If you have anything bad to say about kids today, just shut up
I guess you could find something wrong with some kid, somewhere, but come on. Data are from the 2016 National Survey on Drug Use and Health. In each of these charts, kids 12-17 are the RED LINE.
Things don’t look good for all age groups, but for adolescents – the red line – we’re pretty much at the lows. Not to mention teen pregnancy rates and teen births continue their all time lows. What more do you want from them?
Healthcare Triage News: Congress is Back, and Healthcare Should Be on the To-do List
Congress is back in session, and it has a full month ahead. They have to deal with hurricanes, raise the debt limit, fund the government, keep us out of war, AND they want to talk about cutting taxes, too. With all this going on, it’s going to be hard to get anything done around healthcare, but there’s lots that needs to be done.
The basic structure of the American health care system, in which most people have private insurance through their jobs, might seem historically inevitable, consistent with the capitalistic, individualist ethos of the nation.
In truth, it was hardly preordained. In fact, the system is largely a result of one event, World War II, and the wage freezes and tax policy that emerged because of it. Unfortunately, what made sense then may not make as much right now.
Well into the 20th century, there just wasn’t much need for health insurance. There wasn’t much health care to buy. But as doctors and hospitals learned how to do more, there was real money to be made. In 1929, a bunch of hospitals in Texas joined up and formed an insurance plan called Blue Cross to help people buy their services. Doctors didn’t like the idea of hospitals being in charge, so some in California created their own plan in 1939, which they called Blue Shield. As the plans spread, many would purchase Blue Cross for hospital services, and Blue Shield for physician services, until they merged to form Blue Cross and Blue Shield in 1982.
Most insurance in the first half of the 20th century was bought privately, but few people wanted it. Things changed during World War II.
In 1942, with so many eligible workers diverted to military service, the nation was facing a severe labor shortage. Economists feared that businesses would keep raising salaries to compete for workers, and that inflation would spiral out of control as the country came out of the Depression. To prevent this, President Roosevelt signed Executive Order 9250, establishing the Office of Economic Stabilization.
This froze wages. Businesses were not allowed to raise pay to attract workers.
Businesses were smart, though, and instead they began to use benefits to compete. Specifically, to offer more, and more generous, health care insurance.
Then, in 1943, the Internal Revenue Service decided that employer-based health insurance should be exempt from taxation. This made it cheaper to get health insurance through a job than by other means.
After World War II, Europe was devastated. As countries began to regroup and decide how they might provide health care to their citizens, often government was the only entity capable of doing so, with businesses and economies in ruin. The United States was in a completely different situation. Its economy was booming, and industry was more than happy to provide health care.
This didn’t stop President Truman from considering and promoting a national health care system in 1945. This idea had a fair amount of public support, but business, in the form of the Chamber of Commerce, opposed it. So did the American Hospital Association and American Medical Association. Even many unions did, having spent so much political capital fighting for insurance benefits for their members. Confronted by such opposition from all sides, national health insurance failed — for not the first or last time.
In 1940, about 9 percent of Americans had some form of health insurance. By 1950, more than 50 percent did. By 1960, more than two-thirds did.
One effect of this system is job lock. People become dependent on their employment for their health insurance, and they are loath to leave their jobs, even when doing so might make their lives better. They are afraid that market exchange coverage might not be as good as what they have (and they’re most likely right). They’re afraid if they retire, Medicare won’t be as good (they’re right, too). They’re afraid that if the Affordable Care Act is repealed, they might not be able to find affordable insurance at all.
This system is expensive. The single largest tax expenditure in the United States is for employer-based health insurance. It’s even more than the mortgage interest deduction. In 2017, this exclusion cost the federal government about $260 billion in lost income and payroll taxes. This is significantly more than the cost of the Affordable Care Act each year.
This system is regressive. The tax break for employer-sponsored health insurance is worth more to people making a lot of money than people making little. Let’s take a hypothetical married pediatrician with a couple of children living in Indiana who makes $125,000 (which is below average). Let’s also assume his family insurance plan costs $15,000 (which is below average as well).
The tax break the family would get for insurance is worth over $6,200. That’s far more than a similar-earning family would get in terms of a subsidy on the exchanges. The tax break alone could fund about two people on Medicaid. Moreover, the more one makes, the more one saves at the expense of more spending by the government. The less one makes, the less of a benefit one receives.
The system also induces people to spend more money on health insurance than other things, most likely increasing overall health care spending. This includes less employer spending on wages, and as health insurance premiums have increased sharply in the last 15 years or so, wages have been rather flat. Many economists believe that employer-sponsored health insurance is hurting Americans’ paychecks.
There are other countries with private insurance systems, but none that rely so heavily on employer-sponsored insurance. There are almost no economists I can think of who wouldn’t favor decoupling insurance from employment. There are any number of ways to do so. One, beloved by wonks, was a bipartisan plan proposed by Senators Ron Wyden, a Democrat, and Robert Bennett, a Republican, in 2007. Known as the Healthy Americans Act, it would have transitioned everyone from employer-sponsored health insurance to insurance exchanges modeled on the Federal Employees Health Benefits Program.
Employers would not have provided insurance. They would have collected taxes from employees and passed these onto the government to pay for plans. Everyone, regardless of employment, would have qualified for standard deductions to help pay for insurance. Employers would have been required to increases wages over two years equal to what had been shunted into insurance. Those at the low end of the socio-economic spectrum would have qualified for further premium help.
This isn’t too different from the insurance exchanges we see now, writ large, for everyone. One can imagine that such a program could have also eventually replaced Medicaid and Medicare.
There was a time when such a plan, being universal, would have pleased progressives. Because it could potentially phase out government programs like Medicaid and Medicare, it would have pleased conservatives. When first introduced in 2007, it had the sponsorship of nine Republican senators, seven Democrats and one independent. Such bipartisan efforts seem a thing of the past.
We could also shift away from an employer-sponsored system by allowing people to buy into our single-payer system, Medicare. That comes with its own problems, as The Upshot’s Margot Sanger-Katz has written. She also has covered the issues of shifting to a single-payer system more quickly.
It’s important to point out that neither of these options has anything even close to bipartisan support.
Without much pressure for change, it’s likely the American employer-based system is here to stay. Even the Affordable Care Act did its best not to disrupt that market. While the system is far from ideal, Americans seem to prefer the devil they know to pretty much anything else.
After a dramatic series of failed Senate votes in July, there’s one repeal-and-replace plan for the Affordable Care Act left standing. Trump is pushing for a vote, per Politico, and John McCain has announced his support, but the bill has yet to gain significant traction.
The proposal, crafted by Sens. Bill Cassidy (R-La.), Lindsey O. Graham (R-S.C.) and Dean Heller (R-Nev.), essentially turns control of the health-care markets over to the states. Rather than funding Medicaid and subsidies directly, that money would be put into a block grant that a state could use to develop any health-care system it wants. It also allows states to opt out of many ACA regulations. “If you like Obamacare, you can keep it,” Graham has said, using a common nickname for the health-care law. “If you want to replace it, you can.”
In reality, that may not be true. The Medicaid expansion and subsidy funding would be cut sharply compared to current spending, going to zero in a decade.
“You can’t actually keep the same program if your federal funding is being cut by a third in 2026,” said Aviva Aron-Dine, a senior fellow at the left-leaning Center on Budget and Policy Priorities. And even putting aside the cuts, she said, the block grant structure would fundamentally change the health-care landscape. “[Funding] is capped, so it wouldn’t go up and down with the economy,” when fewer or more people become eligible for subsidies.
Republicans contest this. The drop in funding “gives strong incentives for the states to be more efficient with their program,” said Ed Haislmaier, a senior fellow at the conservative Heritage Foundation. That is, states may be able to maintain the ACA structure and regulations as long as they streamline operations.
If the streamlining turns out to be insufficient, the cuts would hit liberal states the hardest, according to a report by the Center for Budget and Policy Priorities. This is largely because they tend to be the biggest spenders on health care: They’ve expanded Medicaid and aggressively signed people up for marketplace coverage. They have the most to lose.
On the whole, Aron-Dine says, “This is a lot more similar to the [Senate repeal bill] than different. All of them end with devastating cuts to marketplace subsidies, Medicaid, and weakening of consumer protections.”
Haislmaier agreed, pointing out the Cassidy-Graham plan was originally intended as an amendment to the Senate bill.
Here’s the nitty gritty of what would change, compared to the ACA and the Senate plan that failed in July:
Under the Cassidy-Graham plan, the mandates would be eliminated at the federal level. States could choose to keep the measure, replace it or get rid of it completely.
The federal health insurance subsidies that help most people with ACA marketplace plans afford their coverage would change. This bill would shift those subsidies to the state-level, so people in some states may see their subsidy scaled back or eliminated.
The bill would restructure Medicaid and decrease its funding. That would make it very difficult for states to maintain the Medicaid expansion.
http://www.politico.com/story/2017/09/05/trump-obamacare-repeal-senate-242346
The odds are slim, but the White House still hopes for action on a bill drafted by Lindsey Graham and Bill Cassidy.
President Donald Trump and some Senate Republicans are refusing to give up on Obamacare repeal, even after this summer’s spectacular failure and with less than a month before a key deadline.
The president and White House staff have continued to work with Republican Sens. Lindsey Graham of South Carolijna and Bill Cassidy of Louisiana over the summer on their proposal to block grant federal health care funding to the states. And though the bill is being rewritten and Congress faces a brutal September agenda, Trump and his allies on health care are making a last-gasp effort.
“He wants to do it, the president does. He loves the block grants. But we’ve got to have political support outside Washington,” Graham said in an interview. He said the bill needs to have a “majority of the Republican governors behind the idea” to gain momentum in the Senate.
But there’s far more work to do even than that. Senate Majority Leader Mitch McConnell would need to find room on the packed calendar this month to hold another uncertain push to repeal Obamacare on party lines. The Senate has only until the end of the month to pass the measure using powerful budget reconciliation procedures, but is also planning to fund the government, raise the debt ceiling, write a new defense policy bill and extend a host of expiring programs.
Cassidy said he hopes to have the bill text finalized by this week and has declined to reveal details about what changed in the bill during August.
“We are still refining the legislative language — just things you got to clear up,” he said. “We think we have good legislation, good policy.”
The Congressional Budget Office would also still need time to analyze the cost of the bill, a process that could take several weeks.
Trump berated McConnell and the Senate GOP over the summer for falling one vote short of sending repeal into conference with the House in July, when Sen. John McCain of Arizona voted down the GOP’s “skinny” repeal bill. So the White House has continued to work on the Graham-Cassidy bill behind the scenes, seeing it as the best option to make progress, according to several administration officials.
The bill would keep most of Obamacare’s taxes and devolve many spending decisions to the states. It was submitted as an amendment to the repeal bill in July but did not receive a vote; aides say it could not pass the Senate in its current form.
Trump has intermittently told aides he wants progress on health care and is still frustrated that the bill failed. The White House’s legislative team has talked with Republican governors in recent weeks and is planning to bring more to the White House, according to one of the officials. Internally, White House officials say they have listened to concerns from governors and tried to tweak the state block grant formulas.
Hill leadership hasn’t played a central role in the effort.
McConnell said in Kentucky last month that the path forward is “somewhat murky” and pointed to efforts by Sen. Lamar Alexander (R-Tenn.) to stabilize insurance markets as one avenue forward, though he doubted Democrats’ resolve on the bipartisan effort.
“We’re going to see what Sen. Alexander and his team can do on a bipartisan basis. The Democrats have been pretty uninterested in any reforms. They’re really interested in sending money to insurance companies but not very interested in reforms,” McConnell said then.
Inside the White House, there is little hope that a health care bill can happen quickly, with a stacked legislative agenda. And some close to the president prefer he would focus on tax reform and other immediate fiscal issues.
The Senate parliamentarian has ruled that the chamber’s reconciliation instructions, which allow the GOP to evade a Democratic filibuster and the chamber’s 60-vote requirement, expire at the end of the month. Republicans are planning to use their next budget measure to pass tax reform via a simple majority. But Graham insisted there’s a short window to fulfill the party’s seven-year promise if the GOP goes into overdrive, starting this week.
“It’s possible, yes. But you’ve got to do it quickly … introduce it this week, have a hearing soon about the bill, then the process is set to actually take it to floor and vote,” Graham said. “Everything has to fall in place.”
http://www.chcf.org/publications/2017/08/california-workforce
California’s health care industry employed more than 1.4 million people in 2015. Five Almanac guides provide data on wages, education, and workplaces for selected health professions.
California’s health care industry employed more than 1.4 million people in 2015. Among these workers, nearly 55% were employed in ambulatory settings, about 25% in hospitals, and 20% in nursing or residential care facilities. An aging population, population growth, and federal health reform will likely contribute to increased demand.
This series of Quick Reference Guides from the CHCF California Health Care Almanac examines specific segments of the state’s health care workforce, focusing on pharmacists and pharmacy technicians, physician assistants, health diagnostic and treatment therapists, clinical laboratory scientists and technicians, and imaging professionals.
Among the trends:
The complete guides, as well as the 2014 editions, are available as Document Downloads.
State insurance officials pleaded with senators on Wednesday to quickly act to stabilize the ObamaCare markets, calling for a multiyear extension of key payments to help fund premiums for low-income customers.
Congress must pass a fix by the end of September to shore up the wobbly individual markets, several officials said, in particular funding for key ObamaCare insurer payments known as cost-sharing reductions (CSR).
“The CSR funding issue is the single most critical issue that you can address to help stabilize insurance markets for 2018 and potentially bring down costs,” Tennessee’s insurance commissioner Julie Mix McPeak told the Senate Health Committee.
The panel kicked off a series of hearings Wednesday on stabilizing the markets. If Congress can pass a bill, it would represent the biggest bipartisan update since President Obama signed the law in 2010.
Health committee Chairman Lamar Alexander (R-Tenn.) wants to find consensus by the end of next week. To sell the fix, he and ranking member Patty Murray (D-Wash.) held a private meeting with senators not on the committee and the witnesses who testified as Wednesday’s hearing.
“If we can do two things, that would be two more things that we have agreed on in a bipartisan way in the last seven years in health insurance,” Alexander told reporters.
“And then let the leaders see if we can pass it, and hope the House does and that the president signs it.”
Despite some pushback that could still come from conservatives calling the payments an “insurer bailout,” Alexander and Murray hope to cobble together a bipartisan group that agree some continuation of the payments is necessary.
The cost sharing subsidies, which reimburse insurers for giving discounted deductibles and co-pays to low-income customers, have been made by the Trump administration on a month-to-month basis.
Republicans had sued the Obama administration over the payments, calling them unconstitutional, but many have since acknowledged they need to continue at least in the near term to prevent steep premium hikes.
Insurers have asked for long-term certainty on the payments, threatening to hike premiums and leave the ObamaCare markets altogether if they don’t get it.
Democrats, and some Republicans like Alexander, agree Congress should fund the payments, but there’s disagreement on the time frame.
Alexander wants to fund the payments through 2018 while Murray has pushed for multiple years.
“It is critical that we work toward a multiyear solution in order to provide the kind of certainty that will have the most impact on families’ premiums and choices in the marketplaces,” Murray said.
America’s Health Insurance Plans, the nation’s largest insurer trade association, and other stakeholder groups urged Congress to fund the payments through at least 2019.
“Without two years of CSR funding, uncertainty will persist and the Congress will need to address these same issues early next year,” the groups wrote in a letter to the committee Tuesday.
Meanwhile, Republicans say a bipartisan health bill must include changes to ObamaCare’s state waivers so states have more control over what their insurance plans look like.
Alexander said ObamaCare’s waivers should be amended so “states can have more flexibility to devise ways to provide more coverage with more choices and lower costs.”
“It just hasn’t been very appealing to states because it is a difficult tool to use,” he said.
This point was echoed by Pennsylvania’s insurance commissioner Theresa Miller, who called the process to get approved cumbersome.
“Baseline coverage requirements should be kept intact as much as possible … but make it easier for states to respond to market issues,” she said.
For example, it takes at least six months to get a waiver approved with the federal government, which the commissioners said made it difficult to quickly respond to market issues.
But Democrats have been wary of anything they say could result in coverage losses and the availability of less comprehensive insurance plans.
The Senate GOP’s ObamaCare repeal plan, which failed in a dramatic vote with Sen. John McCain (R-Ariz.) joining two other Republicans in opposition, contained language intended to make it easier for states to approve less comprehensive plans.
However, Democrats say that is going in the wrong direction.
We should be “moving forward not backward on affordability, coverage and quality of care,” Murray said.
“We’re all well aware threading this needle won’t be easy,” she said, “but I do believe an agreement that protects patients and families from higher costs and uncertainty, and maintains the guardrails in our current health care system, is possible.”
Several commissioners also recommended setting up a temporary reinsurance program to help insurers with high cost patients with the intent of lowering premiums for healthier ones.
“Congress should enact a federal reinsurance program with a minimum duration of three years,” said Washington state insurance commissioner Mike Kreidler, adding that it would “significantly help stabilize the individual health insurance market.”
But Alexander indicated it’s unlikely for the bill to include reinsurance funding, noting that the U.S. is already trillions in debt.
“If a reinsurance program is such a good idea … why don’t states do it?” he asked, suggesting states impose small fees on every insurance plan sold to help fund it.
Democrats are also pushing for a bill to restore ObamaCare outreach funding after the Trump administration announced drastic cuts to the program.
Alaska’s insurance director Lori Wing-Heier said the cuts concern her because “these programs reduce the number of uninsured citizens and maximize public participation.”
A Pennsylvania insurance official told Congress Wednesday that ObamaCare is not collapsing, as some Republicans have argued.
Speaking at a Senate Health Committee hearing on efforts to stabilize Affordable Care Act (ACA) markets, Teresa Miller, Pennsylvania’s acting Human Services secretary and former insurance commissioner, said that the notion is “just false.”
“I’m not going to sit here this morning and tell you that the ACA is perfect,” she said. “I think we all know that it’s not, but the narrative that the ACA is failing and imploding is just false.”
Miller, who works in the administration of Democratic Gov. Tom Wolf, noted that insurers in the state filed average premium increases of just 8.8 percent for next year, and that most enrollees receive government subsidies to help them afford premium costs.
While there have been “difficulties” in the market, she said, “our individual market is not collapsing.”
Other states have encountered more problems with their markets, but every state is on track to have at least one insurer offering ObamaCare coverage in every county next year, after some worries that there would be empty counties.
The insurance commissioners testifying largely called for efforts to further stabilize ObamaCare markets, for example by funding key payments known as cost-sharing reductions, which President Trump has threatened to cancel.
Multiple commissioners also called for a program called reinsurance that provides government funding to bring down premiums by paying for part of especially sick enrollees’ claims.
The Senate Health Committee is trying to reach a deal on a bipartisan stabilization bill by the end of next week, a tough task on such a polarizing issue.
According to findings reported by the Department of Health and Human Services Office of Inspector General (OIG), accountable care organizations (ACOs) participating in the Shared Savings Program are learning how to achieve greater cost savings over time. The Medicare Shared Savings Program is one of the largest alternative payment models implemented by CMS to reward providers for the quality and value of their services in order to keep patients healthy and lower costs.
The OIG’s report suggests many positive outcomes of the program, including that one-third of the ACOs that reduced their spending lowered costs enough to receive a portion of the savings. CMS data on quality measures also shows that ACOs generally improved the quality of care they provided, with a rate of 82% performance improvement on the individual quality measures within the first three years of the program. ACOs also outperformed fee-for-service providers on 81% of the quality measures.
A small portion of ACOs are reported to have gone above expectations, reducing Medicare spending by an average of $673 per beneficiary, including spending reductions for high-cost services such as inpatient hospital care and skilled nursing facility care. The OIG reports that these high-performing ACOs’ frequent use of primary care services, which can lower utilization and costs for other care, and cost reductions for services such as emergency department visits, was a factor in their cost savings. These strategies are compared to other Shared Savings Program ACOs and the national average for fee‐for‐service providers, who showed an increase in per beneficiary spending for key Medicare services.
The OIG concluded that ACOs show promise in reducing Medicare spending while also improving quality. These improvements come at a critical time, as Medicare spending is predicted to grow to $1.4 trillion by 2027. A large portion of Medicare spending has been attributed to overbilling, with the Medicare program losing more money to this error than any other program government-wide.
With the eclipse of Republican efforts to repeal and replace the Affordable Care Act (ACA), bipartisan approaches to improving the law are having a moment in the sun. This week, Senators Lamar Alexander (R-Tenn.) and Patti Murray (D-Wash.) are cosponsoring hearings before the Senate Health, Education, Labor and Pensions (HELP) committee on bipartisan solutions to stabilizing private health insurance markets. The Problem-Solvers — a new caucus of House Democrats and Republicans — are similarly at work on a cross-party package of reforms. Eight governors have released a bipartisan plan, as has a group of health policy experts with mixed party affiliations.
The value of bipartisanship is indisputable. The alternative — on excruciating display over the last seven months — is ongoing partisan warfare that destabilizes our health care system. Health care providers and insurers cannot function effectively when changes in party control at the federal level threaten to upend the health care system every two to four years. And the fear of health coverage loss is unquestionably stressful for the millions of Americans who depend upon the ACA.
But the growing apparent consensus on key elements for a short-term, cross-party package is encouraging. These proposals focus on strengthening individual insurance marketplaces by legislating cost-sharing reduction payments; helping private insurers manage the risk of very high-cost patients using reinsurance and other means; creating a source of backup coverage for “bare markets” that lack private insurers; and offering states greater flexibility in implementing federal regulations governing private insurance markets.
Different groups propose additional bells and whistles, and there is much room for disagreement on how to design and implement specific provisions. But at least both parties are at the table. Where there’s a will, there may be a way.
Still, important practical questions remain. One is whether the will really exists. Republican supporters of repeal and replace continue to divide the Senate Republican caucus. Conservatives in the House — including the Freedom Caucus — will likely oppose anything that threatens their hope that the ACA will collapse of its own weight. And it is possible that President Trump, still grumbling about the failure of repeal and replace, will veto any narrow package that he believes pours salt in his health care wound.
Ironically, the failure of ACA markets to self-destruct may also sap the will for bipartisan reforms. Deadlines and crisis drive congressional action and, until recently, the threat that some individual markets — admittedly, small in number and population — would lack any insurer was an important spur for Congress to act. Now, that threat has receded as the last of the bare markets has found a carrier. Bipartisanship is the legislative equivalent of nuclear fusion; it needs major external pressure to push those mutually repelling atoms together.
Even if there were a will, there might not be a way to get an ACA package into the queue. The fall congressional calendar is packed with other high-profile, high-stakes, deadline- and crisis- driven legislation. By September 30, Congress must reauthorize the Children’s Health Insurance Program (CHIP), which has traditionally enjoyed bipartisan support and is vital to the health care of more than 9 million American children. To respond to Hurricane Harvey, Congress also needs to rapidly enact emergency aid for Texas and Louisiana, which will require the extension of previously controversial flood relief legislation.
And these measures are just the beginning. Congress has to fund the federal government by September 30 — with or without support for the border wall — or face a government shutdown. There is the need to pass a controversial increase in the federal debt ceiling by the same date. And to have any hope of enacting major tax reform before the 2018 election, work must accelerate right after Labor Day. Putting the tax project off until after January is dangerous for proponents, because passing controversial tax legislation is infinitely more difficult in an election year.
Bipartisanship on health care action could lay vital groundwork in the short term for bolstering the individual health insurance market. Longer term, bipartisanship is essential for the kind of fundamental change that is necessary to increase coverage and contain costs in our health care system. We should not, however, underestimate the huge political and procedural obstacles that lie in the way of current admirable efforts to bring the two parties together on health care. It will take all the skill of committed Senate and House leaders from both parties to make progress on health care this year — or thereafter.
HENRY KOTULA 