Sunday, February 12, 2017

Show notes::What's the big deal: repeal and replace (Pt 1)

Just an FYI, this is sorta, kinda a "work in progress".  While it includes information discussed during BTTP, there is information we didn't get to (as mentioned).  As I do more reading, I will be adding such to each part (tentatively 3 - Mini History Lesson, Some Common Arguments Against ACA, General Flaws of What's Been Offered So Far).  So in essence, this blurp is not complete, and may never be so as the discussion concerning healthcare insurance is never ending.  Part 1 is a basic transcript of the episode in question.   Parts 2 & 3 are forthcoming as I convert the content to HTML and tidy some loose ends.

While my overall intention was to show that the ACA is a Republican plan at it's root, I also wanted to provide good external commentary and resources concerning the whole debate of "Repeal & Replace".  Why it may sound like a good idea but isn't.  I do realize that my bias, liberal/progressive mixed with democratic socialism, is going to taint what I present (something I hope to counter in the near future by offering commentary from the "other side") but I believe it is good, solid information in favor of "fixing" the perceived problems; instead of scraping the ACA leaving people vulnerable.

That is the real issue.  IF the ACA is repealed, with no replacement set, people are going to be dangerously vulnerable. (A vulnerability some within the GOTP don't care about,,, read the Bloomberg articles and you will understand why I say that.)  We cannot go back to pre-ACA days, and looking at the history as a whole, the intention of universal coverage was at one time a GOTP goal - WTF happened?

Also note that this does not address concerns of small and large businesses.  From precursory reading, that would add a whole other dimension to this conversation that I personally am not versed in. 

1] Why this episode?
I had been doing some FB postings, as well as general comments and IRL discussions, concerning the issue of "Repeal and Replace". While I have no issue in the idea of R&R, IF the Repugs had something comparable to replace it with, but the loss of insurance is too real an issue for me personally as well as many others.
I am 56 years of age, a former marathon runner and physical therapist by profession. Four years ago I became plagued by chronic health conditions that have rendered me to the side-lines: Severe intestinal perforation with sepsis + ileostomy; Addison's disease; Complete pituitary failure; Avascular necrosis of both hips and jaws. I am on Palliative Care. I receive no government assistance, as my finances are healthy. But I do purchase medical insurance through the ACA. I receive no federal subsidy and pay and full premium due.

I am eternally grateful to the ACA and its provisions. Without its protections for pre-existing conditions and no lifetime cap I would be "in a pickle." I am a high consumer of health care.

With fear of the repeal of the ACA, I am in a worse "pickle." I fear that I will be without comprehensive coverage and that my savings will be on course for fast-track depletion. I will honestly consider suicide.  
When people hear my "story" the reaction is WTF. Sadly what the Repugs are offering is junk and it will kill me and many others. I am not being hyperbolic in that assumption. IF I lose my insurance, I lose access to my medication (medication I cannot afford otherwise). Without my medication, I'm dead or really fucked up. End of story.

There is a lot of information and misinformation and what I have found is many do not understand what the Repugs are offering instead of the ACA. Instead of straight forward language, what the GOTP offers is couched in very vague language (ie. "access" vs "guaranteed" which we will touch on later).

Before we delve into the nitty-gritty,,,

2] Mini History Lesson
The reasoning, will become obvious, but it comes down to this argument being an old issue. Unless you have been hibernating in a cave far from civilization the past 6 yrs or so, we have what is called the PPACA (Patient Protection and Affordable Care Act) or better known as Obamacare (and yes peoples, they are the exact same thing. The ACA is not some replacement spun together as a quick fix for Obamacare.)

I know I am not the only one, but this is what I face on almost a daily basis,,,

Along the same line of thinking, how stupid are people, Kentucky counties with highest Medicaid rates backed Matt Bevin, who plans to cut Medicaid The 66 percent of Owsley County that gets health coverage through Medicaid now must reconcile itself with the 70 percent that voted for Republican Governor-elect Matt Bevin, who pledged to cut the state's Medicaid program and close the state-run Kynect health insurance exchange.

This is a pre-election story concerning KY, Bevin, and Kynect. The gist,
From the earliest days, Kentucky’s efforts to implement Obamacare have earned national acclaim. As the troubled roll out of the national health care exchange website was ruthlessly mocked by late night television, Fortune praised “one health exchange success story”: Kentucky’s new state-level marketplace.
During the past 6 yrs or so, the GOTP has attempted to repeal the ACA some 60+ times (at a total cost of $40+ mill) and failed, as they did not have the votes to override the pending veto of President Obama. Recently, due to the election results that has changed, and the orange man in charge has stated he will sign the repeal.

So we have a quagmire,,,

But first some caveats.
  • There is no solid time table as to how things will proceed could be 3 months it could be 3 years. While I have seen some GOTP estimates of end of Feb 2017, TBH I have no fucking clue exactly what they mean. IOWs do they plan on having a "replacement" set and ready to go on March 1 and how exactly will it be "rolled-out". Implementation, as far as I can tell, has not been discussed in any detail. (That alone should be a marker of how serious the GOTP are concerning replacement. IMO, all they want to do is get rid of Obamacare, fuck everything else!!)
  • There are 3 6 possible replacement plans that have been put forth so far, none with much detail other than from a fiscal standpoint, they will all crash and burn and they do not offer the same coverage as the ACA. In order to lessen cost they have cheapened the benefits.
  • We are presenting worse case scenarios, my situation the example of choice. There are too many "ifs" involved to look at it otherwise
With that said, some have ask me why I am making such a big deal out of something I cannot control and don't have all the facts. This is why,,,
  • You see people need to be prepared. Even if the worst doesn't come about. Like myself, many individuals can not be scrambling at the last minute to secure their medications or treatments. They will cut you mid-stream, and you will be left in the lurch.
  • People have to be informed of what is transpiring (and trust me, some people I know have no fecking clue as to what has been going down) so that maybe, some how,,, we can push things till 2018 and hopefully make corrections. It's not just healthcare either,,, SNAP, Medicaid, CHIP, Medicare, Social Security, and many other social safety net programs are on the chopping block as well as drastic changes in how, many programs are going to work. (Case in pt: Carson hates HUD, DeVos hates public Education, dude slated to be in charge of FDA hates the FDA)
FYI the Post-Gazette article, below, is enough for the gist concerning history and all you would need to read. These are just other sources I read,,,
A. The earliest of attempts at healthcare began with the 1854 Bill for the Benefit of the Indigent Insane and in 1865-1872 the Freedmen's Bureau. While the BBII passed both the House and Senate, at the time, it was eventually vetoed setting precedent for 70 years concerning federal non-participation in social welfare. The FB was part of early reconstruction of the South and faced a similar backlash that is still prevalent today, it "would prevent freed slaves from becoming independent by offering too much assistance."

B. It wasn't until the 1910s that a push for compulsory gov't run insurance began although it was in constant battle with the industrial sickness insurance available through employers. What is important to take from this period, (The Post-Gazzette link is being quirky, this is the title of the article: BUILDING A HEALTHIER PITTSBURGH: Rethinking the way we pay for care -- How did America end up with this health care system?)
Like much else about our nation, employer-based health insurance has roots in our industrial past. In the decades after the Civil War, those who worked in the most dangerous jobs — mining, steel, railroads, riverboats, lumber — had access to company doctors, on the company’s tab, often in “industrial clinics” or in union-operated infirmaries. As insurers grew more sophisticated, they began selling “accident” policies that included disability, death and burial benefits to employers. The policies didn’t resemble the health coverage we know today, but the precedent of businesses having a stake in the well-being of their employees was established.

As unions grew more powerful in the late 1800s, they began taking out their own sickness protections, having realized that “employed persons needed economic protection against the unforeseeable losses” created by illness and accidents,,, 
It was the latter that took precedent with Montgomery Ward soliciting what is now considered the nation’s first multi-employee health insurance policy, through the London Guarantee and Accident Co. of New York. As the Post-Gazette notes, the
The country was years away from a health plan that would directly pay for the actual hospitalization and medical care of workers. That no such plan existed was partly because there was no cohesive health care “system” to speak of in the early 1900s, and most health care — even primitive surgery — often still happened in the home, not a clinical setting. Of the care that was available, mostly for infectious diseases and traumatic injuries, much of it was unscientific by today’s standards. With some exceptions, hospitals were mental wards and homes for the indigent, operated by nurses and nuns, treating only specific ethnic or religious groups.
Even so, the science of medical care was progressing rapidly, and debate over who ought to pay for such care — and whether it was a right, or a privilege — was fomenting. Workplace reformers such as I.M. Rubinow — a doctor, the head of the American Association for Labor Legislation, a Russian emigre and a socialist — wanted “compulsory” sickness coverage that would pay for medical costs and disease prevention for all workers, modeled after similar plans taking hold in Europe. Economist Irving Fisher believed health insurance was necessary “to tide workers over the grave emergencies [and to] reduce illness itself.”
So this whole notion had a really nice start in the early 1900s, a net savings for society, but “the situation suddenly turned very, very negative.”

Modeled after what was occurring in Europe at the time, costs were deemed too high and gasp,,, "a system of universal medical coverage would be identical to 'German socialist insurance,' a grave insult in the late 1910s, now that America was at war with Kaiser Wilhelm II." According to the Post-Gazette,
Insurance companies and physicians weren’t on board, either. Doctors worried then, as now, that health insurers would have too much control over prices and practice methods; insurers worried that a system of “compulsory” health insurance would interfere with their lucrative life insurance business.
C. In the end, national compulsory insurance was dead. That didn't change until, like
everything else in this country, the Depression. By 1939, the precursor to Blue Cross and Blue Shield was formed.
,,,a group of 1,500 Dallas-area teachers offered to prepay premiums to the Baylor Hospital in exchange for up to 21 days of future care, and the forerunner to Blue Cross was born.
Soon plans would involve multiple sets of employees, covering multiple hospitals. By 1935, 19
prototype Blue Cross plans existed in 13 states. By 1939, prepayment plans were being created for physicians, too — forerunners to the modern Blue Shield.
In the West, dam workers for the Kaiser Construction Co. were among the first to have voluntary premiums deducted from their paychecks. Those premiums then were steered to an insurer, which then sent money to an on-site Kaiser doctor who treated those who were injured while working on the dams. In short, everyone — insurers as well as doctors — was paid in advance, and the program was replicated at construction sites up and down the West Coast.
D. Enter WWII and the 1942 Stabilization Act, a work of Congress designed to limit wage increases during wartime. The result, businesses can’t attract workers with higher pay so they compete through added benefits, including health insurance, which grows into a workplace perk. "[T]he era of third-party health insurance was fully underway. Insurers began adding new types of coverage — “major medical” evolved in the 1950s, vision care in 1957 and dental benefits in 1959."

But tying health care to employment naturally left out two vulnerable groups — those who are unable to work or worked in low-paying jobs without health benefits, and those who were beyond working age. And at that point is where the creation of Medicare and Medicaid come into play (1965), but not something we will cover today. We may at a future date as both are slated for drastic cut-backs and/or elimination. Just to give a bit of foreshadow, over 100 million individuals are covered by these 2 programs alone

The 1970s and 80s in regards to healthcare access was actually a quite busy time with various proposals going back and forth. While important in the over-all scheme of things, we're going to skip over that part and get right to the meat of the matter.

Blame Watergate!! (Seriously)

E. 1993/94: HRC and the Heritage Foundation
So like I said, the issue is not new, and sadly in 70 aught years we hadn't progressed much if at all. It wasn't until the 90s that another attempt was made. "Millions of Americans are just a pink slip away from losing their health insurance, and one serious illness away from losing all their savings." That according to Bill Clinton in a speech given September of 1993.

Needless to say, HRC's efforts were for naught, as the Health Security Act was basically dead before it even reached Congress thanks to an extensive lobby effort that convinced some legislators, there really wasn't a health care crisis (insurance). What is bizarre about this rejection, the mandate included in her plan, was a Heritage Foundation idea. In fact it has roots in 1986 piece of legislation known as Emergency Medical Treatment and Active Labor Act (EMTALA); signed by none other than St. Ronald Reagan.

While EMTALA was and still is a good piece of legislation it created, according to some, the problem of "free-riders" (people who would intentionally go without health insurance, knowing that federal law required hospitals to care for them anyway) which led to debate concerning individual mandates vs employer mandates in regards to required insurance policy.  This then led to a 1989, Heritage Foundation proposed plan called “Assuring Affordable Health Care for All Americans”. This plan according to source, is the "first published proposal of an individual mandate in the context of private-sector-managed health systems." (This article offers some nice backing material, well worth the read.)

So this debate surrounding Hillarycare is arduous. What it did lead to was further discussion and 2 more notable proposals that we'll just mention briefly.
  • The 1993 "Health Equity and Access Reform Today Act" which did include a "universal coverage" requirement with a penalty for noncompliance—an individual mandate—as well as subsidies to be used in state-based 'purchasing groups'
  • In 1994 the "Consumer Choice Health Security Act", again contained an individual mandate with a penalty provision; however, the mandate was eventually removed from the bill
What is very important to take out of this Hilliarycare debate, at the time of these proposals, Republicans did not raise constitutional issues with the mandate. As noted by many sources, Mark Pauly, who helped develop a proposal that included an individual mandate, remarked, “The way it was viewed by the Congressional Budget Office in 1994 was, effectively,as a tax,,, So I’ve been surprised by that argument."
Now this discussion concerning Heritage, is for those of us who are nerds, quite interesting and gets a bit convoluted. Heritage can deny the origins of the individual mandate all they want, but the fact remains, they did put out in 1989's "Assuring Affordable Health Care for All Americans". In 1993, it was embraced by Repugs as a alternative to some of the liberal health care approaches. As Newt Gingrich has been quoted as saying, “In 1993, in fighting ‘Hillarycare,’ virtually every conservative saw the mandate as a less dangerous future than what Hillary was trying to do.”

What's important to take away from this era, HRC - even though she failed - set the stage for what we have now and are soon to lose (maybe).

F. 2006: Mitt Romney a 'model for the nation"
Although Romneycare was nothing like what Heritage proposed in 93, that didn't prevent giving
credit where it was do,
Hence, when Mitt Romney designed his health plan in Massachusetts, he did so in large part with the assistance of the Heritage Foundation, especially Bob Moffit and Ed Haislmaier. “I want to begin by saying thank you to Bob Moffit and Ed Haislmaier,” said Romney at a Heritage event in 2006. “Bob and Ed worked very extensively with our team as we were developing our plan for health care.” Replied Moffit, “We’ve been honored by your request—myself and my colleague Ed Haislmaier, who’s done a lot of the work on this bill—to participate in giving our best advice and our technical assistance in designing a new and different kind of health insurance market.”
In 2006, an insurance bill was enacted in Massachusetts. The bill contained both an individual mandate and an insurance exchange. Mitt Romney's implementation of the "Health Connector" exchange and individual mandate was Heritage on steroids.
Romney had accomplished a longstanding Democratic goal—universal health insurance—by combining conservative policies. Massachusetts would help the uninsured buy private insurance; it would create a deregulated online marketplace; and it would require that everyone carry insurance. Uninsured citizens no longer would use the emergency room as a primary-care facility and then fail to pay their bills. “It’s a Republican way of reforming the market,” Romney said later that day. “Because, let me tell you, having thirty million people in this country without health insurance and having those people show up when they get sick, and expect someone else to pay, that’s a Democratic approach. That’s the wrong way. The Republican approach is to say, ‘You know what? Everybody should have insurance. They should pay what they can afford to pay. If they need help, we will be there to help them, but no more free ride.’ 
And make no mistake, Romneycare was a grand hit among Repugs.
Even in his first Presidential campaign, Romney’s health-care plan was an asset. South Carolina Senator James DeMint, the Senate’s most conservative Republican, cited it, in January, 2007, as a principal reason for endorsing Romney. “He has demonstrated, when he stepped into government in a very difficult state, that he could work in a difficult partisan environment, take some good conservative ideas, like private health insurance, and apply them to the need to have everyone insured,” DeMint said. The following month, during a speech in Baltimore, Romney boasted, “I’m proud of what we’ve done. If Massachusetts succeeds in implementing it, then that will be a model for the nation.”
So again I will say, if someone tells you the ACA is not rooted in republican thought, they are lying to you.

While important for an overall discussion of the healthcare debate, there was discussion in 2007.  Not quite germane to our discussion here

F. 2008/2009/10 the ACA or Obamacare

Enter the ACA (HR 3590) together with the Health Care and Education Reconciliation Act (HR 4872) . Together they represents the most significant overhaul of the U.S. healthcare since Medicare and Medicaid in 1965. Again for our purpose the fine details are not important as we will hit some of those as we go through the GOTP talking points.

What one has to realize, there was a lot of debate going into the 2008 election season, as both Obama and McCain had "competing" ideas for reform. As well as the prior debate between HRC vs Obama.  Our conversation is going to be very limited, but centered on this question: How do you feel knowing that, at its root, the ACA is a republican plan?

Most arguments that we hear today are base in one thing, and one thing only - as much as I hate to say it:  "Let's put the white, back in the White House."  That was a meme going around in the 2012 election season and summed up ALL the arguments against Obamacare.  How else could one explain a rejection of this point from Slate in 2007, "the United States pays roughly twice as much per capita for health care as Canada, France, and the United Kingdom yet experiences slightly lower life expectancy than those countries and significantly higher infant mortality. The problems inherent in the U.S. system of health care are literally killing people."  Those statistics have not changed much in 10 years BTW.  (And just a bit of foreshadow.  The talk now is basically "Trumpcare", the ACA stripped of its language and replaced with suitable GOTP talking points.)
The repair language was discussed by Republicans during their closed-door policy retreat in Philadelphia last week as a better way to brand their strategy. Some of that discussion flowed from views that Republicans may not be headed toward a total replacement, said one conservative House lawmaker who didn’t want to be identified.

Using the word repair “captures exactly what the large majority of the American people want,” said Frank Luntz, a prominent Republican consultant and pollster who addressed GOP lawmakers at their retreat.
As a caveat, to the above, I will toss out that while the GOTP says, via Tom Price, it "wants to build on what works and find ways to drive down costs overall so you can incentivize people to purchase health care coverage on their own.”  I personally do not see that, as their replacement ideas (HSAs, HRPs, tax rebates, etc) are not practical.  I see a total dismantling of the ACA out of spite only.

What's worse, I have yet seen what specifically needs "repair".  They talk of cost, but as you will see, premiums have been rising even before the ACA was implemented as well as not comparing apples to apples. And, as Bernie Sanders aptly points out, the solution would be to "scrap the for-profit system altogether." It does not help the GOTP's cause that they still cant agree on exactly what it is they are trying to accomplish, R&R or scrapping Ocare altogether.

As the Hiltzik notes,
Before we get into the details, such as they are, we should recognize that if one takes as the goal of healthcare policy to provide universal coverage in which everyone is “beautifully covered,” as Trump promised, then a few limitations immediately appear. Health coverage is the product of three factors: How many people are covered; the benefits provided; and the cost of those benefits. Since the 1940s, U.S. politicians and policymakers have tried to find a balance among these factors. Every effort has been confounded by the immutable facts that treating the sick costs money and treating more people costs more money. One can save money by treating fewer people, or giving the same number of people less treatment. So any politician who says he can do more for less money is almost certainly blowing smoke.
I have yet to see a proposed plan by Trump or the GOTP that takes that point into consideration.

So as you can see providing healthcare insurance has not be an easy task.  The same ole ugly arguments have been in existence since the debate began some 160 years ago.  Whether that is a good point, or sad commentary of our country remains to be seen.  But, the fact that others have overcome those issues makes me think it's a bad thing.  
The fact remains, though, the ACA of any plan enacted has been the best forward step in insuring the millions that inhabit our country.  Is it perfect? No.  Should it be scrapped per the GOTP? No.

Next we will look at some of the talking-points put forth by the GOTP and why they fail.

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