Do You Think Congress Needs More Working Class Members? Or Should It Just Be A Playground For The Wealthy?

At the end of the week, a non-political source, Teen Vogue, featured Nabilah Islam's proposal on behalf of working class candidates. It's something we discussed with Nabilah earlier as part of the Blue America endorsement process. A dedicated advocate for Medicare-for-All, his advocacy for health care for candidates is related but different. The idea is to help elect more working class candidates who, in turn, will advocate more working family-friendly policies. That's not going to happen if only relatively wealthy people can run for Congress. Her idea is pretty simple: allow candidates to use their campaign contributions for health insurance.

She wrote OpEds for both Teen Vogue and Vox. She began her piece for Vox with an all-to-familiar statement: "About four months ago, I canceled my health care plan. A couple of months before that, I put my student loans-- of which I still owe $30,000-- into forbearance. My story isn’t unique among working-class millennials in the country. But what sets me apart is that I had to do all of this because I decided to run for Congress... I’m here to tell you what I’ve learned: Political campaigns are often a pastime for the wealthy, meaning they’re off-limits for working-class people with backgrounds like mine. Let’s start with the fact that it’s nearly impossible to run for Congress while holding down a job. Campaigning is a full-time endeavor that requires having enough money to live without a salary for months on end. It also usually means paying out of pocket for health insurance, forgoing money that could have been put toward a retirement account, buying a house, or caring for loved ones.

All of this might be fine if you’re independently wealthy, but that’s not me. I grew up in Gwinnett County as the daughter of Bangladeshi immigrants, attending Gwinnett public schools. My father was a file clerk with the IRS for nearly 30 years, and my mother has worked multiple low-wage jobs all my life. I worked odd jobs as a teenager and in college, putting myself through school and helping my family make ends meet.

I never thought I was electable. But 2018, the year we elected the most diverse Congress in history, showed me that “electability” is a myth. So I came back home and worked really hard to put together a grassroots campaign.

And yet, hard work isn’t enough. People like me can do everything in their power to cut costs and climb the ladder, and still find themselves at the bottom financially.

I thought I would be able to hold down a part-time job waitressing or driving for Uber while campaigning, but the demands-- calling and meeting with voters, attending events across my community, pursuing endorsements-- became too high. For a while, I was paying out of pocket for a junk health care plan. It was unfortunately the only plan I could afford, especially since Georgia has refused to expand Medicaid. I knew the plan wouldn’t do much for me if I got sick or got hurt on the trail, so eventually, I canceled it. Having no income also means I’ve eaten enough packets of dollar ramen to last a lifetime.

My situation is difficult, but it’s not unique. Working-class people don’t usually run for Congress, and when they do, they often find themselves struggling like I am. It’s hard to build up independent wealth if you aren’t paid fairly, and women and people of color are disproportionately impacted by the wage gap. I’m struggling to support just myself, and I know it would be nearly impossible for me to continue my bid for Congress if I had a family to care for too. It’s no wonder nearly 40 percent of Congress members are millionaires. Three of my competitors in this race have spent more than $250,000 to self-fund their campaigns.

If we don’t eliminate barriers that prevent candidates from supporting themselves while running for federal office, we’ll continue to see a Congress that’s largely composed of wealthy, older white men. Americans will be deprived of representation by people who understand their lived experiences, and will continue to struggle under mounting student and medical debt.

The Federal Election Commission currently doesn’t allow candidates to use campaign funds for health care. I’m challenging the FEC to change its rules and to explicitly allow working-class candidates to use campaign funds to pay for health care, so at least one hurdle to running for Congress is eliminated for the non-wealthy.

I have hope that the FEC’s position will change. Liuba Grechen Shirley, an activist and founder of Vote Mama, successfully petitioned the FEC to use campaign funding for child care costs in 2018 while running for Congress, and it’s why I’m hoping to change the face of health care funding for candidates for years to come.

Running for Congress has taught me that the process is not designed for the working class. It’s also taught me that voices like my own are badly needed in the House of Representatives. And that starts with creating a system where people like me can run in the first place.

She's been reaching out to progressive members of Congress for advice and support. Today Ro Khanna announced his endorsement for her campaign. Iron worker and former congressional candidate Randy Bryce told me yesterday that "It’s tough enough finding an everyday working person willing to put their life on pause for a while in order to run for Congress but most of us can agree that we need more working people to be elected to Congress. There are already quite a few hurdles. Money is probably the biggest. Not only do we need it to fund a campaign but we need it to pay our bills and it needs to come from a different source. Too many live paycheck to paycheck. One of the biggest worries is health care. Imagine having an amazing campaign that comes screeching to a halt because the candidate can’t afford to go to the doctor? Until we have Medicare for all this is going to be an issue. Appears most of those running for office who would benefit from being covered the most have a M4A platform to make sure all of us have health care. It says a lot to oppose a candidate being allowed to cover their health insurance while expecting them to take care of their staff. We can take care of everyone and we should be looking for ways to remove the hurdles if we really want to see people like us representing people like us. If we don’t we’ll keep having people elected who just view us as money farms.And we still won’t be able to afford to see a doctor ourselves."

I asked some of the other Blue-America endorsed candidates what they think about Nabilah's proposal. Kara Eastman is running for the second time in the Omaha swing district (NE-02) and she's experienced this already. "When I decided to run," she told me, "people told me to pull out my 'Rolodex' and call my friends and ask them for money. As a nonprofit CEO, I asked 2 questions. 'What is a Rolodex?' And 'how will I fund my race with the $50 each one of my nonprofit friends and colleagues can afford to give me?' As a mom, and the primary breadwinner in my family, running is and has been a sacrifice. The system is set up for wealthy people to run since the average net worth of a sitting congressperson is $1 million. Before we finally get around to getting money out of politics, we need to make running more attainable for regular working people. Allowing candidates to use funds for healthcare and childcare would certainly help."

This is Robin Wilt's first congressional campaign, but not the first time she's run for office. "Today, the majority of members of Congress are millionaires," she reminded me, "and the typical congressional representative has an estimated net worth of over $500,000-- roughy fives times the median US household net worth. At the same time we are more likely to be represented by a member of the financially elite, running a Congressional campaign has become increasingly costly. If we don’t want running for and serving in Congress to be exclusively the province of the wealthy-- those who don’t have to pay a mortgage, college tuition or student loans, or other every day real-life expenses-- we need the campaign finance rules that allow fundraising to relieve some of the burdens that are associated with running for office. If more people like Nabilah ran for office, we would have more representatives that share our priorities-- like Medicare for All and legislation to remove money from politics. That’s why we need more people like Nabilah in Congress that share the average Americans experience!"

California Central Valley progressive Kim Williams told us last night that she "grew up in Nabilah’s home county, and I’m behind her 100%. She is spot on when she says that the candidates we need are hampered by a system that supports the candidates we don’t. Like her, I’ve had to make hard choices. I’m a single mom, and I’ve had to maintain my full-time job to support my child. This means I start my day at 4:00 a.m. to get a jump on my day before work and then I drive to events all over the district in the evenings and on weekends. But I have great hope that the system will change, and I know every working class candidate that makes it into office will fight to make sure those behind them have a fair shot. It's why I back Nabilah’s proposal and why I support publicly funded elections."

Rachel Ventura, the Will County reformer running for Congress against New Dem multimillionaire Bill Foster: "I certainly agree with Nabilah that we need to allow candidates to use campaign funds to pay for healthcare. In my first two campaigns I went without insurance and it was unsettling. Working people have it much harder than the 40% of Congress that fall into the millionaire category. The only way we are going to take our democracy back is to build a powerful grassroots movement that can propel working people into the halls of power without corporate campaign contributions. I look forward to fighting alongside Nabilah to pass a Medicare for All system and transform our political system to being one that serves all Americans."

"Running a campaign while working full time," said Arizona progressive and labor activist Eva Putzova, "is almost unheard of and even that is a privilege most people don't have-- they don't have an understanding employer that allows a candidate to flex their time to run. We need a complete overhaul of the campaign finance law and we need campaigns to be publicly funded-- to ensure that it's not just rich and corrupted to have a chance to represent us in Congress. Until we have such system, the campaign finance law should allow candidates to raise money to reasonably replace their income and non-wage benefits, including healthcare."

The Crazy Republican Party War Against Health Care

Yesterday CNN interviewed John Kasich, who was in Munich for a security conference. Among other things, they asked him about Paul Ryan's and the House Republicans' plans to take away health care from millions of Americans by "phasing out" the Medicaid expansion under the Affordable Care Act. You can listen to Kasich's response in the short video above. In short, he's appalled. "That is a very, very bad idea," he said, "because we cannot turn our back on the most vulnerable." But that's exactly what Ryan's plan, timidly and partially presented last Thursday, does, by forcing the already hard-pressed states to pay more of what the feds were paying towards the health costs. 31 states-- where most Americans live-- would be impacted by the GOP power play. Ryan's plan pits the extremist Republican House against more mainstream Republican senators and governors.

The plan was sent to Republican House members to take home to study it over the break-- and several of them, for a variety of reasons, promptly leaked it to the press. The far right is fuming because they oppose the tax credits that aren't offset in the budget and more mainstream Republicans are unhappy because it will leave poor people out in the cold. The new plan also repeals the mandate, which, according to the Congressional Budget Office, would almost immediately raise insurance premiums by around 20%, something most Republican congressmen don't want to see happen before the 2018 midterm elections, when increases like that would likely cost the GOP at least 35 seats-- and control of the House.

On Saturday, The Atlantic's Vann Newkirk took a stab at explaining what the House Republican leadership is doing. Remember the vast majority of Medicaid recipients are either disabled or low-income seniors, many with serious (i.e., expensive) health care needs. Those costs have been split between the states and the feds. Ryan (and Trump's new Secretary of Health, Tom Price) want to change that now, not just in regard to their Obamacare obsession but also as a as a way to destroy Medicaid entirely. "The plan," he wrote, "is short on specifics, including the mechanics of its implementation, and looks like a watered-down combination of some existing Republican repeal plans, including Ryan’s and Price’s. It would repeal Obamacare’s taxes and mandates, and replace the tax subsidies for purchasing insurance on the exchanges with tax credits and incentives for health-savings accounts. The details of those tax credits are not provided, save that they would be age-rated and refundable but not adjusted by income."

The proposal appears "likely to sharply reduce the number of people covered, since it rolls back funding for the Medicaid expansion, ends subsidies, and eliminates the mandate to purchase insurance. Their tax-credit policy would invert Obamacare’s progressive financing scheme. Under current law, subsidies increase as income decreases, but the Republican plan would flatten that tax advantage, thus no longer proportionally increasing affordability for low-income people. It would age-rate the credits, granting more affordable coverage to older people, who tend to be sicker than younger Americans, but would not control for costs among poorer individuals, who also tend to be sicker and more prone to disability than their middle- and upper-class counterparts."



And it establishes "a per capita cap on federal Medicaid funding for individuals based on state economic and health factors, as well as the category of beneficiary (whether they are aged, blind and disabled, children, or otherwise able adults). That reform erases the open-ended funding of Medicaid and essentially replaces it with a set annual allotment of federal funds to each state. The brief would allow states to receive that funding as a block grant, provided that they 'transition' people covered under the Obamacare Medicaid expansion to other programs. That block grant appears to come with rather significant relaxation on states’ requirements to meet eligibility standards and provide comprehensive services for Medicaid enrollees."

The per capita cap and block-granting scheme would certainly save the federal government money. The main appeal of universal spending caps is not only that they promote thrift among states, but that pegging them to economic factors, at the start of a prescribed “base year,” basically underfunds them in the future. But this scheme might also work against the ability of Medicaid to effectively cover people. A report from the Kaiser Family Foundation shows that such a policy could “lock in” funding to states based on their position in the base year, and would create long-term “winners” and “losers” in states. States would no longer be able to react in real time to crises like drug epidemics, disasters, or job crunches, and funding would not respond to demographic changes. In essence, people might be blocked from receiving care simply based on where they live. That this problem recreates the geographic incoherence of the current Obamacare Medicaid expansion-- where people covered under the expansion in some states will lose coverage if they move to non-expansion states-- is no small irony.

The logic behind block grants and per capita caps on federal funding is that they force states to be efficient with Medicaid dollars since they’re on the hook after that money is gone. But there are no guarantees that states wouldn’t simply create that “efficiency” by dropping people from coverage, diminishing the services covered, or reducing payments to providers. In fact, the House plan appears to encourage just that, as it only specifies coverage of mandatory services for disabled and elderly people in its requirements for block grants. The ensuing system, then, would no longer be a safety-net entitlement for all people who need care, but one where many of the riskiest patients with the most pressing issues might simply be forced to do without. That’s a strong departure from the underlying logic of the program, outlined when President Lyndon Johnson railed against “the injustice which denies the miracle of healing to the old and to the poor” when he signed the amendment to the Social Security Act, which gave the country Medicare and Medicaid in 1965.

DWT has heard that Lee Rogers, the progressive doctor who previously ran for Congress in Los Angeles, is being recruited by district supporters to run again in 2018. And we think thats good news because Dr. Rogers knows how to give Republicans a taste of their own bad medicine. Dr. Rogers offered the following diagnosis and prescription on Paul Ryan's plan:

"Republicans are fixated on their belief the healthcare is a privilege. But they use confusing language to hide this unpopular fact. They state that they want everyone to have 'access to healthcare.' We all know that having access to care is in not the same as having care. As Senator Bernie Sanders pointed out, you currently have access to one of Donald Trump's mansions, but without 5 million dollars, you can't afford it. I believe healthcare is a right. There is nothing more precious than your life. Medicaid expansion has helped low-income patients get the care they need and it has also been an economic stimulant for the states. We can't put greedy insurance companies and the pharmaceutical industry back in charge of healthcare."

Hopefully demonstrators at Ryan's house Wednesday will remind the rogue-Catholic of this

We Don't Have Grayson To Call Them Out On It Any Longer But Republican Health Care Is Still "Die Quickly"

This week NBC News and the Wall Street Journal released a poll showing Trump with an unfavorable rating from 46% of Americans and a favorable rating with 40%, an improvement for him since last month, but the lowest favorability rating of any president-elect about to take office ever. Although he's being installed by an antiquated, anti-democratic electoral college that should have been abolished at the turn of the century (the 20th Century), Trump actually lost the election to Clinton 65,844,610 (48.2%) to 62,979,636 (46.1%). Trump has no mandate to make any drastic changes-- not that that will stop him, of course.

And the first drastic change he and his party want to make is to health care. Everyone wants "change" but we'll soon see if the kind of change the GOP has been talking about-- basically, less health care-- is what Trump voters are going to feel comfortable with. As Steve Benen explained it, the long-standing difference between the progressive approach (embraced by most, but not all, Democrats) and the conservative approach) embraced by all Republicans, is that "Dems saw a system in which too many Americans paid too much and received too little, while the GOP saw a system in which Americans’ health coverage was too good and families enjoyed too many benefits." That second one takes a lot of tap-dancing to explain to constituents. Benen references an unremarkable right-wing backbencher, Bill Huizenga, from west Michigan who admits that when the GOP starts rolling back Obamacare parents will have to consider waiting and thinking about more carefully before bringing in their sick or injured kids for costly treatments.

The Republican congressman explained to the Michigan outlet that he and his wife thought about taking their son to the emergency room, but they decided instead to wait and gauge his injuries the next day, to see if the child’s arm improved. (It didn’t.) Huizenga sees this anecdote as a model for how the process should work on a more systemic level.

“If you don’t have a cost difference, you’ll make different decisions,” the congressman said, adding that financial burdens should be shifted to consumers because the current system “continue[s] to squeeze providers.”

Huizenga went on to say, “Way too often, people pull out their insurance card and they say ‘I don’t know the difference or cost between an X-ray or an MRI or CT Scan.’ I might make a little different decision if I did know [what] some of those costs were and those costs came back to me.”

This is not a new argument. Among Republicans, it’s not even unusual. It is, however, kind of terrifying.

I first started writing about this about seven years ago, right around the time former House Majority Leader Dick Armey (R-Texas) summarized the Republican position in just 17 words: “The largest empirical problem we have in health care today is too many people are too over-insured.” Two Republican congressman had a Wall Street Journal op-ed around this time making the same case: “When was the last time you asked your doctor how much it would cost for a necessary test or procedure?”

It wasn’t a rhetorical question. For most of us, if we have an ailment, we see a doctor and follow his or her recommendations. If physicians recommend tests they consider medically worthwhile, we naturally agree, knowing insurers will cover most of the costs.

And for Republicans, therein lies the problem. If the system shifted the cost burden away from insurers and employers and onto individuals and their families, the result would be amazing savings-- because consumers would seek and receive less health care.

The GOP idea, in other words, is to create a medical environment in which Americans are acutely aware of costs, to the point that we turn down recommended treatments. Our kid may have a broken arm, but can we really afford an emergency-room visit? My doctor says I need a CT scan, but can I really afford such an exam? My friend has a lump and an unsettling family history, but can he really afford to have it removed and sent to pathology? His spouse was prescribed medication by her doctor, but does she really have to take it or can she save some money by going without?

In the Republican model-- by GOP officials’ own admission-- these are the kinds of questions Americans should be asking themselves. Having excellent health coverage, Republicans argue, is a problem in need of a resolution. As the aforementioned Rep. Bill Huizenga (R-Mich.) put it, “If you don’t have a cost difference, you’ll make different decisions.”

As Republicans move forward with repealing “Obamacare” and looking for some kind of alternative blueprint, keep this simple fact in mind: much of the GOP is convinced your insurance is too good, and they intend to help improve the system by making your coverage worse.

I was delighted that on the same day Benen wrote that, Jonathan Rothwell, writing for Gallup about American healthcare inefficiency made the case against Obamacare that progressives have always made and that I wish-- futilely-- Republicans would adopt. The only social health insurance plan that actually works is single payer-- the polar opposite direction in which Trump, Pence, Ryan, Price and McConnell intend to take the health care system.

Rothwell starts from the supposition that "costs are increasing much faster than any incremental improvement in quality... From 1980 to 2015, healthcare expanded from 9% of the national GDP to 18%. Some of this is natural and good. The aging population requires more healthcare, and even modest economic growth has freed up spending power for healthcare. The problem is that the per-unit costs of healthcare-- actual procedures, visits with doctors, pharmaceuticals-- have all soared. So the question must be asked: Has it been worth it? I conclude not."

One way to evaluate advances in healthcare is to compare new treatments with the current standard treatments (e.g., how a new fever-reducing drug compares with ibuprofen) in terms of both costs and effects on "quality-adjusted life years." University of Chicago economists have done this for every healthcare advancement analyzed in medical journals since 1976. The results suggest that the quality-to-cost ratio has fallen. Most new treatments introduced since 1976 have lower benefits per dollar than standard treatments. Indeed, for typical treatments, quality advances were very modest (1%) but cost increases were substantial (8%).

One can see evidence of systemic healthcare inefficiencies in the general health of the U.S. population, which collectively is much lower relative to peers in other developed countries despite the U.S. spending about twice as much on healthcare on a per capita basis. Mortality rates, which remain high by international standards, have fallen since 1980, but most of the progress has occurred among infants and the elderly. The working-age population has seen little improvement-- and for whites and American Indians, there have been no gains in age-adjusted mortality for people aged 15 to 64, at least since 1999.

Even as Americans are living slightly longer, the quality of life hasn't necessarily improved for people of working age. For U.S. residents, self-reported health status has fallen among each age group between 25 and 59 since 1990.

Additionally, the share of the working-age population suffering from a disability that prevents them from working rose from 4.4% in 1980 to 6.8% in 2015, adjusting for age.

One reason for the decline in Americans' self-reported health status is the extraordinary inefficiency of the U.S. healthcare system.

It may be tempting to dismiss these poor health outcomes as driven by cultural or demographic changes, but the broadest evidence suggests this would be misleading. The fastest-growing minority groups-- Hispanics and Asians-- are typically healthier than whites and blacks. Moreover, compared with 1980, Americans are exercising more, smoking less and eating somewhat healthier diets, and they are less likely to be abusing drugs and alcohol. The exception is the rise of prescription opioid use and related abuse, but our healthcare system bears much of the blame for that.

On the cost side, it is easier to identify specific causes for rising inefficiency.

Administrative costs related to healthcare billing are astronomical (hundreds of billions of dollars annually)-- especially compared with other advanced countries, where single-payer systems streamline procedures. Compared with their Canadian counterparts, nurses in the U.S. spend an extra 18 hours per week on administrative tasks and clerical workers spend an additional 37 hours. In 1983, Medicare started requiring that medical service providers identify the specific diagnostic code (out of roughly 90,000 in the latest system) to get reimbursed. Complicating matters more, Medicare and private insurance companies have different billing, documentation, and submission rules and procedures, making it extremely difficult to create efficient software.

Even without a single-payer system, Congress could reform the medical billing system with the goal of creating a simplified, universal, digital process. The goal should be to require only the minimum information that is necessary to avoid fraud. Reimbursement should be based on reasonable approximations of the actual costs to providers in terms of time and use of equipment, and the application process for providers to become a qualified biller of either private or public insurance should be streamlined.

Another issue relates to competition. Consumer advocates at the Federal Trade Commission argue that state laws protect hospital monopolies and raise prices by blocking the introduction of competitors into the market, driving up costs by tens of billions of dollars. State licensing regulations restrict qualified healthcare providers-- like nurse practitioners and dental hygienists-- from practicing independently, as pointed out by the Institute of Medicine. Addressing these restrictions could reduce the costs of medical care.

There are other problems with the U.S. healthcare system. The complicated practice by which pharmaceutical companies develop new drugs and set their (often very high) prices continues to come under scrutiny and provides the opportunity for potential reform. Likewise, agencies are forbidden by Congress to explicitly recommend or deny public funding for treatments based on the most widely used quality-to-cost comparisons.

The overarching point is that the absurd inefficiency of U.S. healthcare is not necessary or permanent. The system we have now is harming us through its exorbitant costs and weak efficacy, which drive down economic growth and deprive future generations of greater prosperity.

If only Price, Ryan, Pence and McConnell weren't so deeply committed to the right-wing ideological frame for looking at this. The only hope that this change that's coming won't be change for the worse is if the one person on the team not wedded to the ideology, the captain of the team, somehow gets persuaded to do the right thing for the American people. I'd say the chances of that are one in a hundred-- which was about the chances he had of winning the Republican nomination and then the electoral college.

UPDATE:

"The law, in its majestic equality, forbids the rich as well as the poor to sleep under bridges, to beg in the streets, and to steal bread." – Anatole France

"The GOP, in its majestic equality, prevents the ill as well as the healthy from affording the care that they need to stay alive." - Alan Grayson

Why No "Market-Based" Health Care Reform Can Succeed

The cost of health care vs. the consumer price index for the last ten years (source; click to enlarge). Note especially 2009 and 2010, recession years for the CPI. If you do click through to the source, note that its author apparently doesn't understand the relationship between monopolies and pricing power.

by Gaius Publius

A little while ago I speculated on the future of the ACA given its recent problems and said I wasn't sure whether it would survive or not. Meanwhile, others are predicting its demise.

It's certainly true that the ACA attempts to be a so-called "free market" solution to providing health insurance and health care. And it's also true that the ACA does not have within it mechanisms to restrain the cost of either the insurance itself or the health care that citizens are buying the insurance for.

In the light of those facts, let's look again at the questions I asked earlier:

• Is the ACA poised to collapse?
• Will the ACA be fixed? (Or even, can the ACA be fixed?)

Benjamin Day writing at Jacobin would answer Yes to the first question and No to either of the second. His reason: No "free market" solution to providing health care can work without price controls. Is he right? Let's take a look.

(By the way, the reason I put "free market" in quotes above is that the health insurance market is actually highly consolidated and monopolistic, and no monopoly-controlled market — think Standard Oil and the petroleum market at the turn of the 20th century, or Comcast today — is in any sense "free." If you need it, you pay what the only supplier will charge you.)

Day's analysis starts with this (emphasis mine):

Why Obamacare Didn’t Work

Obamacare has failed, and so will other market-based plans. We need a socialized system.

News broke late last month that yet another of the nation’s largest health insurers, Aetna, is pulling out of state health exchanges in 2017. The company’s action marks the failure of every market-based reform included in the Affordable Care Act (ACA).

The insurers that remain in the exchanges find themselves with unprecedented leverage to demand double-digit premium increases next year, which will leave eleven million patients with few options. The collapse of policies designed to increase competition between health insurers should serve as a lesson in an election year when both candidates, Donald Trump and Hillary Clinton, have been running on the promise of even more such reforms.

He then expands his theme of the failure of "market-based reform":

The first market-based reform to collapse was the introduction of CO-OPs, new consumer-owned health insurers designed to compete with large commercial plans. Of the twenty-three CO-OPs launched for 2014, sixteen have already closed their doors or been shut down by state regulators. The CO-OPs failed in part because they expected government subsidies that never arrived, but more importantly they didn’t have the size or leverage to negotiate rates with large hospital and physician groups, paying more for the same patient care than the dominant insurers they were competing with.

Not having market pricing leverage matters, obviously. In other countries, "market-based" solutions work because of decidedly non market-based practices, like government-mandated price-setting. Day again:

Most countries put hospitals on fixed budgets under a universal health-care system, but the few with private health insurers set uniform rates so market power doesn’t matter for the price of care. The Wild West capitalism that characterizes health care in the United States actually works against competition, rewarding mergers and consolidation by both insurers and providers, and undermines competition-based policy initiatives like the CO-OPs.

Any solution that places pricing power in the hands of monopolies and near-monopolies will always fail to deliver an affordable product, whether that market is cable TV or health insurance. Monopolies inevitably lead to high prices.

Day then looks at both the Clinton and Trump proposals for reform. After dismissing Trump's proposal, he says this about Clinton's proposal, the public option:

Clinton has promised to revive the Democratic campaign for a “public option,” a publicly administered health insurance plan that would compete with private insurers on the exchanges. If a new public insurance plan must negotiate with providers while trying to attract new enrollees, it’s likely to meet the same fate as the CO-OPs.

If allowed to use Medicare’s provider network and Medicare’s payment rates, a public option would have a tremendous advantage over private insurers since Medicare pays lower rates and few providers can afford to opt out of accepting Medicare patients. A weak public option that has to negotiate health-care costs as a small startup plan will fail, while a strong public option allowed to pay Medicare’s low rates is more likely to replace private insurers than compete with them.

Again, a "weak public option" will fail and a "strong public option" will replace private insurers, not compete with them. The second, replacing private insurers, is obviously a problem for the program's designers, since the ACA was created to prop up private insurers, not undermine their profitability. Day:

The last gasp of the ACA’s market-based reforms reveals an uncomfortable truth about our health-care system: we cannot afford to expand or even maintain our current access to care without cost controls, and health-care costs cannot be controlled with competition or markets.

The only cost control that works without undermining access to care is also the kind that Republican and Democratic leadership have foresworn this election: public budgeting and rate-setting through a single-payer system, or regulations that force nonprofit insurers to act like a single-payer.

And there you have it. American elite policymakers, from Clinton to Trump, from mainstream Democrats to any kind of Republican, are hell-bent on a "market" solution to health care reform, and Day is certain no market-based reform can succeed. I think he's right.

Day's piece is called "Why Obamacare Didn't Work." But it hasn't failed ... yet. In my present view, though, that's just a matter of time. What's next? This brings us back to the clash between the Sanders wing and the neoliberal (republican-aligned) wing of the Democratic Party. Until that's resolved, perhaps nothing is next but the shambles of what we have now.

GP
 

Obama Administration Confirms Double-Digit ACA Premium Hikes

BREAKING: Obama administration says https://t.co/Elaw2I8wgo premiums will go up by double-digit percentages next year.

— The Associated Press (@AP) October 24, 2016

by Gaius Publius

It's not looking good for the ACA, commonly called Obamacare. From the AP:

Obama administration confirms double-digit premium hikes

WASHINGTON (AP) — Premiums will go up sharply next year under President Barack Obama's health care law, and many consumers will be down to just one insurer, the administration confirmed Monday. That's sure to stoke another "Obamacare" controversy days before a presidential election.

We can pause here briefly. First, premiums will go up. Second, markets (choices) will contract. A feature of neo-liberal rule is an increase in monopolies and inflated prices. And without doubt the ACA is right up the neo-liberal alley. Even the much-wanted Public Option was killed by the way Obama and his people manipulated the Senate version.

But onward (emphasis mine):

Before taxpayer-provided subsidies, premiums for a midlevel benchmark plan will increase an average of 25 percent across the 39 states served by the federally run online market, according to a report from the Department of Health and Human Services. Some states will see much bigger jumps, others less.

Moreover, about 1 in 5 consumers will only have plans from a single insurer to pick from, after major national carriers such as UnitedHealth Group, Humana and Aetna scaled back their roles.

"Consumers will be faced this year with not only big premium increases but also with a declining number of insurers participating, and that will lead to a tumultuous open enrollment period," said Larry Levitt, who tracks the health care law for the nonpartisan Kaiser Family Foundation.

This all gives fodder to Republican opponents, of course, and the article points that out. The Yes-But from the administration looks like this:

The vast majority of the more than 10 million customers who purchase through HealthCare.gov and its state-run counterparts do receive generous financial assistance. "Enrollment is concentrated among very low-income individuals who receive significant government subsidies to reduce premiums and cost-sharing," said Caroline Pearson of the consulting firm Avalere Health[.]

But an estimated 5 million to 7 million people are either not eligible for the income-based assistance, or they buy individual policies outside of the health law's markets, where the subsidies are not available. The administration is urging the latter group to check out HealthCare.gov.

One problem is that, as the plan is designed, it becomes welfare via the subsidies at the same time that it stops being a right that everyone can afford. It's one thing to subside low-income households; it's another to make the the products of the plan unaffordable without subsidies to middle-income households. In a slightly more extreme version, it would be a gift to the poor and only that. Again, welfare.

The Clinton solution to this appears to be more of the same, at least as the AP puts it:

Clinton has proposed an array of fixes, including sweetening the law's subsidies and allowing more people to qualify for financial assistance.

Is the ACA poised to collapse? It's hard to say. On the one hand, even the insurance companies are withdrawing from what looked designed as a "health insurance industry protection scheme," complete with mandated purchases. Increasing unaffordability and lack of market choice — with the resultant effect of little competition — are likely making this patched-together program (relative to Medicare or any single-payer alternative) quite unpopular.

On the other hand, the relentless Republican attacks on any health insurance plan offered by Democrats is bound to stimulate that "rally 'round our Party" enthusiasm on the part of cultural Democratic Party voters, which might allow it to limp along for a while.

Will the ACA be fixed? Not with a Republican-controlled House and perhaps Senate, and not if Clinton restricts her proposals to increased subsidies. After all, the only real fix is to revert to the original LBJ-era plan — well-funded publicly-run health insurance for all citizens as a right (like the Sanders plan), or at the very least least, inclusion of a Public Option into ACA that simulates Medicare and is offered as a competing nonprofit alternative to private insurance products — or an insurer of last resort, if it comes to that.

As to the Public Opton, note this from last July:

Clinton Reaffirms Support For Public Option In Bid For Sanders Supporters

Sanders gushes, saying the health care proposals "will save lives.

Hillary Clinton reaffirmed her support on Saturday for creating a “public option” within Obamacare and allowing people to enroll in Medicare at age 55.

The presumptive Democratic presidential nominee also called for a substantial increase in funding in medical clinics that serve low-income Americans, fully embracing a proposal from Sen. Bernie Sanders (I-Vt.).

While Clinton has long supported the creation of new government-run insurance options and reiterated that support several times this year, Saturday’s statement comes three days before she is scheduled to make her first joint campaign appearance with Sanders ― who has championed government-run insurance and federally financed clinics throughout his career and during his own bid for the presidency.

I read this as two proposals, one to offer a "public option" (described below) to everyone, and one to lower Medicare eligibility to age 55. About the public option:

The idea of the public option ― as first sketched out by Jacob Hacker, a Yale political scientist ― is to create a separate, government-run insurance plan that would compete with private insurers offering coverage through the Affordable Care Act’s exchanges. The hope is that this competition can help keep premiums for all the insurance plans low, particularly if the government-run plan has the ability to dictate low reimbursement rates to doctors, hospitals, drugmakers, and other suppliers of medical care.

Definitely a step in the right direction. Will this actually be proposed? Perhaps, but it's a campaign promise, like Obama's promise to the unions to pass the Employee Free Choice Act (EFCA), which was introduced into an all-Democratic Congress in 2009 and then left to lie. If a public option proposal is introduced into this Congress, the odds of it passing are nil.

So to answer the original question — will the ACA be fixed? — I would say the chances are slim to none. Stay tuned; ACA may not be on thin ice now, but it could be getting close.

GP
 

Why Would Anyone Possibly Assume Trump Isn't A Health Care Expert?

I don't know what it's like in your state. I know a lot of nurses in Florida come from Haiti. When my friend Stephen's mom died after a long, protracted illness, he gave her primary nurse several hundred thousand dollars from his mom's estate. His mom wanted him to and Stephen described the nurse to me as an angel who made his mother's last years not just bearable, but worthwhile for her. Here in California, many nurses are also immigrants, but not from Haiti. Many come from the Philippines; many come from Mexico.

I just spent a couple of years battling a rare form of cancer and City of Hope was a second home for me. I picked City of Hope because a doctor there-- also an immigrant-- is one of the world's foremost specialists in this particular type of cancer. She has been successful in her efforts and she'll always be part of my life and in my prayers.That said, the people who I was with every day and sometimes 24 hours a day were the nurses, many of them from the Philippines. One, Cindy, makes my heart soar whenever I think of having to go to the hospital for blood tests, even now. When I heard Trump ranting ignorantly about Filipino immigrants in August, I nearly lost it. Does he have any idea about what these nurses bring to the table-- any idea how much more they contribute to society that he or his monstrous offspring do? Of course not.

I can't imagine how I could have survived without the skill and love from the medical professionals like nurse Cindy-- one of several dozen nurses who cared for me in the hospital and when I was recovering at home. I was reminded of the fragility we face as we get older and as we become susceptible to opportunistic diseases yesterday when I read about a Rand study contrasting Trump's and Clinton's health care approaches. Clinton's is far from perfect, but it's moving the country in the right direction. Trump's will help hasten the deaths of as many as twenty million Americans. Republicans like his plan because it saves the wealthy money and could allow lower tax rates for them.

William Hoagland, once a Cigna lobbyists and GOP Senate staffer and now a top executive the Bipartisan Policy Center, warns that Trump's jumbled hodge-podge of a plan only proves one thing, that, in his words, "Trump does not understand health care." He doesn't?

The premise of Clinton's plan is to make sure several million more people-- probably 9.6 million more-- would be able to afford health care premiums through ObamaCare. Trump's plan would deprive as many as 20 million people of health insurance, a death sentence for many.

Clinton wants to add the public option to Obamacare while giving individuals whose out-of-pocket medical spending exceeds 5% of their income a tax credit of up to $2,500 and lowering the maximum amount that people would have to pay toward Obamacare insurance plans from 9.7% of income to 8.5% of income (for people who earn less than $47,000 a year). Her plan moves the country in the direction of universal coverage, too tepidly for progressives but beyond what Obama achieved and nothing at all like what Trump is trying to "achieve" by going backwards. Sahil Kapur, reporting for Bloomberg, summed up the Rand findings with a key figure: "19.7 million lose coverage if Trump repeals Obamacare." His plan would also increase the federal deficit by $33.1 billion in 2018. He proposes tax credits that are meant to benefit rich people, like virtually all of his proposals.

To evaluate Trump’s plans, Rand modeled the effects of repealing Obamacare and replacing it with his proposals. The Affordable Care Act, or ACA, gave states funds to expand the government-run Medicaid program for the poor, and created markets where individuals could buy health plans, often with federal subsidies. It also lets children stay on their parents’ health plans to age 26, requires the purchase of health insurance, and bars insurers from excluding people who are sick, with so-called pre-existing conditions, from buying plans. Clinton’s plans were evaluated as extensions of the current law.

The researchers said they asked both campaigns to help with the modeling. Clinton’s campaign provided answers, while Trump’s campaign referred the researchers to its website, they said. Both campaigns were given copies of the analysis before it was published.

In his proposals, Trump would replace the ACA with a tax deduction letting people with health plans fully deduct their insurance premiums from their taxes. He would move to a system of Medicaid block grants, which would cut costs because the federal government would provide states with a limited, fixed amount of money. And he wants to allow insurance to be sold across state lines.

The deduction for insurance premiums would add about $8 billion in costs to the ACA repeal, increasing the federal deficit by an estimated $41 billion, while reducing the number of individuals losing coverage to 15.6 million, the Rand study found. The deduction would lead to lower health costs for higher-income people, who benefit more from reduced taxes, the researchers said.

“Distributionally, it benefits higher income people more than lower income people," Collins said.

From Clinton’s side, the researchers looked at four proposals, all of which would increase coverage and lower costs for individuals. Three of the proposals would add to the deficit, and one would cut it modestly.

The biggest proposal, according to the study, is a refundable tax credit of as much as $2,500 for individuals and $5,000 for families whose health-care costs exceed 5 percent of income. She also wants to fix what’s called the family coverage glitch, which prevents some low-income families from getting financial assistance.

But the proposal that’s attracted the most attention recently-- a government-run public option health plan to compete with private carriers on the ACA’s exchanges-- has some of the smallest effects. It would provide insurance to 400,000 additional people, while cutting the deficit by $700 million. The Rand analysis assumes the plan would pay providers Medicare rates, which are typically lower than those paid by commercial insurers, helping account for its lower cost.

In her analysis for The Atlantic yesterday, Olga Khazan pointed out that "Trump’s plans would lead to even greater numbers of poor people left uninsured... All of his proposals would also make health care more expensive for people buying insurance on the individual market, with the exception of high-income people, who would benefit from Trump’s proposed tax deductions. "Without subsidies, middle income and lower income folks can’t afford to buy coverage,” [Harvard Professor of Public Health John] McDonough said. “It’s only going to benefit higher-income people who are already buying coverage. [Trump’s plan] won’t expand coverage at all, and it will hurt the federal debt.”

Trump’s Medicaid block-grant idea has been put forward by other Republican policymakers, including the House Speaker Paul Ryan. Medicaid block grants won’t necessarily boot people from Medicaid rolls-- the federal government could, after all, make the grants very generous-- but past block-grant proposals have been stingier than the existing Medicaid system.

Selling insurance across state lines has been proposed by every Republican presidential nominee since 2005, as the New York Times’ Margot Sanger-Katz reported. The idea, built on the promise of competition in the free market, seems appropriate for a businessman like Trump. But it’s already been tried in some states, and it failed to catch on with insurers, who struggled to build up networks of doctors in other states.

Sara R. Collins, vice president of health-care coverage at the Commonwealth Fund, pointed out that if interstate insurance sales did pick up, insurers might flock to states with the weakest consumer protections.

It would be a race to the bottom, with insurance companies selling cheap plans that don't cover much and leave consumers up shit's creek without a paddle when they are most desperate for help. That pretty much defines Ryan's #BetterWay across all categories-- something Trump seems happy enough to go along with as long as he can put his logo on the White House.

A #BetterWay?

Your Captured Government at Work: Conn. Gov. Malloy Met With Cigna and Anthem CEOs During Merger Review

by Gaius Publius

Cigna and Anthem are health insurance giants that want to merge. Cigna is Connecticut-based (the "C" in Cigna stands for "Connecticut") and pulls in over $1.6 billion in revenue. Its 2012 total assets topped $50 billion.

Anthem, Inc. used to be known as Wellpoint, and if you click the link, you'll see that it too is a player. Anthem pulls in over $2 billion annually and its 2012 assets also topped $50 billion. Both companies truly are giants in the health insurance industry. Connecticut is an insurance state, so as you can imagine, the industry controls most politicians (because, "jobs," about which see below.)

Dan Malloy is governor of Connecticut, current chair of the Democratic Governors' Association (DGA) and former co-chair of the Democratic Convention in Philadelphia. Malloy is a mixed bag as governor, supporting some reasonably advanced progressive policies (for example, marijuana reform, opposition to capital punishment) and some not-so-progressive policies ("shared sacrifice" and "union concessions" during budget negotiations).

Malloy also has ethics issues, especially involving the insurance industry:

Connecticut’s Ethics Board is debating whether to launch an investigation into Malloy’s administration. Under Malloy’s watch, one of the largest health insurance mergers in United States history—a $48 billion deal—could potentially increase premiums and reduce health care coverage for 53 million people across the country.

According to the Norwich Bulletin, “When the deal between Connecticut-based Cigna and Anthem Blue Cross Blue Shield was being negotiated in early 2015, Malloy appointed Katharine Wade as the state insurance commissioner. Wade, a former lobbyist for Cigna with a handful of family ties to the company and a firm that lobbies for it, appointed a deputy and an agency counsel who had worked for Cigna.”

Did I mention Malloy was also co-chair of the Democratic Convention in Philadelphia. You don't get to run an operation like that if you're not deeply in favor with those who really run all operations like that — in this case, the money-soaked mainstream of the modern Democratic Party.

The Cigna-Anthem Merger

In 2015 Anthem announced it wanted to acquire Cigna:

In June 2015, U.S. health insurer Anthem Inc. announced an offer to acquire Cigna for more than $47 billion in cash and stock.^[13] Anthem confirmed it had reached a deal to buy Cigna on July 24, 2015.^[14] On 21 July 2016 the US Justice Department filed an antitrust suit to block the proposed merger.^[15]

Part of the problem the Justice Department has with this merger — it will combine the number 2 and number 5 insurance providers — is that Humana and Aetna also want to merge, in a deal that will combine the number 3 and number 4 providers as well. (And for good measure, there are some stories that United Health may have been interested in Aetna.) No good, for consumers, can come from any of this.

David Sirota at IBT (my emphasis throughout):

Citing unnamed sources, Bloomberg and Reuters both reported that Justice Department officials are positioned to file lawsuits to halt Anthem’s multibillion-dollar acquisition of Cigna, as well as a separate merger between Aetna and Humana. The mergers would create the largest private health insurance companies in American history, and reduce the total number of major insurers to just three — a situation that groups representing physicians and consumers said could raise premiums and limit medical care for tens of millions of consumers across the country. The companies have argued that the mergers would create cost-saving efficiencies that would benefit their customers.

So faced with Justice Department opposition, the Cigna-Anthem merger is under multistate national review. Who's leading that review? The Connecticut insurance commissioner and a Malloy appointee:

Connecticut Insurance Commissioner Katharine Wade, a former Cigna lobbyist [runs the] agency ... leading the national multistate review of the transaction.

Turns out Malloy not only seemed to favor the merger — by appointing a Cigna lobbyist as his state's insurance commissioner while the merger was being negotiated. He also personally met with Cigna and Anthem execs during the same time.

Sirota again:

Money In Politics: Connecticut Gov. Malloy Met With Cigna And Anthem CEOs During Merger Review

Facing criticism over his decision to appoint a former Cigna lobbyist to a position regulating Cigna's controversial merger, Connecticut Governor Dan Malloy has sought to distance himself from the merger review. The regulator in question, Katharine Wade, has said she followed all applicable conflict-of-interest rules. But newly unearthed documents detail Malloy's meetings with company officials and with Wade — and also raise new questions about Wade's financial connections to Cigna.

The emails were released to International Business Times in response to a series of open records requests amid a state ethics probe that has helped throw the colossal Cigna-Anthem deal into turmoil. Connecticut has been leading the multistate regulatory review of the deal, which physicians and consumer groups say could raise healthcare premiums for up to 53 million Americans across the country....

One set of documents shows that the governor met with Anthem CEO Joseph Swedish on August 28, 2015. That was two days after Anthem and Cigna executives met with Wade’s agency specifically about Connecticut’s merger review, and the same day Anthem donated $25,000 to the Democratic Governors Association, which backed Malloy’s closely contested election campaigns. At the time, Malloy was already gearing up to lead the DGA in 2016.

Emails previously obtained by IBT show that Malloy spoke with [Anthem CEO Joseph] Swedish and Cigna CEO David Cordani the night before the merger was announced. They also show that Malloy’s top economic development official told Cordani the governor’s administration would help Cigna if the company pursued the merger. Calendar items just obtained by IBT show Malloy later met with Cordani in the governor’s office in June of 2016 — three days after Connecticut Common Cause called for the ethics probe of Wade over her ties to Cigna.

The $25,000 that Anthem donated to the DGA wasn't the only money that changed hands.

While pushing the merger, Swedish and Cordani’s companies have in the 2016 election cycle delivered more than $1.1 million to the DGA, which Malloy now chairs. In fact, Anthem is now the single largest donor to the Malloy-run organization. Documents previously obtained by IBT show that under Malloy, the group has promised donors access to governors' policy meetings in exchange for large contributions.

There's much more at the link. Do you wonder why the nation is on the verge of revolt? I certainly don't.

When the Rich Say "Jobs" They Mean "Profit"

A side note. Why is Malloy doing this? Sirota again:

Asked whether Malloy discussed the merger with the CEOs, Malloy spokesperson Chris McClure told IBT in a written statement: “Governor Malloy fights for each and every job, and he believes in cultivating quality relationships with our employers — which our residents expect of us.

"Jobs" is a magic word; it erases (or obscures) all sins. But it also does more than that. "Jobs" is a tell — it tells the truth if you perform a simple substitution. Noam Chomsky:

In contemporary Newspeak, the word “jobs” means “profits”...

When the rich or their agents say "jobs," they always mean "profits." Perform that substitution yourself and everything they say will make sense. For example:

Protests Erupt in San Juan as President Obama Forms Unelected Control Board to Run Puerto Rico

... "I came to see the PROMESA conference that’s going on. I’ve actually made a great sacrifice to come here. I’m not—I’m not rich. I’ve worked hard, and I’ve made—I’ve made a choice in my life to move away from my family to come here to try and create jobs, to invest in Puerto Rico."

Of course the "unelected control board" about creating profit, even if the speaker doesn't recognize it. Just watch. PROMESA will turn out to exist to protect hedge fund investors, even those who bought PR bonds at pennies on the dollar, and their profit. That's why it's unelected, like Michigan's emergency managers.

Or an old favorite:

[President] Clinton, while signing the NAFTA bill, stated that "NAFTA means jobs. American jobs, and good-paying American jobs"...

NAFTA was always about outsourcing jobs and sweetening the profit pie. We know the kind of local jobs NAFTA created; people who sell these things for example.

It's cruel that they do this — dangle the reason (no good jobs) most Americans are close to revolt as a tease to protect the reason (even more excessive profit) those jobs went away in the first place. But there you have it. Your captured government at work.

GP
 

UnitedHealth May Quit Obamacare Market

by Gaius Publius

Thanks to the Democratic primary, there's been a lot of discussion on the left about the benefits and ills of ACA, the Obamacare public health law, versus single-payer and "Medicare For All," which Bernie Sanders is advocating. Clinton is a strong defender of the ACA and a strong, if disingenuous, critic of Sanders' Medicare For All.

From the second debate, here's Clinton defending Obamacare over Medicare For All (h/t Lambert Strether at Naked Capitalism for quotes and analysis):

NANCY CORDES: Secretary Clinton, back in– (CHEERING) Secretary Clinton, back in 1994, you said that momentum for a single-payer system would sweep the country. That sounds Sandersesque. But you don’t feel that way anymore. Why not–

HILLARY CLINTON: Well, the revolution never came. (LAUGHTER) And I waited and I’ve got the scars to show for it. We now have this great accomplishment known as the Affordable Care Act [ACA]. And– I don’t think we should have to be defending it amount [sic] Democrats. We ought to be working to improve it and prevent Republicans from both undermining it and even repealing it. [...]

I’ve looked at the legislation that Senator Sanders has proposed. And basically, he does eliminate the Affordable Care Act, eliminate private insurance, eliminates Medicare, eliminates Medicaid, Tricare, children’s health insurance program. Puts it all together in a big program which he then hands over to the state to administer. [...]

And I have to tell you, I would not want, if I lived in Iowa, Terry Branstad administering my healthcare. (APPLAUSE) (CHEERING) I– I think– I think as Democrats, we ought to proudly support the Affordable Care Act, improve it, and make it the model that we know it can be–

The middle paragraph in Clinton's reply above is disingenuous; it makes people fear what they're losing while mischaracterizing what they get in exchange. Here's Sanders on his proposal:

BERNIE SANDERS: We don’t– we don’t eliminate Medicare. We expand Medicare to all people. And we will not, under this proposal, have a situation that we have right now with the Affordable Care Act. We’ve got states like South Carolina and many other Republican states that because of their right-wing political ideology are denying millions of people the expansion of Medicaid that we passed in the Affordable Care Act. Ultimately, we have got to say as a nation, Secretary Clinton, is healthcare a right of all people or is it not?

As I said, the debate has been reignited on the left. It's also been reignited among the populace, as more and more people are finding they don't qualify for subsidies but can't pay the premiums without signing up for large deductibles:

Many Say High Deductibles Make Their Health Law Insurance All but Useless

Obama administration officials, urging people to sign up for health insurance under the Affordable Care Act, have trumpeted the low premiums available on the law’s new marketplaces.

But for many consumers, the sticker shock is coming not on the front end, when they purchase the plans, but on the back end when they get sick: sky-high deductibles that are leaving some newly insured feeling nearly as vulnerable as they were before they had coverage.

“The deductible, $3,000 a year, makes it impossible to actually go to the doctor,” said David R. Reines, 60, of Jefferson Township, N.J., a former hardware salesman with chronic knee pain. “We have insurance, but can’t afford to use it.” ...

That's just a taste; much more at the link.

You can see the controversy, which in truth started the day the ACA was proposed and which has more or less never stopped, even on the left. The problem for single-payer (Medicare For All) advocates is, what to do? Has the failing private insurance industry, which the ACA was designed to prop up, fully and permanently occupied the space that should have belonged to a public program like Medicare? How can we "fix" ("improve" in Clinton's framing) the ACA in a way that gives us what, frankly, most citizens would support — again, Medicare for all of us?

Which is why this news is so intriguing...

UnitedHealth May Quit Obamacare Market

The industry that ACA was designed to prop up may be starting to abandon it. Bloomberg:

UnitedHealth May Quit Obamacare Market in Blow to Health Law

The U.S.’s biggest health insurer is considering pulling out of Obamacare, a month after saying it would expand its presence in the program.

UnitedHealth Group Inc. is scaling back marketing efforts for plans it’s selling this year under the Affordable Care Act, and may quit the business entirely in 2017 because it has proven to be more costly than expected. It’s an abrupt shift from October, when the health insurer said it was planning to sell coverage in 11 new markets next year, bringing its total to 34. The company also cut its 2015 earnings forecast.

A pull-back would deal a significant blow to President Barack Obama’s signature domestic policy achievement. While UnitedHealth has been slower than some of its rivals to sell Obamacare policies since new government-run marketplaces for the plans opened in late 2013, the announcement may indicate that other insurers are struggling, said Sheryl Skolnick, an analyst at Mizuho Securities.

“If one of the largest and presumably, by reputation and experience, the most sophisticated of the health plans out there can’t make money on the exchanges, then one has to question whether the exchange as an institution is a viable enterprise,” Skolnick said.

UnitedHealth said it suspended marketing its individual exchange plans and is cutting or eliminating commissions for brokers who sell the coverage. ...

There's quite a bit more. For example:

Insurers have struggled to profit from the government-run marketplaces created by Obamacare. About a dozen non-profit “co-op” plans created under the Affordable Care Act have failed, after charging too little to cover the cost of patients’ medical care, and because an Obama administration fund designed to stabilize the market paid out just 12.6 percent of what insurers requested. And Anthem last month said some rivals were offering premiums too low to provide the coverage patients require and book a profit.

If the industry that ACA was supposed to benefit won't offer policies, and if policies that are offered are unaffordable for those who fall "in the cracks" of the population that was supposed to benefit, what's next for ACA?

Letting the Blackmailer Kill the Hostage

The argument all along for Obama's health care proposal, minus his never-intended-to-be-enacted public option, was the number of uninsured Americans combined with the lack of alternatives the administration would support. If you wanted to insure uninsured Americans, you could take ACA as offered, or take nothing. For progressives in the House, who insisted on a public option (though most supported single-payer), this was a very tough vote. Would they bend to administration blackmail — "Vote for the ACA or millions go without health insurance" — or would they tell the blackmailer, "You're the one with the power. You're the one with the gun. It's not my fault you didn't give us a bill we could vote for."

Ultimately, the entire House progressive caucus took "Dennis Kucinich's plane ride" and enough let the blackmailer win, thus passing the ACA into law. They couldn't, in our blackmail metaphor, let the blackmailer kill the hostage. Perhaps the right decision, perhaps not, but it's why we're here today.

Will Health Insurers Kill the ACA?

But the ACA's holes, its inadequacies, its dependence on the private health insurance industry to "do the right thing," remain. UnitedHealth is not "doing the right thing," if the right thing is serving the public. They are doing the right thing if the right thing is serving themselves and their CEO compensation package:

UnitedHealth CEO Stephen Hemsley made more than $66 million in 2014

CEO Pay Watch UnitedHealth Group Inc.
Stephen Hemsley, CEO
Total compensation: $66,125,208 for the year ended Dec. 31, 2014
Salary: $1,300,000
Non-equity incentive pay: $3,949,000
Other compensation: $107,479
Exercised stock options: $45,569,049
Value realized on vesting shares: $15,199,680
New stock options: 83,918

Keep that in mind the next time someone talks about a CEO's "salary." Hemsley made $66 million with a base salary of just $1.3 million. Nice multiplier. His "non-equity incentive pay" alone was three times that. Tell me he's not a predator.

The broader point though may be more important than one man's predation. If progressives weren't able to replace the ACA with Medicare for All, will the insurance companies inadvertently do the job instead, by killing the ACA themselves and clearing space for a rewrite?

Is this the end of the ACA? Stranger things have happened.

(Blue America has endorsed Bernie Sanders for President. If you'd like to help him, click here. This page also lists every progressive incumbent and candidate who has endorsed him. You can adjust the split in any way you wish.)

GP