The GOP Plan to Kill Employer-Based Health Insurance

Mabel Goodwin, forty-five, is examined by a woman doctor at the employment office of the Bell Aircraft plant.  Our Employer based health insurance has its roots in World War II. Library of Congress photo.

I don't know what worries me more, the fact that after eight years, Republicans don't have any single plan as they rush to replace the Affordable Care Act, or the plans that they DO have all involve higher out of pocket costs for healthcare and more people losing their insurance.
Trump's pick for Health and Human Services is Rep. Tom Price. Like all of Trump picks, he is an extreme conservative who hates the agency that he is being asked to lead.

Rep Tom Price has wanted to get rid of the Affordable Care Act more than anyone.

He also has a plan to get rid of employer based health insurance.

As noted in this morning's Talking Points Memo, there has long been an idea in Republican circles that providing healthcare to employees is a drag on the American economy. Even liberals like me think that our way of providing health care is inefficient, an accident of history that created a convoluted system.

Employee based healthcare came about during World War II. With workers in high demand, offering health benefits became a way for companies to attract and keep employees. In 1943, the government decided that the costs of companies providing this health insurance to employees should be ta deductible.  This was good for companies -- in that they could write off the cost of their contribution to employee health insurance. It was good for employees too as health care became increasingly expensive with new technology.

They problem with that system is that if you lose your job, you lose your health insurance.

The Affordable Care Act tried to offer an alternative, allowing individuals sign up for health insurance even if they didn't have a job. Some found that plans on the individual market where better than what was offered by their employer.

That said, seven times as many people get their health insurance through work than through the Affordable Care Act -- half the living US population gets health insurance that way.

Price's idea make it much more expensive for the employee and the employer to do so, thereby pushing more people out into the individual marketplace to buy insurance.

Employers would lose tax incentives to provide health insurance to their employees -- the amount of taxes they could write off would be capped. That would mean either passing more of the cost of health insurance to the employee contribution -- making it more expensive -- or vouchering a set amount to the employees to go buy their own insurance. Eventually, the idea would be to drive employees out into the individual marketplaces.

This aligns with Rep Paul Ryan's plan to privatize Medicare too. Ryan wants to turn Medicare from an insurance program to a voucher program which relies on individuals to choose their own plans in the open marketplace. Price's bill would allow people to opt out of Medicare and buy individual insurance plans that likely would be attractive because they cost less, but would also likely not cover as much of the healthcare costs.

The problems with that are several:

1) Republicans also want to repeal the individual mandate - the requirement that people buy health insurance. That means young and healthy people won't buy insurance, which makes insurance much more expensive for those who need it.

2) Republicans want to repeal the requirements that health insurance plans have a basic set of things that are covered. That means you would have to choose from a huge menu of confusing plans, pay in for years and never really be sure if your insurance is actually going to cover you when you get sick.

The idea is that, by having more people choosing their own plans -- and by having insurers freed of many of the ACA's regulations -- younger and healthier people will be able to get cheaper, but skimpier plans.
However, that approach comes with its downsides. With younger and healthier people shifting to more meager plans, the risk pools for people who need more comprehensive care -- the older and the sicker -- decrease in size while growing in average cost. For them, Price proposes a high-risk pool set-up by the states, though the amount of federal money he's willing to invest in them is dwarfed by what it's expected they'd cost.
"There's a lot here that is oriented towards separating the cost of people who have health issues from people who don't," Blumberg said.

Employer based health insurance was a way to share the costs of healthcare. The young and healthy pay in, but use less, reducing the cost for the older patients who need more expensive healthcare.

This is all about how the GOP views health insurance. They feel it is an individual responsibility to pay up or suffer. Moreover, their corporatist leanings have them working to reduce the burdens on employers to provide health insurance -- pushing that burden onto the individual. They emphasize "access" and "choice" to indicate that anyone will be able to buy health insurance if they have enough money.

If you don't have the money, you'll get what you pay for. 

You are going to see a lot more high deductible and catastrophic health insurance options on the marketplace and these options are going to be attractive because they will cheap. Yet they won't cover most health care. Indeed, under most Republican plans you and I are going to pay a lot more out of pocket for our health expenses. 

Where as the ACA tried to broaden the risk pools, which reduced the costs for everyone, the GOP plans want to segment the types of insured so insurance companies can charge much higher premiums to the elderly and sick. This at a time when medical bills are already the biggest source of debt -- even for people with health insurance.

"What this does is it helps you when you are young, when you are perfectly healthy. But we don't stay that way," Health Policy Analyst Linda Blumberg told TPM. "The costs go up tremendously and access decreases tremendously when you have health care needs."

That seems to be a theme among all the Republican health care proposals -- put more responsibility on the individual both for the cost of the premiums and the bills when they come due. They all involve the hope that somehow insurance companies become more efficient and less profit driven, which is unlikely to happen. 

Finally, there is the problem of responsibility. What happens if someone doesn't buy health insurance - or if the bargain basement plan purchased by someone with limited or fixed income doesn't cover unforeseen healthcare costs.  

Aside from the return of medical bill bankruptcies -- which decline under the first years of the ACA -- Republicans propose decreasing support for medicaid and medicare with few backstops for the poor, sick and uninsured. 

As I said earlier, I think employer-based healthcare is a drag on the economy, but I differ from Republicans in thinking we should put even more burden on the American people. 

That's because I believe putting individuals deep into debt or bankruptcy to pay for healthcare is a burden on our nation as whole -- a drag on the economy. 

Other industrialized nations don't have medical bankruptcies.

However, that is because other industrialized nations have public healthcare options. 


Required Reading:
The Accidental History That Created the US Healthcare System NPR
Sara Kliff Read All the Republican Health Care Plans, Here is What She Found, VOX
Price's Bill HR 2300
Obamacare seems to be reducing medical debt NYT
Even the Insured Can Face Crushing Medical Debt The Upshot
Why Americans are Drowning in Medical Debt. The Atlantic


Trump is going to kill children with this one

TRUMP is anti-science and pro conspiracy theory -- a dangerous combination where the health of millions of American children are concerned. 

Now he selected an anti-vaccine kook to head the Commission on Vaccine Safety.

As the Washington Post reports Trump is selecting vaccine conspiracy theorist Robert Kennedy Jr
The stunning move contradicts established science, medicine and the government’s position on the issue. The announcement was met with alarm from health professionals who say that putting a proponent of a conspiracy theory in a position of authority on this issue is dangerous.

“That’s very frightening, it’s difficult to imagine anyone less qualified to serve on a commission for vaccine science,” said Peter Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine, and president of the Sabin Vaccine Institute, a nonprofit that works to control, treat and eliminate vaccine-preventable and neglected tropical diseases. 
“The science is clear: massive evidence showing no link between vaccines and autism, and as both a scientist who develops vaccines for poverty related neglected diseases and the father of an adult daughter with autism, there’s not even any plausibility for a link,” Hotez continued. “Autism is a genetic condition."

Kenndy JR doesn't believe that, he and Trump are still hooked on the Andrew Wakefield con that finds continued irrational support on the fringes of the Left and the Right. 

As vaccination rates have decreased, we are seeing the re-emergence of preventable childhood disease -- that are killing children. This lie has real life and death

Required reading:
Washington Post: Trump Taps Vaccine Skeptic to Head Vaccine Safety
Death toll at What'stheHarm.net at least 4,000 children and counting.
NCBI: The MMR and Autism: Sensation, Retraction, Refutation and Fraud 
Forbes: The Anti-Vaccine Movment and Trial-Lawyer Funded Climate of Fear
Brian Deer: Andrew Wakefield and the MMR Vaccine Fraud


What's Going to Happen to Obamacare?

Republicans have been elected on a single promise over the past few elections -- repeal Obamacare.

Most people have heard the name, but don't know what it means. If you ask them about the benefits of individual provisions of the law, they are in favor of it. If you call it Obamacare -- they hate it.

The problem all along has been that there is no  Republican alternative -- that's because the private insurance based ACA WAS the Republican alternative to expansion of medicare and medicaid.

And just repealing the law would leave 22 million people without insurance -- not surprising then that Trump has softened his stance since the election. 

Five Thirty Eight untangles the thread of what "repealing Obamacare" might actually mean:

The law is built on interlocking provisions; removing one puts pressure on others. That’s what happened when the Supreme Court made the Medicaid expansion optional for states, leaving 2.5 million people in states that chose not to expand in what has been called the Medicaid gap: too poor to be eligible for the marketplace subsidies but ineligible for Medicaid. Leaving in place the mandate for insurance companies to cover people with pre-existing conditions, as Trump said he’s considering, while getting rid of either the individual mandate — the requirement that people get insured — or the subsidies that motivate low-income healthy people to join the insurance rolls could also create instability in the insurance market. Without the necessary mix of healthy people in a plan to offset the costs of insuring people with pre-existing conditions, premiums rise, becoming unaffordable for everyone.
So far there is no prescription of replacing Obamacare that won't result in increasing costs and decreasing coverage. That's the problem with governing -- people feel the effect of what you do and you actually have to follow through with your promises.

Forbes details a lot of things that are going to be bad for health and healthcare on the Republican agenda. If you want a dozen more things to be scared of it is worth reading --  The anti-science crackpots he has in line have all kinds of bad news.


Required Reading:
What the Republicans are going to do to your health.
What Will Trump Do to Obamacare  538
What will Happen to Obama Care


You Can Only Do What You Can Do

full steam a head
Triage is all about sorting out the sick from the un-sick prior to the application of limited resources.

It is a vital part of the job we do.

There are times when it feels like bailing water with a teacup on a sinking ship.

A well designed Emergency Department will have enough nurses and doctors to handle the daily expected volumes of bellyaches and runny noses as well as the chest pains and traumas. It will also have a good triage system where a nurse puts eyes on a patient on arrival and determines whether they are sick or not sick.

Yet there are always time when you will get fooled. Patients lie -- often because they don't know the truth. They don't know the important information, or their presentation is unusual, their story is vague. The medical team goes down the wrong path -- prioritizes the labs before the head CT or vice versa.

There will always be times when a department gets overwhelmed and resources just aren't available. Things get missed or miscommunicated, computers go down. Things go wrong.

I've just been through a week of these brutal days: Of restrained psych patients tipping over their gurneys and ambulances coming through the door of our little ED two at a time. Six 12 hour shifts of waves crashing against one doc, two nurses and a tech.

On my last night, I knew I was in for another 12 hours of pounding surf.

When the day shift nurse gives you a hug because they are so glad to see you come on, you know they've had a brutal 12. It took us a while to figure out that the misery to acuity ratio was out of control. Once we sorted the drama from the trauma, we took care of the sick people first and finally got thing restored to baseline chaos.

We spent most of the night, feeling like we were underwater and no amount of swimming was going to bring us to the surface.

I could see it in dayshift's eyes as they were leaving. The next shift finally comes in to clean up the mess and you kick yourself as you go home. It is tempting to blame others, or blame yourself for what went wrong.

Yet, blame doesn't fix anything ... and doesn't make anyone feel better or work better.

When other team members make a mistake how we respond can be the determining factor in helping that person recover and get better. As author Justin Bariso writes:

"leaders are in a unique position to help individuals recover from mistakes. When a leader keeps his or her own failures in mind, it's easier to use words to encourage and build up than to dishearten and tear down. By choosing to focus on the positive, skillfully sharing your own personal experience, or simply reminding the person that everyone has a bad day, you do everything in your power to help that person recover."

Of course we need to review the breakdowns in the system to make it better, to innovate to better allocate resources if possible. When the heat of battle has died away, we need to talk to our team to discuss what could have gone better. We need to learn whether we got it right or got it wrong. That's why experience in emergency medicine is the most precious resource.

However, internalizing our mistakes can take the form of self-abuse, battering our confidence and diminishing our ability to make decisions that have to be made.

It is times like this when I find myself consoling my coworkers with a mantra I've picked up over the years.

"You can only do, what you can do."

As a human being and as a system, resources are finite. We cannot see or know everything, we cannot be everywhere at once. We must triage and prioritize our tasks, triage the demands on our minds and on our souls. We are not superhuman and we cannot bear all the burdens of the world.

Nor should we expect that of ourselves or others.


Required reading: A Lesson in Leadership


The Profit-Making Costs On Our Health

photo: Library of Congress
The profit-motivated US healthcare system not only makes our healthcare more expensive than other industrialized nations, it also changes our our culture and our behavior to make us less healthy.

One of the biggest problems with the American healthcare system is that it is a rigged economic game where you don't know the price of what anything costs, and yet the price of the unavoidable healthcare needs could bankrupt you.

This price blindness is a fundamental flaw in our so called free-market system, but it is far from the only flaw tied to profit-driven healthcare.

Since so many people fear the boogeyman of socialised medicine, let's talk about some of the problems with the alternative system we now suffer through.

As an aside, please don't equate Obamacare or the ACA with socialised medicine -- it is not. The ACA simply required people to get health insurance and required private insurance companies to sell it to them. These companies are still profit motivated and opposed to cooperating with each other for the sake of good patient care.

For profit corporations are poor actors in the healthcare business, and yet we continue to place more of our lives in their greedy hands. Drug companies in particular have finally been exposed to the spotlight as they have cranked up prices on life saving medications just to boost the share on Wall Street and the bonus of the top executives. While a few high profile examples have recently gotten attention of the media, this practice is widespread and continuing unabated.

As Fortune Magazine reported:
More than two-thirds of the 20 biggest pharma companies used price hikes to drive revenue growth in the first quarter of 2016, according to an analysis of corporate filings and earnings statements by the Wall Street JournalThe review also found that drugmakers have been relying on this tactic more and more and raising prices by higher amounts than before despite multiple Congressional inquiries into the practice and proposed reforms to tackle drug costs from President Obama, Hillary Clinton, Donald Trump, and others. The findings underscore the enormous power that the biopharmaceutical industry maintains in a system where negotiations over prices and discounts are stratified across a decentralized mix of private insurers, government health programs, and drug benefit managers.
Yet another way that for profit companies negatively influence our healthcare decisions is through twisting science and lobbying government.

A recent episode of Tom Ashbrook's On Point had an excellent sampling of the horrifying impact on our nation's health.

Investigative reporters have recently uncovered evidence that drug makers lied to doctors to push the aggressive prescription of addictive oxycontin as "less addictive" alternative to drugs on the market. Documents show the drug makers knew this was not true. 

Moreover, these same pharmaceutical companies were responsible for lobbying to implement increasing the aggressive treatment of pain with narcotics. This is where the whole "pain is the 5th vital sign" originated.

Thus doctors in the United States are being penalized for creating an epidemic of narcotic addiction while at the same time their compensation is linked to surveys of patients asking if they got enough pain medication. That's why the United States -- which has only 5 percent of the world's population consumes two-thirds of the world's prescription pain medication.

It's not an accident of culture, but a concerted, planned out lobbying effort on multiple fronts designed to increase demand for a product. Millions of dollars are spent each year to boost demand for a product that is detrimental to the nation's well being.

In the same show, Ashbrook interviews researchers who discovered that a few well placed science papers in the 1960s allowed the sugar industry to divert scientific research away from carbohydrates and toward saturated fats as the cause for chronic health problems.

Of course this lead to the marketing of products with reduced fats and greatly increased the consumption of sugars.

On both issues we see the way our health culture has been altered by the pursuit profits at the cost of American lives.

Required reading:

Secret Trove Reveals Bold Crusade to Make Oxy a Blockbuster

The LA Times Series on the Oxycontin

How the Sugar Industry Shifted the Blame to Fat

To Make Big Profits, Drug Companies Use Monopoly Shenanigans

Drug Rep Arrested in Opiod Kickback Scheme

The whole On Point podcast is available and worth listening to.