact, the US has the worst rate of maternal deaths in the developed world at 26.4 per 100,000 live births. rates range from 9.2 (UK) to 3.8 (Finland). ( http://www.npr.org/2017/05/12/528098/u-s/has-the-worst-rate-of-maternal-deaths-in-thedeveloped-world) “The most notable way the U.S. differs from other industrialized countries is the absence of universal health insurance coverage…Unfortunately, many still equate “universal healthcare” with “Government run” or “single payer” healthcare”. It isn’t”. (https://www.forbes.com/sites/danmunro/2014/06/16/u-s-healthcare-ranked-dead-last-compared-to-10-othercountries/ )The U.S. does rate first--on costs.

    Rising death rates: Nearly 45,000 deaths each year are associated with lack of health insurance. This rate could rise according to the projections of the increased numbers of uninsured in the 2017 CBO report on the AHCA. The American Journal of Public Health, citing a study conducted at Harvard Medical School and the Cambridge Health Alliance, showed that “uninsured working age Americans have a 40% higher risk of death than their privately insured counterparts. ”(http:/news.harvard.edu/gazette/story/2009/09/new-study-finds-45000-deaths-annuallylinked-to-lack-of-health-coverage/ )

    There is also a prevalent feeling among many politicians and their supporters that healthcare is not a right but a privilege. They say if people live a healthy life style, premiums would be lower and more affordable. Those who do not live a healthy life style then would and should have higher premiums. This opinion leaves out the fact that even healthy people can get cancer or Alzheimer’s, or any number of illnesses. A skimpy policy can spell disaster for a healthy person.

    Gutting Medicaid as could happen under the AHCA and current Senate proposal could have life and death consequences for people currently on Medicaid. A healthy population contributes greatly to a healthy economy.

IMPROVED MEDICARE FOR ALL
in the News…

RESOURCES

  • CALL TO ACTION!
    Fix It movie handout

    What Can I Do
    To help pass Single Payer/Expanded and Improved Medicare for All?

    Get Involved - Take Action - Make reform happen!
    Be an advocate for Medicare for All - Help educate your friends & colleagues
    Be an informed voter - Be heard - VOTE! Hold your elected officials accountable

    Every single person is important to make change happen. No matter the level of involvement, every action becomes part of the force that eventually creates change. Only doing nothing ensures that change will never happen.

    1. If you think the movie "FIX IT-Healthcare at the Tipping Point" is educational and helpful, host a showing in your home and/or ask an organization to show it.

    2. Continue to do further research to educate yourself. Read articles posted online at Physicians for a National Health Plan web site: www.pnhp.org; and
    www.healthcare-now.org

    3. Regardless of what candidate wins this Presidential election, they have all vowed to change our present healthcare system.
    A. Republicans have all vowed to get rid of the Affordable Care Act (Obamacare); find out what are they going to replace it with.
    B. Democrats have vowed to build on it. Research what each candidate is proposing.
    C. Write your candidate of choice and recommend they research the facts about Single Payer/Medicare for all; ask them to support cost-effective, comprehensive universal healthcare, a concrete example being U.S. House Resolution 676*, the "U.S. National Health Care Act or the Expanded and Improved Medicare for All Act". (See details below)
    D. Vote carefully for all candidates.

    4. Share the facts about Single Payer and advocate for its passage by writing letters to the editor of newspapers, magazines, and newsletters.

    5. Encourage your affiliated groups/organizations to support bills advocating Single Payer and pass a resolution endorsing HR 676*, the United States Universal Health Care Act.

    6. Talk to your elected officials, City, County, State, and Federal, about Single Payer national health care. Educate them to its benefits. Get your city council to pass a resolution endorsing HR 676*.

    7. Urge your elected officials to work toward implementation of Medicare for All. Write, visit, or call the general switchboard for all House and Senate members, 1-866-338-1015 toll free; ask for the elected officials representing your area. Then…
    A. Ask your U.S. House of Representatives to co-sponsor HR 676*
    B. Urge your U.S. Senators to introduce/sponsor a companion bill in the Senate
    C. Write the president at http://whitehouse.gov/contact/ or call the comment line at 1-202-456-1111

    Definition: "Single Payer" - "one payer-one policy" ~ one single source receives and pays all bills vs. healthcare providers having to deal with thousands of insurance plans and companies; a working example is Medicare.

    *Summary of HR 676: It would institute a single payer health care system, expanding and improving the present Medicare system and making it available to every citizen. It would end deductibles, co-payments, the problems of the uninsured/ underinsured, and the expensive overhead of employers who provide insurance to their employees. It would cover all necessary medical care including prescription drugs, primary and preventive care, hospital, outpatient services, dental, mental & home health, physical therapy, rehabilitation (including substance abuse), vision, and long-term care.
    You could chose your doctors and hospital. You and your doctor would decide on the best treatment for you vs. having an insurance company dictate it. It would save billions annually by negotiating lower drug prices and eliminating the high overhead and profits of the private health insurance industry and HMOs. Presently 30-35% of your health care premiums are wasted on CEO salaries, advertising, and paperwork. Under a simplified Single Payer system like Medicare, only 3-5% is spent on overhead leaving 97% for health care for everyone.

    Testimonial from one who served on the frontlines: Most physicians are, unfortunately, only too familiar with the complexities and injustices of the present health care payment mess. (I hesitate to use the word "system.") During my decades of medical practice, I have seen this mess evolve. I've known several physicians who just gave up practice because their small offices could not deal with the expense and frustration. And I have seen needless deaths because people could not afford timely medical care. I certainly would like to see the U.S. adopt a single payer system for health care. It's logical, and works well in the rest of the civilized world.

    Laurence R. Simson, Jr, M.D., Former Adjunct Professor, Michigan State University, Former Forensic Pathologist and Chief of Medical Staff @ Sparrow Hospital, Lansing, MI

  • COLORADO CARE
    The economics of ColoradoCare: Theory and Practice

    The Economics of ColoradoCare: Theory and Practice

    Anders Fremstad, Assistant Professor
    Economics Department, Colorado State University

    This year Coloradans have the opportunity to vote “yes” on Amendment 69 and ensure that all Coloradans receive healthcare when they need it. Amendment 69 would replace our inefficient private insurance system with a single cooperatively-run insurer, which would cover Coloradans in the same way that Medicare covers our seniors. ColoradoCare would be funded primarily by a new payroll tax. No one likes to pay taxes, but ColoradoCare would cost employees just 3.3% of wages and employers 6.7% of wages – significantly less than most workers and businesses spend now on private insurance premiums, deductibles, and copays. Voters can use ColoradoCare’s online calculator to see how the measure would impact their bottom line.
    The opposition to Amendment 69 claims that ColoradoCare would be bad for the economy, but the data suggest otherwise. A careful analysis by the Colorado Health Institute, a nonpartisan think tank that has taken no stance on the Amendment, finds that ColoradoCare can cover 350,000 uninsured Coloradans and improve coverage for a million Coloradans while reducing total health care expenditures. Amendment 69 does this by eliminating the profit and administrative waste in the current system. This is consistent with international evidence, which shows that the US pays 50 percent more than countries with universal healthcare systems, but that Americans are less healthy and live shorter lives than people in other advanced countries.
    Although the data shows that ColoradoCare would be an economic boon, many critics view the plan as government intervention in an otherwise ideal market. What’s wrong with the private-insurance system, and how will ColoradoCare fix it?
    First, the market for private health insurance is hopelessly complex. There are nearly a hundred plans for sale on the health insurance exchange for Larimer county with a wide range of premiums, deductibles, copays, coinsurance rates, and provider networks. While this ostensibly gives individuals and families the ability purchase the insurance that is right for them, the fact is that most people cannot intelligently compare plans. In an experiment, only 11% of participants were able to calculate the cost of a hospital stay given a hypothetical insurance policy. A recent study shows that most people purchase plans that cost them more than an available alternative. Insurance companies carefully craft their policies to exploit the fact that we are not human calculators. ColoradoCare would give us the ability to focus on health care rather than health insurance.
    Second, the healthcare market is monopolistic, and private insurers make that problem worse. In competitive markets, like the market for bicycles or peaches, consumers choose what product to purchase. This isn’t the case in healthcare, because many communities depend on a single hospital. Health insurance companies exacerbate the issue by limiting patients’ access to narrow networks of providers. As a result, prices for medical procedures are not made public and vary enormously across providers. Knee replacement surgery in Denver costs anywhere from $14,600 to $45,200, depending on the hospital. ColoradoCare would improve transparency, reduce price variability, and let patients pick their healthcare providers.
    Third, the private-insurance creates a huge problem that economists refer to as moral hazard. For-profit insurance companies have a financial incentive to deny needed medical coverage. Insurance companies refer to what they spend on healthcare as “medical loss” because it leaves less money for corporate profit and CEO paychecks. Insurers don’t always shirk their ethical responsibility to do what is right, but if you talk to folks with serious illnesses, you’ll hear plenty of horror stories. With ColoradoCare, no one would profit from denying coverage.
    Our private-insurance healthcare system is deeply inefficient. The market for health insurance is impossible to navigate, private insurers reduce competition between providers, and for-profit insurance companies have a financial incentive to deny care. By addressing these issues, ColoradoCare is able to cover everyone for less money than we currently spend. It isn’t just ColoradoCare’s supporters who understand this. Out-of-state insurance companies are spending millions of dollars to defeat Amendment 69. Don’t let them win.

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