Monthly Archives: July 2019

Saving Thomas Jefferson’s soul

Posted on by • Posted in Direct Communication, Founding Fathers, Human Morality, Human Reasoning, Independence Day, Intellectual Liberty, Personal Rights, Thomas Jefferson • Leave a comment

https://www.washingtonpost.com/history/2019/07/03/saving-thomas-jeffersons-soul/?fbclid=IwAR20Yp3YntVqipx8IN2Q7F3sd8TSZFeAcf7vBGdj-8UW-CHhwOjbT8AXE5c&utm_term=.34e27bf5b4c0

In a long letter, a mariner-turned-minister worried about Jefferson’s salvation. The founding father’s response was remarkable.

One midnight in the spring of 1814, Miles King, a pious former sea captain in Mathews, Va., woke up thinking about Thomas Jefferson’s soul.

When it happened again a month later, King took it as a sign. So he put quill to parchment and wrote a letter to the former president, who had retired to Monticello, his estate in Virginia.

In the grip of what he considered divine inspiration, King let it rip. His letter is something like 8,000 words — equivalent to about 32 typed pages. But the basic message is simple: All your accomplishments mean nothing if you don’t adopt Christian zeal before you die.

Miraculously, Jefferson responded. His reply is the calm, respectful rebuttal most people only dream of writing to a critic. Jefferson also offered a sincere and moving declaration of freedom of thought. As a slave owner, he may not have lived his ideals. But almost four decades after writing the Declaration of Independence, Jefferson could set out the words of liberty in ways that few can match and that continue to inspire.

With all the correspondence that swamped Jefferson, it must have taken great patience to wade through King’s stream of consciousness, which unfolds in loops of exhortations and references to Scripture.

But buried in there is the hint of a fascinating tale. King says he was “brought up to the Sea,” commanding a trading vessel to Europe from an early age. He spent a couple of years in the Navy during the John Adams administration, then resumed being a prosperous sea captain. He “was much disposed to a luxurious life of debauch and intrigue,” he writes. “I lived a life of pleasure and gaiety, with now and then a hair Breadth escape from death, either by shipwreck or other casualty.” He hosted parties and weekly card games and generally caroused with a bunch of other rich sots.

You’d like to hear more about that guy. But after his second wife died, he married a wealthy widow who eventually prevailed on him to go to church. There, King learned the error of his ways. He renounced his old life and became a Methodist minister.

He viewed the world darkly. The new nation had wandered from God, as evidenced by the latest clash with Great Britain. “Our impiety hath provoked this war upon us,” King wrote. Judgment Day is coming soon, he warned, and the people need pious leaders to show them the path to righteousness.

“It is not sufficient that our rulers & private worthies . . . merely tolerate religion: they must themselves become religious — thier Light must shine to the Glory of God!” he wrote.

King had a high opinion of Jefferson, of course, but other people were saying some troubling things about the great man.

“I had often heard you indignantly called, deist, infidel, illuminati &c &c,” King wrote. Surely, Jefferson did not want to be lumped in with “horrid” figures such as Voltaire and other free thinkers who questioned the value of central religion? Their writings had “poisoned the minds & proved fatally ruinous to many.”

There can be no neutrality on religion, King argued — and he quoted the gospel of Matthew to say that whoever is not for it is against it. “Does this quotation,” he asked Jefferson, “not rub you pretty close Sir?”

With the earthly world soon ending, he beseeched Jefferson not to be satisfied with rational thought and simple faith in the divine — what King called “head religion.” “Never rest untill you feel it in the heart! Influencing all Your words and actions & regulating the thoughts of your heart!” Saying he had heard that Jefferson was reading the prophecy of Isaiah, he quoted another Bible verse to ask, “Understandest thou what thou readest therein?”

He closed with the wish that he would one day meet Jefferson in the “Kingdom of Everlasting Glory.”

Jefferson wrote back a little more than a month later. He thanked King for his letter “because I believe it was written with kind intentions, and a personal concern for my future happiness.”

As for whether King’s revelations were directly from God, “your reason alone is the competent judge.” Human reasoning “is the only oracle which god has given us to determine between what really comes from him, & the phantasms of a disordered or deluded imagination,” Jefferson wrote. (On social media he might have added: “Just sayin’.”)

With lawyerly guile, Jefferson said that if God wanted to give him a direct communication, he would “obey it with the same fidelity with which I would obey his known will in all cases.”

Until then, he wrote, humans may use the power of reason gifted to them by God to figure things out for themselves. Sometimes that means making a mistake, he added. But in that case, he said, “I have trust in him who made us what we are, and knows it was not his plan to make us always unerring.”

God is too far above humans to take pleasure or pain from their actions, he explained. Instead, the purpose of human morality is to guide people in their treatment of others: “by acting honestly towards all, benevolently to those who fall within our way, respecting sacredly their rights bodily and mental, and cherishing especially their freedom of conscience, as we value our own.”

Jefferson’s failure to live by those words on the crucial matter of enslavement is something that history — if not his maker — must judge him for. But his vision of personal rights and intellectual liberty remain central to the country’s founding principles. In this letter, Jefferson put those revolutionary concepts on a personal scale. It’s good advice, and just as provocative today as it must have been 200 years ago.

Religious beliefs, he told King, “are a subject of accountability to our god alone. I enquire after no man’s, and trouble none with mine.”

He argued that humans have no way to know which type of religion is “exactly the right.” In heaven, he said, there are no denominations — “not a quaker or a baptist, a presbyterian or an episcopalian, a catholic or a protestant.”

“Let us not be uneasy then,” he wrote, “about the different roads we may pursue, as believing them the shortest, to that our last abode: but, following the guidance of a good conscience, let us be happy in the hope that, by these different paths, we shall all meet in the end.”

He closed with a salute of “brotherly esteem and respect.”

King apparently didn’t write Jefferson again.

Two years later, King sent a similar — and only slightly shorter — entreaty to another of the founders, James Madison.

Madison’s reply was brief. He thanked King for his concern, but said that letters on religious subjects “have been so numerous and of characters so various, that it has been an established rule to decline all correspondence on them.”

Thank God that Jefferson had a different policy.

 

 

Downside risk contracts still less common for ACOs, study finds

Posted on by • Posted in ACA, Accountable Care Organization (ACO), Downside Risk, Health Insurance Industry, Health System, Hospital, Hospital Industry • Leave a comment

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The proportion of ACOs taking on downside risk remained relatively stable, with the majority in upside-only risk contacts.

While the number and variety of contracts held by Accountable Care Organizations have increased dramatically in recent years, the proportion of those bearing downside risk has seen only modest growth, according to a new study published in Health Affairs.

ACOs, which use financial incentives in an effort to improve patient care and reduce healthcare costs, have become one of the most commonly implemented value-based payment models by payers. In 2018, there were more than 1,000 ACOs nationally, covering an estimated 33 million lives and including more than 1,400 different payment arrangements.

Yet debates about the impact of the ACO model persist, especially pertaining to the contribution of downside risk, in which ACOs share responsibility for financial losses with payers if the former fail to meet their targets.

WHAT’S THE IMPACT

To help improve understanding of the rapid growth and evolution of ACOs, the research team analyzed ACO structure and contracts over a six-year period from 2012-2018, using data from the National Survey of Accountable Care Organizations.

They found that while the number of ACOs had grown fivefold during that time period, the proportion of ACOs taking on downside risk remained relatively stable — increasing from 28 percent in 2012 to 33 percent in 2018. Overall, the majority were upside-only risk contracts, which reward cost and quality improvements but do not financially penalize poor performance.

There’s concern among industry experts that these kinds of contracts might not provide adequate incentives to boost ACO performance.

When examining the leadership, services and size of ACOs, the researchers said those bearing downside risk were less likely to be physician-led or physician-owned, more likely to be part of larger, integrated delivery systems (that included hospitals), had more participating physicians, and were more likely to provide services such as inpatient rehabilitation, routine specialty care, and palliative or hospice care.

In addition, the authors found that ACOs with downside risk contracts were more likely to have participating providers who had experience with other forms of payment reform, such as bundled or capitated payments, and had more ACO contracts across payer types — Medicare, commercial and Medicaid.

THE LARGER TREND

The authors said increasing the number of ACO payment contracts per ACO suggests a broadening of financial incentives around value-based care, but that there’s been “stagnation in the proportion of ACOs with deeper financial incentives.” In 2018, just one-third chose contracts with downside risk.

CMS recently issued a rule mandating that ACOs take on financial risk sooner.

 

Democrats have lurched leftward on health benefits for undocumented immigrants

Posted on by • Posted in 2020 Election Issues, Health Policy, Undocumented Immigrants • Leave a comment

https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2019/07/01/the-health-202-democrats-have-lurched-leftward-on-health-benefits-for-undocumented-immigrants/5d18b0a61ad2e552a21d51bf/?utm_term=.63e054feab31

President Trump could barely hide his glee when every one of his potential Democratic opponents shot up their hands at Thursday night’s debate when asked whether undocumented immigrants should be included in government health plans.

And for a clear reason. Extending public benefits to immigrants who are in the United States illegally has long been a fraught issue, even among Democrats. Nine years ago, the Democratic-led Congress banned such immigrants from the Obamacare marketplaces — even if they use their own money to buy a plan — and even the most liberal states have struggled to expand coverage to the undocumented population. Undocumented immigrants are excluded from the Medicare and Medicaid programs, with some exceptions for children and pregnant women.

It’s hardly the first time a Republican has pounced on a Democrat for appearing to support government health benefits to the undocumented. Many will recall the infamous moment in 2009 when Rep. Joe Wilson (R-S.C.) yelled, “You lie!” in the House chamber as President Obama told them health proposals wouldn’t cover undocumented immigrants.

Wilson was wrong — the eventual ACA did indeed exclude undocumented immigrants from health insurance expansions, as Obama had promised. But this is one of several issues on which the 2020 Democratic contenders are now moving quite a bit further leftward as they seek the presidential nomination. They’re certainly far from where the last Democratic presidential nominee — Hillary Clinton — stood on the issue.

In her 2016 health-care platform, Clinton would have allowed undocumented immigrants to buy marketplace plans, one step further than the ACA’s outright ban. But she would have still excluded them from getting the ACA’s income-based subsidies, increasing the likelihood undocumented immigrants still couldn’t find affordable coverage.

Rewind to two decades before that, to when Clinton as first lady was trying to get a health-care revamp passed from her perch at the White House. At the time, the first lady expressed concern that extending benefits to the undocumented could encourage more people to enter the country illegally.

“We do not think the comprehensive health-care benefits should be extended to those who are undocumented workers and illegal aliens,” Clinton told Congress in 1993. “We know now that too many people come in for medical care, as it is. We certainly don’t want them having the same benefits that American citizens are entitled to have.”

The Democrats onstage last Thursday sounded a lot different.

NBC moderator Savannah Guthrie posed this question to them after an extended discussion about the Medicare-for-all and public option plans they are proposing to offer Americans:

“A lot of you have been talking tonight about these government health care plans that you have proposed in one form or another,” Guthrie said. “Raise your hand if your government plan would provide coverage for undocumented immigrants.”

All the candidates — which included the two front-runners, former vice president Joe Biden and Sen. Bernie Sanders (I-Vt.) — raised their hands in response.

But Biden’s stance was notable, considering where mainstream Democrats used to stand on the issue. “You cannot let people who are sick, no matter where they come from, no matter what their status, go uncovered,” Biden said on the stage. “It’s just going to be taken care of, period … it’s the humane thing to do.”

Both Biden and South Bend, Ind., Mayor Pete Buttigieg noted that undocumented immigrants pay Social Security taxes if they have jobs and sales taxes when they purchase goods and services, arguing that’s another reason they should be included in public health-care programs.

“This is not about a handout,” Buttigieg said. “This is an insurance program. And we do ourselves no favors by having 11 million undocumented people in our country be unable to access health care.”

To Buttigieg’s point, there’s considerable evidence that helping people buy health insurance results in less spending in the long run. When hospital emergency departments care for uninsured patients, the hospitals end up passing along the costs to the insured patients, resulting in higher premiums for everyone.

Julian Castro, former HUD secretary under Obama, reiterated his support yesterday for giving health insurance to undocumented immigrants.

“What I’d like to Americans to know, right now, No. 1, undocumented immigrants already pay a lot of taxes,” Castro said on ABC’s “This Week with George Stephanopoulos.” “Secondly, we already pay for the health care of undocumented immigrants. It’s called the emergency room.”

That’s a reason California — home to about one-fifth of the country’s undocumented immigrants — recently passed a budget extending Medicaid to some of the undocumented. But it’s the only state to do so, and it chose the most limited, least-costly option.

Last week, Gov. Gavin Newsom (D) signed a $214.8 billion budget into law that extends California’s Medi-Cal program to undocumented adults ages 19 to 26. That measure also expands on the federal health-care law in a number of ways, reinstating its individual mandate to buy coverage — which Congress repealed a few years ago — and raising the income threshold for getting marketplace subsidies.

But the Medi-Cal expansion is only a shadow of what many state lawmakers wanted. The state’s Senate passed a bill also opening its door to undocumented immigrants over age 65, while the Assembly’s version would have opened it up to everyone. Newsom insisted on expanding coverage only to young adults, a much less expensive option estimated to cover 138,000 undocumented immigrants.

The political obstacles to such a move were evident back in 2010 when Congress was constructing the ACA and barred people in the country illegally from participating in any part of the law.

California took some steps in 2016 toward asking the federal government for permission to let undocumented immigrants buy marketplace coverage but withdrew its request over fears the young Trump administration might use the request to target immigrants for deportation. New York lawmakers have proposed similar legislation, but it hasn’t gained traction.

 

 

 

These are the judges holding Obamacare’s future in their hands

Posted on by • Posted in 2020 Election Issues, ACA, Appellate Court, Health Policy, Lawsuit, Supreme Court • Leave a comment

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Image result for aca in court

The future of Obamacare is at stake next week, when the country’s most conservative appeals court will consider whether to uphold a ruling striking down the whole law. But the politically fraught, high-stakes case is at least likely to get a fair hearing by three judges whose names were announced yesterday, legal experts say.

Two of the judges were GOP-appointed; they include Jennifer Walker Elrod, a George W. Bush appointee, and Kurt Damian Engelhardt, an appointee of President Trump. But they’re known for being some of the more measured and thoughtful members of the U.S. Court of Appeals for the 5th Circuit, distinct from other judges who might be more politically inclined.

“There’s no doubt there are a couple firebrand jurists out there … but none of those judges are on this panel,” New Orleans litigator Harry Morse, who has argued before Engelhardt, told me.

“There’s nothing about these three that strikes me that they’ll be looking for headlines or take a stand on anything other than their fair reading of the law,” he added. “They’re all pretty careful folks.”

A third judge, Carolyn Dineen King, was appointed by former Democratic president Jimmy Carter. She, along with Elrod and Engelhardt, will hear oral arguments on July 9 in the closely watched lawsuit brought by nearly two dozen GOP-led states who are trying to unravel the ACA, even after it survived years of court challenges and repeal attempts in Congress.

It’s a deeply disturbing situation for California and other Democrat-led states defending the health-care law, who fear its consumer protections and insurance expansions could be wiped out in a moment. They’ve stepped up to defend the law because President Trump’s Justice Department is refusing to do so — even though a decision overturning the law would create a logistical and political mess for the administration.

The states, led by Texas, were certainly strategic in where they mounted the challenge. The 5th Circuit — whose 16 active judges include 11 appointed by Republicans — is widely viewed as being more sympathetic to Republican arguments that the ACA must now be struck down because Congress repealed the basis for its constitutionality, the individual mandate to buy coverage.

Because the panels are chosen randomly, it would have been unlikely for the trio hearing next week’s ACA lawsuit to include three or even two judges appointed by Democrats. The Elrod-Engelhardt-King panel is a good reflection of the 5th Circuit’s overall makeup, said Barry Edwards, a lecturer at the University of Central Florida who has written about U.S. appeals courts.

“I’d say the Democratic states were hoping for a better panel, but this is the panel they expected,” Edwards said.

Engelhardt was sent to the 5th Circuit by Trump, who relies heavily on recommendations from the influential Federalist Society. But he was initially made a federal district judge by George W. Bush, indicating he may not be as far to the political right as the judges Trump tends to favor, Edwards told me.

Engelhardt has been on the 5th Circuit for a little more than a year, while Elrod has been on its bench since 2007.

Even those familiar with the 5th Circuit find it hard to predict how the panel will land on last year’s district court ruling striking down the entire ACA, the decision the states are appealing. Its ruling will have bearing on whether the Supreme Court agrees to hear yet another challenge to the ACA, after upholding most of the law in 2012 and then again in 2015.

Edwards guesses the appeals court will upheld the lower-court decision scrapping the health-care law — a scenario in which the Supreme Court would almost certainly take up the case, given how many people the law has touched. But Morse said it’s hard for him to believe the judges would agree to strike down the ACA given how many times it has survived past legal challenges.

“I know it’s two Republican judges and one Democratic judge, but the ACA has been challenged twice in front of the Supreme Court,” Morse said. “The argument being made is the ACA can’t survive without the individual mandate, and Congress has implicitly rejected that.”

Nicholas Bagley, a law professor at the University of Michigan who has watched the case closely, said he’s certain the Supreme Court will hear the case if the 5th Circuit strikes the law. But he doesn’t expect a SCOTUS review if it leaves the law in place.

“If the panel reverses, I’m not at all sure that the Supreme Court will take the case,” Bagley wrote me in an email. “It’s that goofy.”

Last week, before the judges’ names were announced, the appeals court questioned whether the Democratic-led states and the U.S. House have the right to appeal the lower-court decision striking the law. Bagley and some other legal scholars interpreted the request as boding poorly for the law’s future, while others said it was a reasonable request, my Washington Post colleague Yasmeen Abutaleb reported.

 

Trump craves big action on drug prices to take to the campaign trail

Posted on by • Posted in 2020 Election Issues, Food and Drug Administration (FDA), Health Insurance Coverage Adequacy, Health Policy, High Deductible Health Plans, High Drug Prices, Indecision, Leadership Implementation, Out of Pocket Expenses • Leave a comment

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There may be a modest slowdown this year in the growth of drug prices, but it’s nowhere near the seismic shift President Trump has called for. And that seems to be irking the president to no end.

Much of the president’s frustration has been borne by Health and Human Services Secretary Alex Azar, a former drug executive who until very recently pushed back on proposals to allow the importation of lower-cost drugs from Canada and give the government the tools to directly negotiate lower drug prices in the Medicare program, my Washington Post colleagues Yasmeen Abutaleb, Josh Dawsey and Laurie McGinley report.

But now, under intense pressure, Azar has reversed his long-standing opposition to at least one of those ideas: drug importation, an idea typically embraced by Democrats and dismissed by Republicans and the drug industry.

“Inspired by the president’s passion, Secretary Azar has been pushing FDA to go even bigger and broader on importation,” a senior administration official told my colleagues, although the official declined to detail specific policy changes.

It’s been a little more than a year since Trump promised Americans, in a speech from the Rose Garden, he would slash the price of prescription drugs in the United States. In that time, his administration has proposed some bold new regulations that could help move the needle, but only one has so far been finalized — a new requirement that went into effect this month for drugmakers to list prices in television ads.

While Azar has championed a proposal to eliminate the secretive rebates drug manufacturers pay to insurers, opposition to the idea from Domestic Policy Council head Joe Grogan is hamstringing the effort, my colleagues report. Grogan dislikes its estimated $180 billion price tag and doesn’t view the measure as central to the administration’s drug-pricing effort, they write.

There’s another proposal under review at the Office of Management and Budget to tie some Medicare drug prices to those paid by other countries, but it’s opposed by key Senate Republicans and the drug industry.

A senior administration official downplayed talk of tension between Azar and Grogan, saying the two, along with White House legislative affairs director Eric Ueland, speak three times a week about what is happening on Capitol Hill.

And on Monday, the New York Post published a joint op-ed by Azar and Grogan praising a recent executive order from Trump aimed at more transparency around the prices negotiated between hospitals and insurers.

“President Trump has promised a better vision: a health care system that treats you like a person, not a number,” Azar and Grogan write. “He wants to hold providers and Big Pharma accountable to transparency and reasonable prices.”

Meanwhile, drugmakers have continued hiking prices, albeit a bit more slowly on average. List prices for branded drugs grew 3.3 percent in this year’s first quarter, compared with 6.3 percent in the first quarter of 2018, according to SSR Health pharmaceutical analysts. Bernstein analysts told Politico that drug prices jumped 10.5 percent over the past six months, less than over the same period last year but still four times the rate of inflation.

Trump has frequently referenced some encouraging data from the consumer price index, where the index for prescription drugs fell by 0.6 percent for the 12 months ending in December, according to the Bureau of Labor Statistics. The index also dropped in January, February, March and May — a string of monthly declines not seen since 1973, my Post fact-checking colleagues recently noted.

Yet these data are a far cry from the drastic price reductions Trump would love to tout on the campaign trail as he seeks reelection in 2020.

“By all accounts, drug prices are a fixation for Trump, who frequently sends advisers news clippings and summons them to the White House to rant about the issue,” Yasmeen, Josh and Laurie write. “The guy likes to make money, and he thinks they make too much money,” said one former senior administration official.

A senior administration official told my colleagues there was frustration at a lack of executive branch tools to lower drug prices and that some of Trump’s ideas were ambitious but unworkable.

“Disagreements over how to proceed have created a policy free-for-all as different advisers — and the president himself — pursue what appear to be ad hoc and sometimes dueling approaches,” they write. “Trump entertains proposals usually pushed by progressive Democrats one moment and free-market GOP ideas the next.”