Forty Years of Winning Friends and Influencing People

https://www.chcf.org/blog/forty-years-of-winning-friends-and-influencing-people/

An interview with former US Representative Henry Waxman of California.

Of the more than 12,000 Americans who have served in Congress since it convened in 1789, few have had careers as fruitful as Henry Waxman’s. Representing west Los Angeles and its surrounding areas for 40 years, Waxman, 78, left a remarkable imprint on US health policy. His manifold accomplishments were capped by the passage of the Affordable Care Act (ACA) in 2010. A son of south-central Los Angeles, he worked at his father’s grocery store, earned a law degree at the University of California, Los Angeles, and in 1968 won a seat in the State Assembly. He was elected to the US House in 1974 in an era when bipartisanship was ordinary and health care had yet to become an overwhelming economic and political force in American life. Waxman was known in Congress for his persistence at wearing down opposition. Republican Senator Alan Simpson of Wyoming famously called him “tougher than a boiled owl” after negotiating the landmark Clean Air Act amendments of 1990. Waxman led efforts to ban smoking in public places and to require nutrition labels on food products. I talked with him recently about his experiences, the future of health policy, and the changing language of health reform. The transcript has been lightly edited for length and clarity.

Q: In 1974, when Los Angeles voters first sent you to Washington, health policy wasn’t the ticket to political influence. You are a lawyer, not a doctor. What drew you to health care?

A: When I was first elected to the California State Assembly in 1968, I believed that if I specialized in a policy area I would have more impact than if I tried to be an expert on everything. Health policy fit my district in Los Angeles, and I could see that government needed to be involved in a whole range of decisions, from health care services to biomedical research to public health. I was chairman of the Assembly Committee on Health. I was elected to Congress in 1974 in a Democratic wave election. I wanted to get on a health policy committee, which was Energy and Commerce. Democrats picked up so many seats and there were so many committee vacancies that year that it was easy to claim one, and I got on that committee. Within four years there was a vacancy for chair of the health and environment subcommittee, and I stepped up to that. It gave me a lot more impact.

Q: What role do you think health care will play in the upcoming elections?

A: If the Democrats do as well as I expect and hope, it will be more because of what Trump was doing in the health area than anything else. Even though people value health care services and insurance, the idea that the president and the GOP wanted to take away health insurance and reduce benefits for people who needed it — that was something they didn’t expect and were angry about.

Q: Is it feasible to provide health coverage to everyone?

A: I have always felt we needed access to universal health coverage. It wasn’t until we got the ACA under Obama that we were able to narrow the gap of the uninsured — those who couldn’t get insurance through their jobs, who weren’t eligible for Medicare and Medicaid, who had preexisting conditions, or who couldn’t afford the premiums. The ACA helped people have access to an individual health policy by eliminating insurance company discrimination and giving a subsidy to those who couldn’t afford coverage. It wasn’t a perfect bill, but it was important. The idea that Republicans would come along and bring back preexisting conditions as a reason to deny people coverage is what drove enough GOP senators to stop the GOP repeal bill from going forward last year. We’ll see what they do by way of executive orders or through the courts to try to frustrate people’s ability to buy insurance.

The Republican ACA repeal bill last year was a real shock because they also wanted to repeal the Medicaid program and allow states to cut funds for people in nursing homes, people with disabilities, and low-income patients who rely so heavily on that program. And they had proposals to hurt Medicare that House Speaker Paul Ryan had been advancing. The American people do not want to deny others insurance coverage and access to health services.

Q: Bipartisanship has gone out of style. Can it be revived?

A: It doesn’t look very likely now, but I built my legislative career on the idea that there could be bipartisan consensus to move forward on legislation. All the big bills had bipartisan support. The only bill that got through on a strictly partisan basis was the Obamacare legislation, and I regretted that. The Republicans just wanted to denigrate it and scare people into believing the ACA would provide for death panels, hurt people, take away their insurance, and keep them from getting access to care. None of that was true.

Q: A growing number of Democrats want to establish a single-payer health care system for the state. Do you agree with them?

A: A lot of people mistake the phrase “single payer” with universal health coverage. While I share the passion of people who want to cover everybody, single payer is not a panacea. My goal is universal health coverage. The Republican attempt last year to repeal the ACA and send 32 million Americans into the ranks of the uninsured was an albatross around their necks.

But the Democrats could turn this winning issue into a loser if some make a single-payer bill such as Medicare for All into a litmus test. I cosponsored single-payer legislation in Congress with Senator Ted Kennedy, and I always sought to bring the nation closer to universal coverage. I authored laws to bring Medicaid to more children and to establish the Children’s Health Insurance Program, and I led the fight to enact the ACA. These bills were very important. If we passed something like a single-payer bill, which would be extremely hard to do, we would be passing up opportunities to make progress. A lot of people who want a Medicare for All bill don’t realize that those of us on Medicare have to pay for supplemental insurance, because Medicare doesn’t cover everything. Medicare doesn’t generally cover certain services like nursing home care, so to get help you have to impoverish yourself to qualify for Medicaid.

One organization is sending out letters telling voters to support a single-payer bill and you won’t have to pay anything anymore. We can’t afford something like that. Democrats can embrace a boundless vision for a health care future without being trapped by a rigid model of how to get there. We should increase the number of people with comprehensive health insurance and focus on lowering costs. People with Medicare don’t want to give it up. People have health insurance on the job.

I would rather expand on what we have and build it out to cover everybody.

People don’t seem to remember that Democrats could barely muster the votes for the ACA when we had 60 votes in the Senate and a 255–179 majority in the House. Even if we recapture Congress and the presidency, I don’t think we would get a Medicare for All bill passed. It would require such a high tax increase that people would be absolutely shocked.

Q: What would be the national impact of California adopting a universal coverage plan?

A: Californian progress would be a model for the rest of the country, and we would be doing what’s right for the people of California who don’t have access to coverage. I think California is a trendsetter — for good and for bad. Proposition 13 and term limits started in California and spread to other states, and I think they have been a disservice. We’ve also done a lot of good things in California, and the rest of the country follows those things as well.

People who try to marginalize California do so at their own risk. People around the country look at California as a leader. California embraced the ACA, expanded Medicaid, and has been moving forward on making sure our public health care system is reforming itself to represent the needs for population health care and to ensure that uninsured low-income patients get access to decent, good-quality health care.

Q: More states are adopting work requirements in Medicaid. Do you think that will become the standard nationwide?

A: Work requirements are inconsistent with the Medicaid law. We’re talking about making people go to work to get health care when they’re sick. I just don’t think it makes sense. The courts may throw it out, and if not, at some point there will be a reaction against it, and it will be repealed by a future Congress.

Q: Some see parallels between the conduct of tobacco companies and opioid makers. Do you think “Big Pharma” will be held to account like “Big Tobacco?”

A: In the difficult fight against big tobacco, one of the lessons we learned was that even an extremely powerful group like the tobacco industry could be beaten if you keep pushing back. Even though there was overwhelming public support for regulation of tobacco, it took until 2009 before we could enact tobacco regulation by giving the Food and Drug Administration (FDA) authority to act. In the meantime, there were lawsuits by states to recover money they spent under Medicaid programs to cope with the harm from smoking. With opioids, there will be more and more lawsuits against distributors and manufacturers whose actions resulted in deaths of people from opioid addiction. Congress now is grappling with many bills to help people who are addicted, to prevent addiction from spreading further, and to restrict the ability to get the drug product. I’m optimistic we can come to terms with this crisis.

Q: What have you been doing since retiring from Congress?

A: I wanted to stay in the DC area near my son, Michael Waxman, and his family. He had a traditional public relations firm and he asked me to join him. In the health area, we represent Planned Parenthood in California, public hospitals in California, community health centers at the national level, and hospitals that get 340b drug discounts because they serve many low-income patients. We have foundation grants to work on problems of high pharmaceutical prices, and foundation grants to have a program to make sure women know about the whole range of health services available to them for free under the ACA. I enjoy working with my son and pursuing causes I would have pursued as a member of Congress.

 

 

 

Getting Ready for Health Reform 2020: What Past Presidential Campaigns Can Teach Us

https://www.commonwealthfund.org/publications/fund-reports/2018/jun/getting-ready-health-reform-2020-presidential?omnicid=EALERT%%jobid%%&mid=%%emailaddr%%

Getting Ready for Health Reform 2020

Abstract

  • Issue: The candidates for the 2020 presidential election are likely to emerge within a year, along with their campaign plans. Such plans will include, if not feature, health policy proposals, given this issue’s general significance as well as the ongoing debate over the Affordable Care Act.
  • Goal: To explain why campaign plans matter, review the health policy components of past presidential campaign platforms, and discuss the likely 2020 campaign health reform plans.
  • Methods: Review of relevant reports, data, party platforms, and policy documents.
  • Findings and Conclusions: Proposals related to health care have grown in scope in both parties’ presidential platforms over the past century and affect both agendas and assessments of a president’s success. Continued controversy over the Affordable Care Act, potential reversals in gains in coverage and affordability, and voters’ concern suggest a central role for health policy in the 2020 election. Republicans will most likely continue to advance devolution, deregulation, and capped federal financing, while Democrats will likely overlay their support of the Affordable Care Act with some type of Medicare-based public plan option. The plans’ contours and specifics will be developed in the months ahead.

This report is the first in a series on health reform in the 2020 election campaign. Future papers will delve into key reform design questions that candidates will face, focusing on such topics as: ways to maximize health care affordability and value; how to structure health plan choices for individuals in ways that improve system outcomes; and how the experience of other nations’ health systems can inform state block-grant and public-plan proposals.

Introduction

During the 2020 presidential campaign, which begins in earnest at the end of 2018, we are sure to hear competing visions for the U.S. health system. Since 1988, health care has been among the most important issues in presidential elections.1 This is due, in part, to the size of the health system. In 2018, federal health spending comprises a larger share of the economy (5.3%) than Social Security payments (4.9%) or the defense budget (3.1%).2 Moreover, for the past decade, partisan disagreement over the Affordable Care Act (ACA) has dominated the health policy debate. If health care plays a significant role in the 2018 midterm elections, as some early polls suggest it will,3 the topic is more likely to play a central role in the 2020 election.

This report on health reform plans focuses on policies related to health insurance coverage, private insurance regulation, Medicare and Medicaid, supply, and tax policy. It explains why campaign plans are relevant, their history since 1940, the landscape for the 2020 election, and probable Republican and Democratic reform plans. The Republican campaign platform is likely to feature policies like those in the Graham-Cassidy-Heller-Johnson amendment: a state block grant with few insurance rules, replacing the ACA’s coverage expansion. The Democratic platform will probably defend, improve, and supplement the ACA with some type of public (Medicare-like) health plan. The exact contours and details of these plans have yet to be set.

Importance of Campaign Plans

Campaign promises, contrary to conventional wisdom, matter.4 During elections, they tell voters each party’s direction on major topics (e.g., health coverage as a choice or a right in 1992). In some cases, candidates or party platforms include detailed policies (reinsurance in Republicans’ 1956 platform, prospective payment in Democrats’ 1976 platform). Campaign plans tend to be used to solidify party unity, especially in the wake of divisive primaries (2016, e.g.).5 Election outcomes are affected by such factors as the state of the economy, incumbency, and political competition rather than specific issues.6 That said, some exit polls suggest that candidates’ views on health policy can affect election outcomes.7

Campaign plans also help set the agenda for a president, especially in the year after an election. Lyndon B. Johnson told his health advisers, “Every day while I’m in office, I’m gonna lose votes. . . . We need . . . [Medicare] fast.”8 Legislation supported by his administration was introduced before his inauguration and signed into law 191 days after it (Exhibit 1). Bill Clinton, having learned from his failure to advance health reform in his first term, signed the bill that created the Children’s Health Insurance Program (CHIP) 197 days after his second inauguration. Barack Obama sought to sign health reform into law in the first year of his first term, but the effort spilled into his second year; he signed the ACA into law on his 427th day in office. These presidents, along with Harry Truman, initiated their attempts at health reform shortly after taking office.

In addition, campaign plans are used by supporters and the press to hold presidents accountable. For instance, candidate Obama’s promises were the yardstick against which his first 100 days,9 first year,10 reelection prospects,11 and presidency were measured.12 Though only 4 percent of likely voters believe that most politicians keep their promises, analyses suggest that roughly two-thirds of campaign promises were kept by presidents from 1968 through the Obama years.13

Health as a Campaign Issue (1912–2016)

The United States has had public health policies since the country’s founding, with its policy on health coverage, quality, and affordability emerging in the twentieth century. Teddy Roosevelt supported national health insurance as part of his 1912 Bull Moose Party presidential bid.14 Franklin Delano Roosevelt included “the right to adequate medical care and the opportunity to achieve and enjoy good health” in his 1944 State of the Union address, although it was not mentioned in the 1944 Democratic platform.15 Harry Truman is generally credited with being the first president to embrace comprehensive reform. He proposed national health insurance in 1945, seven months after F.D.R.’s death, and campaigned on it in 1948 as part of a program that would become known as the Fair Deal, even though it was not a plank in the Democratic platform. Legislation was blocked, however, primarily by the American Medical Association (AMA), which claimed that government sponsoring or supporting expanded health coverage would create “socialized medicine.”16 Health policy became a regular part of presidential candidates’ party platforms beginning about this time (Exhibit 2).

After Truman’s failure, the next set of presidential candidates supported expanding capacity (e.g., workforce training, construction of hospitals and clinics) and making targeted coverage improvements. In 1960, John F. Kennedy campaigned on a version of Medicare legislation: extending Social Security to include hospital coverage for seniors. It was opposed by the AMA as well, whose spokesman, the actor Ronald Reagan, claimed socialized medicine would eventually limit freedom and democracy.17 It took the death of Kennedy, the landslide Democratic victory in 1964, and persistence by Lyndon B. Johnson to enact Medicare and Medicaid, in 1965. This was about 20 years after Truman introduced his proposal; President Johnson issued the first Medicare card to former President Truman.

Shortly after implementation of Medicare and Medicaid, how best to address rising health care costs became a staple subject in presidential campaigns. Between 1960 and 1990, the share of the economy (gross domestic product) spent on health care rose by about 30 percent each decade, with the public share of spending growing as well (Exhibit 3). In his 1968 campaign, Richard Nixon raised concerns about medical inflation, and subsequently proposed his own health reform, which included, among other policies, a requirement for employers to offer coverage (i.e., an employer mandate).18 Nixon’s proposal was eclipsed by Watergate, as Jimmy Carter’s health reform promises were tabled by economic concerns. Presidents and candidates in the 1980s set their sights on incremental health reforms.19

In 1991, comprehensive health reform helped Harris Wofford unexpectedly win a Pennsylvania Senate race. In 1992, it ranked as the second most important issue to voters.20 Democratic candidates vied over health reform in the 1992 primaries, with Bill Clinton embracing an employer “pay or play” mandate. George H. W. Bush developed his own plan, which included premium tax credits and health insurance reforms. Five days after his inauguration, President Clinton tasked the first lady, Hillary Clinton, with helping to develop health care legislation in the first 100 days. Yet, mostly because he prioritized economic and trade policy, Clinton did not address a joint session of Congress until September and did not send his bill to Congress until November of 1993. Key stakeholders (including the AMA and the Health Insurance Association of America) initially supported but ultimately opposed the legislation. In September 1994, the Senate Democratic leadership declared it could not pass a bill.21 Less than two months later, Democrats lost their majorities in the House and the Senate, and did not regain them for over a decade. This created a view that comprehensive reform of the complex health system was politically impossible.22 Indeed, presidential candidates in 1996, 2000, and 2004 did not emphasize major health policies. That said, by 2004, health system problems had escalated and, at least on paper, the candidates’ plans addressing them had expanded.23

In 2008, health reform was a dominant issue in the Democratic primaries and platform. Hillary Clinton supported a requirement for people who could afford it to have coverage (i.e., the individual mandate). Barack Obama limited his support to a requirement that all children be insured. Both candidates supported an employer mandate.24 John McCain countered with a plan whose scope exceeded those of many Republican predecessors: it would cap the tax break for employer health benefits and use the savings to fund premium tax credits for the individual market.25 Attention to health reform waned during the general election, as the economy faltered. Even so, the stage was set for a legislative battle. President Obama opened the door to his rivals’ ideas at a White House summit in March 2009.26 After more than a year of effort, he signed the Affordable Care Act into law.27 Obama said that he did so “for all the leaders who took up this cause through the generations — from Teddy Roosevelt to Franklin Roosevelt, from Harry Truman, to Lyndon Johnson, from Bill and Hillary Clinton, to one of the deans who’s been fighting this so long, John Dingell, to Senator Ted Kennedy.”28

Nonetheless, the partisan fight over the ACA extended into the 2012 and 2016 presidential elections. Despite the ACA’s resemblance to his own 2006 reform plan for Massachusetts, Mitt Romney, as the 2012 Republican presidential candidate, vowed to repeal the ACA before its major provisions were implemented; Republicans would subsequently replace it with conservative ideas (mostly to be developed). Four years later, even though the health system landscape had dramatically changed following the ACA’s implementation, the Republicans’ position had not altered.29 Candidate Donald Trump joined his primary rivals in pledging to “repeal and replace Obamacare” (he also embraced unorthodox ideas such as Medicare negotiation for drug prices). Democratic candidate Hillary Clinton proposed a wide array of improvements to the ACA rather than a wholesale replacement of it with a “Medicare for All” single-payer proposal, as did her Democratic primary rival, Bernie Sanders.30 The intra-party differences among primary candidates in 2016 increased attention to the party platforms relative to previous elections.31 But despite continued voter interest (Exhibit 4), differences in health policy were not credited with determining the outcome of the 2016 election.

Setting the Stage for 2020

President Trump’s attempt to fulfill his campaign promise to repeal and replace the ACA dominated the 2017 congressional agenda. In January 2017, the Republican Congress authorized special voting rules toward this effort, while President Obama was still in office. On the day of his inauguration, Trump signed an executive order to reduce the burden of the law as his administration sought its prompt repeal.32 Yet among other factors,33 the lack of a hammered-out, vetted, and agreed-upon replacement plan crippled the Republicans’ progress.34 Speaker Paul Ryan had to take his bill off the House floor on March 24, 2017, because it lacked the necessary votes; the House passed a modified bill on May 4. Senator Mitch McConnell’s multiple attempts in June and July to secure a majority in favor of his version of a health care bill failed on July 26, when Senator John McCain cast the deciding vote against it. In September, Senators Lindsey Graham, Bill Cassidy, Dean Heller, and Ron Johnson failed to get 50 cosponsors for their amendment, the prerequisite for its being brought to the Senate floor.35 The Republicans subsequently turned to tax legislation and, in it, zeroed out the tax assessment associated with the ACA’s individual mandate. At the bill’s signing on December 22, Trump claimed that “Obamacare has been repealed,”36 despite evidence to the contrary.37

A different type of legislative effort began in mid-2017: bipartisan attempts to improve the short-run stability of the ACA’s individual market. This was in part necessitated by the Trump administration’s actions pursuant to the Inauguration Day executive order: reductions in education efforts, marketing funding, and premium tax credits, among others.38 On October 12, 2017, the president signed a second ACA executive order, directing agencies to authorize the sale of health plans subject to fewer regulatory requirements.39 On the same day, his administration halted federal funding for cost-sharing reductions, a form of subsidy, claiming the ACA lacked an appropriation to make such payments. Concerns that these actions would increase premiums, reduce insurer participation, and discourage enrollment prompted coalitions of bipartisan lawmakers to introduce bills. Most notable was a bill by Senators Lamar Alexander and Patty Murray; their proposal, released October 18, 2017, had 12 Republican cosponsors and implicit support from all Democrats, giving it the 60 votes needed in the Senate to overcome a filibuster.40 Yet the version that Senator McConnell ultimately brought to the floor for a vote, in March 2018, included changes that repelled Democrats, preventing its passage.41 Partisans on both sides have blamed this failure, in part, for emerging increases in health insurance premiums.

Indeed, benchmark premiums in the health insurance marketplaces rose by an average of over 30 percent in 2018 and are projected to increase by 15 percent in 2019, largely because of policy changes.42 Some data suggest that the growth in health care costs may be accelerating as well.43 This may have contributed to an increase in the number of uninsured Americans. One survey found that the number of uninsured adults, after falling to a record low in 2016, had risen by about 4 million by early 2018.44 These statistics could heighten candidates’ interest in health policy in 2020.

Public opinion, too, could help health reform gain traction. Tracking polls suggest that concerns about health care persist, with 55 percent of Americans worrying a great deal about the availability and affordability of health care, according to a poll from March 2018.45 Interestingly, while the partisan differences of opinion on the ACA continue, overall support for the ACA has risen, reaching a record high in February 2018 (Exhibit 5).

This concern about health care has entered the 2018 midterm election debate. It is currently a top midterm issue among registered voters, a close second to jobs and the economy.46 Some House Republicans who formerly highlighted their promise to repeal and replace the ACA no longer do so in light of the failed effort of 2017.47 Democrats, in contrast to previous elections, have embraced the ACA, unifying around its defense in the face of Republican “sabotage.”48 The debate also has been rekindled by Trump’s decision to abandon legal defense of key parts of the ACA.49 Regardless of what happens in the courts, this signifies his antipathy toward the law. Barring a midterm surprise, the next Congress is unlikely to succeed where the last one failed. As such, “repeal and replace” would be a repeat promise in Trump’s reelection campaign.

Likely 2020 Campaign Plans

Against this backdrop, presidential primary candidates and the political parties will forge their health care promises, plans, and platforms. Common threads from past elections are likely to be woven into the 2020 debate. The different parties’ views of the balance between markets and government have long defined their health reform proposals.50 Republicans will most likely still be against the ACA as well as uncapped Medicare and Medicaid spending, and for market- and consumer-driven solutions. Democrats will most likely blame Republicans’ deregulation for rising health care costs; defend the ACA, Medicare, and Medicaid; and advocate for a greater role for government in delivering health coverage and setting payment policy. Potential policies for inclusion in candidates’ plans have been introduced in Congress (Exhibit 6). But major questions remain, such as: how will these campaign plans structure choices for individuals and employers, promote efficient and high-quality care, and learn from the experience of local, state, national, and international systems?

Likely Republican Campaign Plan: Replace the ACA with Devolution and Deregulation

President Trump has indicated he will run for reelection in 2020.51 His fiscal year 2019 budget included a proposal “modeled closely after the Graham-Cassidy-Heller-Johnson (GCHJ) bill.” It would repeal federal financing for the ACA’s Medicaid expansion and health insurance marketplaces, using most of the savings for a state block grant for health care services. It would also impose a federal per-enrollee spending cap on the traditional Medicaid program. States could waive the ACA’s insurance reforms.52 The congressional bill also would repeal the employer shared responsibility provision (i.e., the employer mandate) and significantly expand tax breaks for health savings accounts, among other policies.53 The framework for this proposal — repealing parts of the ACA, replacing them with state block grants, reducing regulation, and expanding tax breaks — is similar to the 2016 Republican platform.

Trump may continue to express interest in lowering prescription drug costs. In 2016 and early 2017, he supported letting Medicare negotiate drug prices54 — a policy excluded from the 2016 Republican platform and his proposals as president. His 2019 budget seeks legislation primarily targeting insurers and other intermediaries that often keep a share of negotiated discounts for themselves.55 On May 11, 2018, he released a “blueprint” to tackle drug costs, including additional executive actions and ideas for consideration. Polls suggest that prescription drug costs rank high among health care concerns.56

One policy initiative in the recent Republican platforms but not embraced by the president is Medicare reform. The idea of converting Medicare’s defined benefit into a defined contribution program and raising the eligibility age to 67 was supported by Vice President Mike Pence when he was a member of Congress and by Speaker of the House Paul Ryan.57 Major Medicare changes were excluded from the 2017 ACA repeal and replace proposals. In contrast, versions of Medicaid block grant proposals appeared in various bills, including the GCHJ amendment, as well as numerous Republican presidential platforms.

Historically, presidents running for reelection have limited competition in primaries. Those challengers, by definition, emphasize their differences with the incumbent, which may include policy. It may be that John Kasich will run on maintaining the ACA Medicaid expansion but otherwise reforming the program (his position as governor of Ohio throughout 2017). Or, Rand Paul could campaign on his plan to repeal even more of the ACA than the Republicans’ 2017 bills attempted to do. Incumbents tend to have slimmer campaign platforms than their opponents in general and primary elections, since their budget proposals, other legislative proposals, and executive actions fill the policy space (see Reagan, Clinton, George W. Bush, Obama). Exceptions include George H. W. Bush, who in 1992 developed a plan given voters’ concerns about health; and Nixon, who offered a proposal for health reform at the end of his first term.

Likely Democratic Campaign Plan: Improve the ACA and Add a Public Plan

It is possible and maybe probable that the ultimate Democratic Party platform in 2020 will resemble that of 2016: build on the ACA and include some sort of public plan option. Legislation has been introduced during this congressional session that builds on the law by extending premium tax credits to higher-income marketplace enrollees (e.g., Feinstein, S. 1307), lowering deductibles and copayments for middle-income marketplace enrollees (e.g., Shaheen, S. 1462), providing marketplace insurers with reinsurance (e.g., Carper, S. 1354), and strengthening regulation of private market insurance (e.g., Warren, S. 2582). Some proposals aim to increase enrollment following the effective repeal of the individual mandate, by, for example, raising federal funding for education and outreach, and testing automatic enrollment of potentially eligible uninsured people (e.g., Pallone, H.R. 5155). These proposals would have different effects on health insurance coverage, premiums, and federal budget costs.58

The Democrats will inevitably discuss a public plan in their platform, although the primary contenders will most likely disagree on its scale (e.g., eligibility) and design (e.g., payment rates, benefits).59 In September 2017, Senator Bernie Sanders introduced the Medicare for All Act (S. 1804). It would largely replace private insurance and Medicaid with a Medicare-like program with generous benefits and taxpayer financing. “Medicare for more” proposals have also been introduced: Medicare Part E (Merkley, S. 2708), an option for individuals and small and large businesses; Medicare X (Bennet, S. 1970), which is available starting in areas with little insurance competition or provider shortages; and a Medicare buy-in option, for people ages 50 to 65 (Higgins, H.R. 3748). A Medicaid option (Schatz, S. 2001), similar to Medicare Part E, offers a public plan choice to all privately insured people, aiming to capitalize on the recent popularity of that program. Publicly sponsored insurance plans have long been included in Democratic presidents’ platforms, although the government’s role has ranged from regulating the private plans (Carter, Clinton) to sponsoring them (Truman, Obama). It may be that the candidate who prevails in the primaries will determine whether the Democratic platform becomes “Medicare for all” or “Medicare for more.”

This may be the extent of Medicare policies in the 2020 Democratic platform. Relatively high satisfaction and low cost growth in Medicare have limited Democratic interest in Medicare policy changes in recent years. Similarly, Democrats have not introduced or embraced major reforms of Medicaid. However, the public concern about prescription drug costs has fueled Democratic as well as Republican proposals, some of which target the drug companies (e.g., addressing “predatory pricing,” allowing Medicare rather than prescription drug plans to negotiate the prices for the highest-cost drugs).60

Discussion

Predictions about presidential campaigns have inherent limits, as many experts learned in the 2016 election. Events concerning national security (e.g., conflict), domestic policy (e.g., a recession), or the health system (e.g., a disease outbreak) could alter the policy choices of presidential candidates. New ideas could emerge, or candidates could take unconventional approaches to improving the health system. And, while campaign plans have relevance, the long history of attempts at health reform underscores that by no means are promises preordained.

That said, perennial policies and recent political party differences will likely figure in 2020. Republican presidential candidates, with few exceptions, have adopted a small government approach to health reform: shifting control to states, cutting regulation, preferring tax breaks and block grants over mandatory federal funding, and trusting markets to improve access, affordability, and quality. Democratic presidential candidates have supported a greater government role in the health system, arguing that market solutions are insufficient, and have defended existing programs like Medicare, Medicaid, and, now, the ACA. Some will probably support the government’s taking a primary role in providing coverage given criticism of the efficacy and efficiency of private health insurers. The direction and details of the campaign plans for 2020 will be developed in the coming months and year. Given such plans’ potential to shape the next president’s agenda, now is the time to scrutinize, modify, and generate proposals for health reform.

 

 

Two-thirds of Voters Say a Candidate’s Position on Pre-existing Conditions is Important to their Vote, More than Say the Same about Drug Costs, ACA Repeal or Medicare-for-All

https://www.kff.org/health-reform/poll-finding/kaiser-health-tracking-poll-june-2018-campaigns-pre-existing-conditions-prescription-drug-ads/?utm_campaign=KFF-2018-June-Tracking-Poll&utm_medium=email&_hsenc=p2ANqtz-8orvLoN3Zc1aJRbH_sq6YGTN4pbKIKx4TDIH4RZ8ZzSnyxeE2w2qu57DbDo-ybASw8txtjZrEhSUaE3lOVM8ltTeLxyg&_hsmi=64054014&utm_content=64054014&utm_source=hs_email&hsCtaTracking=305973fd-177d-4168-b032-f97d2061db7d%7Cc2f3beab-a53d-416d-b208-46f806ee1dfd

Key Findings:

  • Health care continues to be one of the top issues that voters want to hear candidates talk about during their 2018 congressional campaigns. One-fourth of voters say health care is the “most important issue” for 2018 candidates to discuss during their campaigns, which is similar to the share who say the same about the economy and jobs (23 percent). While health care is a top issue for Democratic and independent voters, it remains a second tier issue for Republican voters.
  • Few voters (about one in ten) say a candidate’s support for a variety of different health care positions will be the “single most important factor” in their 2018 vote choice. But among the health care issues provided, majorities of Democratic voters, independent voters, and Republican voters say a candidate’s support for continued protections for people with pre-existing health conditions is either the “single most important factor” or “very important, but not the most important factor” to their vote.
  • In light of a recent federal lawsuit and subsequent decision by the Trump administration, this month’s tracking poll finds most of the public – including majorities of Republicans, Democrats, and independents – say it is “very important” to them that the ACA’s provisions protecting those with pre-existing conditions remain law. Three-fourths say it is “very important” that the ACA provision prohibiting insurance companies from denying coverage due to someone’s medical history remains law, and seven in ten say the same about the ACA provision prohibiting insurance companies from charging sick people more. Nearly six in ten Americans say they live in a household where someone has a pre-existing medical condition.
  • A majority of the public – including eight in ten Democrats – support President Trump’s plan to require drug manufacturers to publish list prices for their prescription drugs in television advertisements.
  • While most have seen or heard advertisements for prescription drugs, about one in seven say they have talked to their doctor as a result of seeing an advertisement for a prescription drug. Yet, among the fourteen percent of the public who have talked to their doctor about a drug they saw advertised – more than half (55 percent, 11 percent of adults) say they were prescribed the drug they asked about and half (48 percent, 10 percent of adults) discussed the price of the drug with their doctor.

 

Top Issues for 2018 Congressional Campaigns

Health care continues to be one of the top issues that voters want to hear candidates talk about during their 2018 congressional campaigns. One-fourth of voters say health care is the “most important issue” for 2018 candidates to discuss during their campaigns, which is similar to the share who say the same about the economy and jobs (23 percent). Slightly fewer say gun policy (20 percent), immigration (18 percent)1, and foreign policy (13 percent) are the most important issues for 2018 candidates to talk about during their campaigns.

Health Care and Republican Voters

While health care is a top issue for Democratic and independent voters, it remains a second tier issue for Republican voters. One-fourth (27 percent) of Republican voters say the economy and jobs is the most important issue for candidates to talk about during their campaigns, followed by immigration (19 percent), and health care (18 percent). However, the share of Republican voters who say health care is the most important issue has risen slightly since January 2018 when one in ten (13 percent) Republican voters said it was the most important issue.

Which Health Care Issues Matter Most to Voters?

Few voters (about one in ten) say a candidate’s support for a variety of different health care positions will be the “single most important factor” in their 2018 vote choice, but about two-thirds say a candidate’s support for continued protections for people with pre-existing health conditions is either the “single most important factor” or “very important, but not the most important factor.” Fewer – but still a majority – say a candidate’s support for passing legislation to bring down prescription drug costs (58 percent), support for repealing the Affordable Care Act (ACA) (53 percent), or passing legislation to stabilize the ACA marketplaces (52 percent) is either the single most important or a very important factor. Half (48 percent) say a candidate’s support for passing a national health plan, or Medicare-for-all is very or most important to their 2018 vote choice.

Partisans Differ on Top Health Care Positions for Candidates

Partisan voters have different views on how a candidate’s support for various health care positions will affect their vote choice. For Democratic voters, a candidate’s support for continued protections for people with pre-existing conditions is at the top of the list with eight in ten (81 percent) Democratic voters saying it is the most important or very important factor to their 2018 vote choice. This is followed by a candidate’s support for stabilizing the ACA marketplaces (69 percent), support for passing a national health plan, or Medicare-for-all (68 percent), and support for passing legislation to bring down the price of prescription drugs (66 percent). Fewer (57 percent) say a candidate’s support for repealing the ACA will be very or most important to their vote.

Among Republican voters, nearly six in ten say a candidate’s support for repealing the ACA is very or most important to their 2018 vote choice. Half say the same about a candidate’s support passing legislation to bring down the price of prescription drugs (52 percent) and support for continued protections for people with pre-existing conditions (51 percent). Across all other issues, less than half of Republican voters say it will be very or most important to their 2018 vote.

Public Supports ACA Protections for Those With Pre-Existing Conditions

President Trump’s administration announced earlier this month that it will no longer defend the ACA’s protections for people with pre-existing medical conditions. These provisions prohibit insurance companies from denying coverage based on a person’s medical history (known as guaranteed issue), and prohibit insurance companies from charging those with pre-existing conditions more for coverage (known as community rating). The Trump administration argues that both of these protections are unconstitutional and should be deemed invalid once the individual mandate penalty goes away starting January 1, 2019. The majority of the public – including majorities of Republicans, Democrats, and independents – say it is “very important” to them that the ACA’s provisions protecting those with pre-existing conditions remain law.

Three-fourths of the public (76 percent) say it is “very important” to them that the provision that prohibits health insurance companies from denying coverage because of a person’s medical history remains law. An additional fifteen percent say it is “somewhat important” this provision remains law. Similarly, seven in ten (72 percent) say it is “very important” that the provision that prohibits health insurance companies from charging sick people more remains law, while an additional one in five (17 percent) say it is “somewhat important.”

Majorities Across PArty Lines Support Protections for Those With Pre-eXisting Conditions

Majorities, across party identification and household health status, say it is “very important” that these protections remain law. Nine in ten Democrats (88 percent), 77 percent of independents, and 58 percent of Republicans say it is “very important” that insurance companies cannot deny coverage because of a person’s medical history. Similarly, a majority (85 percent of Democrats, 70 percent of independents, and 58 percent of Republicans) – say it is “very important” that health insurance companies cannot charge sick people more. Even among those living in households without anyone with pre-existing conditions – therefore, unlikely to be affected negatively by this change in policy – a majority say it is “very important” these protections remain.

This most recent poll finding is similar to previous KFF polling on this issue. Public support for protections for individuals with pre-existing conditions had broad support prior to the passage of the 2010 health care law. A February 2010 Kaiser Health Tracking Poll found three-fourths (76 percent) of the public saying it is either “extremely important” or “very important” that reforming health insurance so that insurance companies can’t deny coverage based on pre-existing conditions is passed into law. Immediately after the election of President Trump, KFF polling found there was still majority support for the requirement that health insurance companies have to cover everyone regardless of medical history, with majorities of Democrats (75 percent), independents (65 percent), and Republicans (63 percent) saying they had a favorable opinion of this ACA provision.

Nearly Six in Ten Say They or Someone in Their Household Has a Pre-Existing Health Condition

Nearly six in ten (57 percent) say they or someone in their household suffers from pre-existing medical conditions such asthma, diabetes, or high blood pressure. Women (61 percent) are more likely to report someone in their household with a pre-existing condition than men (53 percent), as are older individuals (67 percent of those age 65 or older) compared to half (49 percent) of adults 18 to 29 years old.

Broad Support for Requiring Prices in Prescription Drug Advertisements

On May 11, 2018, President Trump announced his plan titled, “American Patients First,” an effort aimed at lowering the price of prescription drugs. One key element of this plan is to require drug manufacturers to publish list prices for their prescription drugs in television advertisements. Three-fourths (76 percent) of the public favor the federal government requiring prescription drug advertisements to include a statement about how much the drug costs. In a rare instance of bipartisanship, this policy proposal is supported by a majority of Democrats (83 percent), independents (73 percent) and Republicans (72 percent).

Prevalence of Prescription Drug Advertisements

Seven in ten (72 percent) say they have ever seen or heard any advertisements for prescription drugs, which is similar to the share who say they saw or heard such an advertisement in the past 12 months (69 percent).

One in seven say they have talked to their doctor as a result of seeing an advertisement for a prescription drug while more than half (56 percent) say they have seen or heard advertisements for prescription drugs but have never spoken to their doctor about these ads.

Among those who have spoken to their doctor about a specific medicine they saw advertised, nearly six in ten (55 percent) say the doctor gave them the drug they asked about, their doctor recommended a different prescription drug (54 percent), or their doctor recommended that they make changes in their behavior or lifestyle (54 percent). Half (48 percent) say their doctor discussed the cost of the drug while four in ten (41 percent) say their doctor recommended an over-the-counter drug instead.

Public’s Views of the Affordable Care Act

Half of the public continue to hold favorable views of the 2010 health care law, known as the Affordable Care Act. This continues the more than a year-long trend of a larger share of the public viewing the law favorably (50 percent) than unfavorably (41 percent).

 

 

Health Care Is a Universal Value. It’s Time for a Universal Effort.

https://www.chcf.org/blog/health-care-universal-value-time-universal-effort/?_cldee=aGVucnlrb3R1bGFAeWFob28uY29t&recipientid=contact-58e265c0591ce51180f7c4346bac4b78-901e2d5088d64b76b1a6161294dddd2a&esid=1715541d-360c-e811-8157-e0071b6a92f1

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California is the most diverse place on earth. You see that diversity in our people, our culture, and our landscape. Our differences are our strength – but only if we remember the things that bind us together and the values we all share.

The belief that everyone should have health care is one of those universal values. From the day we are born, health care gives people the opportunity to have full lives and the vitality to pursue their dreams. And no one should lack support when illness strikes.

Over the last year, the California Health Care Foundation (CHCF) has been re-examining the work we do, because we want to make sure our efforts and our dollars are making the greatest possible impact in light of what’s happening in the world around us. As we went through that process, one unavoidable truth remained as our top concern: Too many low-income Californians are held back or suffer because it is too hard to get the care they need. Our board of directors and CHCF’s deeply committed staff have decided that the foundation’s top priority should be to address that problem.

Certainly, this undertaking will not be easy, but the good news is that there are clear ways to make health care work for low-income Californians. Here are three that are top of mind for us now.

1. All Californians Should Have Health Coverage

California has made huge gains in recent years under the Affordable Care Act (ACA). We’ve cut our number of uninsured by half. Now we must finish the job and work to ensure everyone has health benefits.

Achieving universal coverage would level the playing field in two key ways. It would allow all Californians to meet basic needs for care, and it would protect all Californians financially from extraordinary health care expenses. Today, three million of our friends and neighbors remain uninsured. Most have jobs and are contributing to our economy and communities, but those jobs do not include health insurance. We must also remember that one in three uninsured Californians is an undocumented immigrant. These people are part of the fabric of California’s society; if we allow them to remain vulnerable, all of California will pay the price.

Never has California been so close to achieving universal coverage. There is no one pathway to get to that goal, but get there we must.

2. Coverage Must Lead to Better Care

Coverage is not an end in itself – it’s really just the gateway to better health. To deliver on this promise, coverage must lead to better care. Our biggest opportunity to improve care for low-income Californians is to make sure that California’s approach to coverage for low-income populations – the Medi-Cal program – delivers high-value care. The program covers one in three Californians. And two-thirds of Californians say Medi-Cal is important to them and their families. When we get Medi-Cal right, the impact is broad and deep because of the program’s overall reach and the profound ways in which it improves a person’s prospects for health.

In the last year, we have seen major new federal threats to Medicaid’s fiscal and policy stability. Given the importance of Medi-Cal to California, we must continue working together locally and with other states to protect Medicaid from ill-advised budget and policy changes.

But it isn’t enough for California to protect the status quo. There is so much potential for improvement in Medi-Cal, which serves Californians with the greatest health burdens. We must be diligent and vigilant in finding new ways to reduce the struggle of those who depend on the program and to give them opportunities to live healthy lives. We can and should make the system easier to navigate and care easier to access. We must modernize the state’s health workforce to make treatment more effective and more cost-effective. And we can and should expect innovation in Medi-Cal to keep pace with the evolution of care in the private sector.

3. Stop Treating Conditions and Start Treating People

Our health care safety net still is organized around the outdated assumption that one person’s body and mind require two or more separate systems of care. Today we know that physical health and mental health are inextricably bound together. It is past time to update our health care system to reflect that understanding.

It is especially important that we better integrate care for low-income Californians who experience mental illness, drug or alcohol addiction, or other complex health conditions. Even though they comprise a relatively small share of the population, they account for half of health care spending. Siloed systems of care cause needless and profound suffering.

Health care leaders and providers across California have been working harder than ever to address this problem. Innovations in policy, like Medi-Cal’s Whole Person Care and Drug Medi-Cal pilots, are giving communities new opportunities to integrate care. Technology innovations can help providers extend those opportunities to larger and larger numbers of people.

Solutions Are Out There. It’s Time to Put Them to Work Everywhere.

California has the power to accomplish each of these goals. We boast the world’s sixth largest economy. California is rich in health care and innovation talent. But even with those advantages, we cannot succeed without working together across sectors, across professions, and across ideological camps.

Health care is a universal value. It will take a universal effort to make sure all Californians can meet their basic need for care.

 

Uwe Reinhardt, 80, Dies; a Listened-to Voice on Health Care Policy

Uwe Reinhardt, an economist whose keen, caustic and unconventional insights cast him as what colleagues called a national conscience in policy debates about health care, died on Monday in Princeton, N.J. He was 80.

The cause was sepsis, his wife, Tsung-Mei Cheng, said. He had taught in the economics department at the Woodrow Wilson School of Public and International Affairs at Princeton University since 1968.

Professor Reinhardt helped shape health care deliberations for decades as a prolific contributor to numerous publications, an adviser to White House and congressional policymakers, a member of federal and professional commissions and a consultant and board member, paid and unpaid, for private industry.

“His work was instrumental in advocating some of the reforms embodied in the Affordable Care Act, such as having Medicare pay for performance rather than entirely on a fee-for-service basis,” Professor Janet Currie, the chairwoman of the Princeton economics department, wrote in an email.

Another colleague, Stuart H. Altman, a professor at Brandeis University, wrote, “No one was close to him in terms of impact on how we should think about how a decent health care system should operate.”

In 2015, the Republic of China awarded Professor Reinhardt its Presidential Prize for having devised Taiwan’s single-payer National Health Insurance program. The system now provides virtually the entire population with common benefits and costs 6.6 percent of the nation’s gross domestic product (about one-third the share that the United States spends).

Just last month, he received the 2017 Bipartisan Health Policy Leadership Award from the Alliance for Health Policy, a nonpartisan research and educational group in Washington.

Professor Reinhardt argued that what drove up the singularly high cost of health care in the United States was not the country’s aging population or a surplus of physicians or even Americans’ self-indulgent visits to doctors and hospitals.

“I’m just an immigrant, so maybe I am missing something about the curious American health care system,” he would often say, recalling his childhood in Germany and flight to Canada and apologizing that English was only his second language.

Then he would succinctly answer the cost question by quoting the title of an article he wrote with several colleagues in 2003 for the journal Health Affairs: “It’s the Prices, Stupid.”

What propelled those prices most, he said, was a chaotic market that operates “behind a veil of secrecy.”

That market, he said, is one in which employers “become the sloppiest purchasers of health care anywhere in the world,” as he wrote in the Economix blog in The New York Times in 2013.

It is also defined by the high cost of prescription drugs, he said, and the astronomical amounts that hospitals spend in dealing with a maze of insurers and health maintenance organizations.

“Our hospitals spend twice as much on administration as any hospital anywhere in the world because of all of this complexity,” he told Managed Care magazine in 2013.

If the nation cut the cost of health care administration in half, he said, the savings would be enough to insure everyone.

Professor Reinhardt’s prescription for a more sensible system included imposing penalties on the uninsured so that people would not postpone buying policies until they got sick. That idea, the so-called individual mandate, requiring most people to purchase health insurance, became an integral component of the Affordable Care Act, otherwise known as Obamacare. Republicans in Congress are now seeking to repeal that provision as part of a tax overhaul.

Professor Reinhardt also advocated providing government subsidies so that low-income families could afford mandated insurance, another feature of Obamacare.

His ideal model was the German system in which insurers negotiate with health care providers to set common binding prices in a specific region.

“I believe it is still the best model there is, because it blends a private health care delivery system with universal coverage and social solidarity,” he told The Times in 2009. “It’s inexpensive and equitable. Coverage is portable. You’re never uninsured in Germany. No family goes broke over health care bills.”

Always opinionated, Professor Reinhardt was also unsparing in inflicting his mordant wit on any self-satisfied expert he considered hypocritical or illogical.

“He was a knife twister of the first class,” the health economist Austin Frakt wrote on the blog The Incidental Economist, of which he is an editor in chief. “Should you hold dearly an idea he targeted for systematic dismantling, you would squirm.”

Professor Reinhardt excoriated college students who blamed loneliness for their binge drinking, describing them as “among the most pampered and highly privileged human beings on the planet.” He suggested that before applying for college young people “be required to spend one to two years in a tough job in the real world.”

And when critics complained that doctors were overpaid, he countered that their collective take-home pay amounted to only 10 percent of national health spending. Slicing it by 20 percent, he wrote, “would reduce total national health spending by only 2 percent, in return for a wholly demoralized medical profession to which we so often look to save our lives.

“It strikes me as a poor strategy,” he added.

With near unanimity, colleagues and admirers praised Professor Reinhardt for transforming raw data into moral imperatives.

Senator Bernie Sanders, the Vermont independent who advocates a “Medicare for all” national health care system, wrote in an email, “Uwe Reinhardt was one of the leaders in the effort to make health care a right, not a privilege.”

And Professor Elliott S. Fisher of Dartmouth called Professor Reinhardt “in so many ways the conscience of the U.S. health care system.”

Uwe (pronounced OO-vuh) Ernst Reinhardt was born on Sept. 24, 1937, in the city of Osnabrück in northwest Germany. His father, Wilhelm, was a chemical engineer. His mother, the former Edeltraut Kehne, was a photographer and painter.

He was raised near the Belgian border and the Hürtgen forest, where American and German soldiers engaged in hand-to-hand combat for four months in 1944.

“I could not help but become witness daily to the horrors of war,” Professor Reinhardt wrote in 2003 in a Times Op-Ed article, praising a Marine chaplain for urging soldiers to pray for their enemies ad well as themselves. “Millions of Europeans of my generation, whom many Americans now disparage so contemptuously as pacifists, had a similar experience.”

His exposure to the war so dismayed him that in the mid-1950s, at 18, rather than be drafted into the army and have to salute a German officer in the wake of “the unimaginable atrocities committed by Nazi Germany” years earlier, his wife said, he left the country, setting off for Canada and leaving his parents and four siblings behind.

He landed in Montreal with $90 in his pocket and no Canadian connections. Having had some apprentice training in shipping in Germany, he found work at a shipping company and worked nights parking cars in a parking lot. He always ate oatmeal for breakfast because it was cheap, his wife said, and to make extra money he routinely volunteered to work overtime for co-workers who had families.

After three years, he had saved enough money to enroll, hundreds of miles away, at the University of Saskatchewan in Saskatoon, the cheapest university he knew of, Ms. Cheng said. (Selling his used Chevrolet and beloved guitar helped defray the costs.)

He graduated with a bachelor of commerce degree and went on to Yale, where he received his doctorate. His thesis was titled “An Economic Analysis of Physicians’ Practices.”

In addition to Ms. Cheng, a health policy research analyst at Princeton who is known as May, he is survived by their children, Dirk, Kara and Mark Reinhardt; his sisters, Heide Cermin and Imeltraut Arndt; his brother, Jurgen; and two grandchildren.

Professor Reinhardt joined the Princeton faculty in 1968 as an assistant professor. At his death, he was the James Madison professor of political economy and professor of economics and public affairs at the Woodrow Wilson School.

“He was so inspired a teacher,” said Henry J. Aaron, a senior fellow at the Brookings Institution, the research organization in Washington, “that he could make accounting the most popular course at Princeton.” Among his students was Bill Frist, a surgeon and a former Republican Senate majority leader from Tennessee.

In 2015, Professor Reinhardt humbly — and facetiously — announced that after reflecting on the global economic crisis that had occurred several years earlier, he was calling it quits.

“After the near-collapse of the world’s financial system has shown that we economists really do not know how the world works, I am much too embarrassed to teach economics anymore,” he wrote.

In an interview not long before that, though, he belied any pretense of self-doubt when he was asked whether he was perplexed by the seemingly insolvable challenges of health care economics.

“Have you ever seen a perplexed economist?” Professor Reinhardt replied. “We have an answer for everything.”

 

Uwe Reinhardt: Giant, mensch, knife twister

https://theincidentaleconomist.com/wordpress/uwe-reinhardt-giant-mensch-knife-twister/

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The renowned Princeton University health economist Uwe Reinhardt died today. The email from his Dean at the Woodrow Wilson school said he passed peacefully and surrounded by family.

Reactions on Twitter resonate with my own. They reflect Uwe’s contributions to and presence in health care policy and education — “insightful, “a treasure,” focused on the “moral underpinnings of policy,” “one of the nicest and funniest people in the field of health econ,” “a godfather of health policy and economics,” “a unique and disarmingly powerful voice in health policy,” a “world-class mensch,” “a gifted teacher and inspiring leader,” one of the “most acerbic speakers in Health Care over the last 20+ years. Never afraid to speak truth to power,” “engaging and understandable,” “a giant.”

I once called him “the narrator of U.S. health care policy.” Any journalist who could get hold of him for a health care story was sure to get pure gold. His wit and precision were evident in his spoken and written word. His command of English was tremendous. His ability to explain to lay audiences, legendary. If you’re unfamiliar, go read anything he wrote for The New York Times Economix blog, where he posted regularly for years. He can teach. You will learn.

Born and raised in Germany, he did it all in a second language. Of this, he reminded audiences regularly. The title of one of his presentations was, “Still Confused, After 40 Years in America!” Don’t believe it. Uwe was always the least confused person in the room.

He opened many speeches with, “I’m just an immigrant so maybe I am missing something about the curious American health care system” (or similar). I heard it many times. It never got old, particularly because I knew what was coming next. Just after such an opening, he would reveal some peculiarity of the health system I had never noticed in the same way. And then he proceeded to show how it was illogical, in violation of basic concepts of economics, immoral, or hypocritical.

He was a knife twister of the first class. Should you hold dearly an idea he targeted for systematic dismantling, you would squirm. If only I could write half as well or think one-third as clearly.

He touched so many lives and careers, including my own.

My first engagement with Uwe was in 2009, over one of his Economix posts. In the comments to that post, I asked him for an economics argument in favor of a public option. He was kind enough to respond at length directly to my inquiry in a follow-up Economix post. I was thrilled, even as I took a beating. I documented the encounter on this blog.

Perhaps due to my repeated blog-based engagement with him — like a fly that just won’t go away — Uwe took some interest in what I was doing on TIE. He noticed my many posts on hospital cost shifting and suggested that an updated literature review should be published. I counter-offered that we do it together, and he accepted.

I knew exactly what this meant. I was to write the first draft and he would serve as senior author and tell me how much more work it needed. Here’s where Uwe surprised me and earned my deepest respect. His response to my first draft was that it was so good he did not think it right that his name appear on it. Instead, I should publish it solo, with his support. This is good mentorship. It was my first solo-authored paper and is my most cited publication.

I met Uwe in person only once, in Princeton in 2010. I was there to visit my parents and give a talk at the Woodrow Wilson School. Learning I’d be in town, he invited me to lunch. I thought it was just going to be the two of us, but he insisted I bring my parents too — his treat. (In advance of the lunch, with some help from YouTube, I practiced how to pronounce his name. It’s “oo-va” not “you-ee.”)

Though I never saw him again in person, for years I encountered him over email. Usually our threads began with me asking a question or him sharing one of his lengthy emails to some other scholar or policymaker. (Oh, what a shame it is he didn’t post those emails for all to see. They were gems.) But frequently he would email out of the blue to inquire about my family. He took an interest in hearing what my children were up to and used that as an opportunity to remind me how different parenting or childhood was in his day.

“Child rearing is so different nowadays,” he wrote me once. “When we were little, we left the house after lunch and came home for supper, roaming the country side in the meantime (and playing with live ammunition [left over from WW II]).” I have very few folders of saved emails, but this one and others of his I filed away, not to be deleted.

Frequently, in the email back-and-forth that ensued he would type out some amazing story of past hijinks. Here’s one:

Once, at a Duke University private sector conference, the entire brass of the AMA happened to be there. It was my turn at the podium and I could not resist the following stunt.

The late James Sammons, then head of the AMA, had given interview in which he said Congress had carved Medicare to death like a turkey. I showed a slide of that quote which happened to have his picture next to it. I then showed data according to which between 1980 and 1988 constant-dollar Medicare spending on physician services per beneficiary rose 83%. Apologizing for this low number on behalf of taxpayers (the growth of 83% real allegedly did not permit physicians to give the elderly adequate care), I asked the AMA people: “What increase would have been adequate in your view?” So I counted out numbers (on a slide) like an auctioneer – 100%, 120% , …– but never got any takers. After +160% I left a blank spot and said: “Evidently 160% would not do it, so you give me the number. Is it 300%?” Icy silence. I then had a slide quoting country-music singer Conway Twitty or whoever it was from his song: “I need more of you (moolah) – more, anything less would not do.”

I then I ended saying that Karen Davis and I, both then serving on the PPRC (now Medpac) would propose a budget for Medicare physician payment (the VPS), because the docs would not come to the table with a reasonable number.

For a while I literally was banned at the AMA; but later I ended up on the JAMA board.

With tales like this, I thought of him as the Richard Feynman of health policy — brilliant in his field but with an appetite for adventure and practical jokes. I encouraged him many times to write up stories like these in a book, interwoven with health policy analysis or history. Sadly, he never did. Though he took pride in his past escapades, perhaps he saw himself differently late in his career.

“When I was younger I was more brash,” Uwe wrote me. “Now I’ve mellowed.”

There are many giants in academia, and many in health care. But there are none I know like Uwe.

Trump to Scrap Critical Health Care Subsidies, Hitting Obamacare Again

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 President Trump will scrap subsidies to health insurance companies that help pay out-of-pocket costs of low-income people, the White House said late Thursday. His plans were disclosed hours after the president ordered potentially sweeping changes in the nation’s insurance system, including sales of cheaper policies with fewer benefits and fewer protections for consumers.

The twin hits to the Affordable Care Act could unravel President Barack Obama’s signature domestic achievement, sending insurance premiums soaring and insurance companies fleeing from the health law’s online marketplaces. After Republicans failed to repeal the health law in Congress, Mr. Trump appears determined to dismantle it on his own.

Without the subsidies, insurance markets could quickly unravel. Insurers have said they will need much higher premiums and may pull out of the insurance exchanges created under the Affordable Care Act if the subsidies were cut off. Known as cost-sharing reduction payments, the subsidies were expected to total $9 billion in the coming year and nearly $100 billion in the coming decade.

“The government cannot lawfully make the cost-sharing reduction payments,” the White House said in a statement.

It concluded that “Congress needs to repeal and replace the disastrous Obamacare law and provide real relief to the American people.”

In a joint statement, the top Democrats in Congress, Senator Chuck Schumer of New York and Representative Nancy Pelosi of California, said Mr. Trump had “apparently decided to punish the American people for his inability to improve our health care system.”

“It is a spiteful act of vast, pointless sabotage leveled at working families and the middle class in every corner of America,” they said. “Make no mistake about it, Trump will try to blame the Affordable Care Act, but this will fall on his back and he will pay the price for it.”

Lawmakers from both parties have urged the president to continue the payments. Mr. Trump had raised the possibility of eliminating the subsidies at a White House meeting with Republican senators several months ago. At the time, one senator told him that the Republican Party would effectively “own health care” as a political issue if the president did so.

“Cutting health care subsidies will mean more uninsured in my district,” Representative Ileana Ros-Lehtinen, Republican of Florida, wrote on Twitter late Thursday. She added that Mr. Trump “promised more access, affordable coverage. This does opposite.”

But Speaker Paul D. Ryan, Republican of Wisconsin, praised Mr. Trump’s decision and said the Obama administration had usurped the authority of Congress by paying the subsidies. “Under our Constitution,” Mr. Ryan said, “the power of the purse belongs to Congress, not the executive branch.”

The future of the payments has been in doubt because of a lawsuit filed in 2014 by House Republicans, who said the Obama administration was paying the subsidies illegally. Judge Rosemary M. Collyer of the United States District Court in Washington agreed, finding that Congress had never appropriated money for the cost-sharing subsidies.

The Obama administration appealed the ruling. The Trump administration has continued the payments from month to month, even though Mr. Trump has made clear that he detests the payments and sees them as a bailout for insurance companies.

This summer, a group of states, including New York and California, was allowed to intervene in the court case over the subsidies. The New York attorney general, Eric T. Schneiderman, said on Thursday night that the coalition of states “stands ready to sue” if Mr. Trump cut off the subsidies.

What the administration has done to weaken the health law.

Mr. Trump’s decision to stop the subsidy payments puts pressure on Congress to provide money for them in a spending bill.

Senator Lamar Alexander, Republican of Tennessee and the chairman of the Senate health committee, and Senator Patty Murray of Washington, the senior Democrat on the panel, have been trying to work out a bipartisan deal that would continue the subsidy payments while making it easier for states to obtain waivers from some requirements of the Affordable Care Act. White House officials have sent mixed signals about whether Mr. Trump was open to such a deal.

The decision to end subsidies came on the heels of Mr. Trump’s executive order, which he signed earlier Thursday.

With an 1,100-word directive to federal agencies, the president laid the groundwork for an expanding array of health insurance products, mainly less comprehensive plans offered through associations of small employers and greater use of short-term medical coverage.

It was the first time since efforts to repeal the landmark health law collapsed in Congress that Mr. Trump has set forth his vision of how to remake the nation’s health care system using the powers of the executive branch. It immediately touched off a debate over whether the move would fatally destabilize the Affordable Care Act marketplaces or add welcome options to consumers complaining of high premiums and not enough choice.

Most of the changes will not occur until federal agencies write and adopt regulations implementing them. The process, which includes a period for public comments, could take months. That means the order will probably not affect insurance coverage next year, but could lead to major changes in 2019.

“With these actions,” Mr. Trump said at a White House ceremony, “we are moving toward lower costs and more options in the health care market, and taking crucial steps toward saving the American people from the nightmare of Obamacare.”

“This is going to be something that millions and millions of people will be signing up for,” the president predicted, “and they’re going to be very happy.”

But many patients, doctors, hospital executives and state insurance regulators were not so happy. They said the changes envisioned by Mr. Trump could raise costs for sick people, increase sales of bare-bones insurance and add uncertainty to wobbly health insurance markets.

Chris Hansen, the president of the lobbying arm of the American Cancer Society, said the order “could leave millions of cancer patients and survivors unable to access meaningful coverage.”

In a statement from six physician groups, including the American Academy of Family Physicians, the doctors predicted that “allowing insurers to sell narrow, low-cost health plans likely will cause significant economic harm to women and older, sicker Americans who stand to face higher-cost and fewer insurance options.”

While many health insurers remained silent about the executive order, some voiced concern that it could destabilize the market. The Trump proposal “would draw younger and healthier people away from the exchanges and drive additional plans out of the market,” warned Ceci Connolly, the chief executive of the Alliance of Community Health Plans.

Administration officials said they had not yet decided which federal and state rules would apply to the new products. Without changing the law, they said, they can rewrite federal regulations so that more health plans would be exempt from some of its requirements.

The Affordable Care Act has expanded private insurance to millions of people through the creation of marketplaces, also known as exchanges, where people can purchase plans, in many cases using government subsidies to offset the cost. It also required that plans offered on the exchanges include a specific set of benefits, including hospital care, maternity care and mental health services, and it prohibited insurers from denying coverage to people with pre-existing medical conditions.

The executive order’s quickest effect on the marketplaces would be the potential expansion of short-term plans, which are exempt from Affordable Care Act requirements. Many health policy experts worry that if large numbers of healthy people move into such plans, it would drive up premiums for those left in Affordable Care Act plans because the risk pool would have sicker people.

“If the short-term plans are able to siphon off the healthiest people, then the more highly regulated marketplaces may not be sustainable,” said Larry Levitt, a senior vice president for the Kaiser Family Foundation. “These plans follow no rules.”

Mr. Trump’s order would also eventually make it easier for small businesses to band together and buy insurance through entities known as association health plans, which could be created by business and professional groups. A White House official said these health plans “could potentially allow American employers to form groups across state lines” — a goal championed by Mr. Trump and many other Republicans — allowing more options and the formation of larger risk pools.

Association plans have a troubled history. Because the plans were not subject to state regulations that required insurers to have adequate financial resources, some became insolvent, leaving people with unpaid medical bills. Some insurers were accused of fraud, telling customers that the plans were more comprehensive than they were and leaving them uncovered when consumers became seriously ill.

The White House said that a broader interpretation of federal law — the Employee Retirement Income Security Act of 1974 — “could potentially allow employers in the same line of business anywhere in the country to join together to offer health care coverage to their employees.”

The order won applause from potential sponsors of association health plans, including the National Federation of Independent Business, the National Restaurant Association, the U.S. Chamber of Commerce and Associated Builders and Contractors, a trade group for the construction industry.

The White House released a document saying that some consumer protections would remain in place for association plans. “Employers participating in an association health plan cannot exclude any employee from joining the plan and cannot develop premiums based on health conditions” of individual employees, according to the document. But state officials pointed out that an association health plan can set different rates for different employers, so that a company with older, sicker workers might have to pay much more than a firm with young, healthy employees.

“Two employers in an association can be charged very different rates, based on the medical claims filed by their employees,” said Mike Kreidler, the state insurance commissioner in Washington.

Mr. Trump’s order followed the pattern of previous policy shifts that originated with similar directives to agencies to come up with new rules.

Within hours of his inauguration in January, he ordered federal agencies to find ways to waive or defer provisions of the Affordable Care Act that might burden consumers, insurers or health care providers. In May, he directed officials to help employers with religious objections to the federal mandate for insurance coverage of contraception.

Both of those orders were followed up with specific, substantive regulations that rolled back Mr. Obama’s policies.

In battles over the Affordable Care Act this year, Mr. Trump and Senate Republicans said they wanted to give state officials vast new power to regulate insurance because state officials were wiser than federal officials and better understood local needs. But under Thursday’s order, the federal government could pre-empt many state insurance rules, a prospect that alarms state insurance regulators.

Another part of Mr. Trump’s order indicates that he may wish to crack down on the consolidation of doctors, hospitals and other health care providers, a trend that critics say has driven up costs for consumers. Mr. Trump said that administration officials, working with the Federal Trade Commission, should report to him within 180 days on federal and state policies that limit competition and choice in the health care industry.