The Avalanche of Death: This is just the start of US healthcare's collapse

The tax plan passed by the GOP last night is mostly a sop to their donors with some ultra-conservative red meat thrown in to win a few senators who may have once pretended to care about fiscal responsibility.

However, one thing included in the bill is essentially a repeal of the individual mandate to have health insurance -- a key component of the Affordable Care Act.

With this mandate gone, millions are expected to lose access to health insurance, and those of us that still have health insurance can expect it to get more expensive.

The reason is simple -- and the basis for all insurance programs. If something is expensive, you spread the cost out over a large group of people so they can pay small amounts. The problem with health insurance is that not enough younger people sign up for it.

That leaves only older, sicker people paying in to the system. The individual mandate sought to increase number of people paying into insurance pools so as to spread out the costs. Moreover, younger people get sick too -- not as often perhaps -- but they get in accidents, get sick, have sick kids. There is good reason to have insurance even if you are relatively healthy, and the more people with insurance, the lower the costs for each individual.

However, drop the mandate and many of those people will likely leave the pool. That means increased insurance premiums for the people who are left.

As premiums go up, fewer people can afford to buy health insurance and more drop out.

Wash, rinse, repeat.

Meanwhile, the Trump White House and Republicans are already planning to pay for their big tax cut with "entitlement reform." That is the GOP's expression for cutting Medicare, Medicaid and Social Security.

It is something they've wanted to do for a long time. Now they've created an excuse - the tax cuts could trigger forced spending reductions in Medicare starting as early as next year. 

Cuts to those programs will lead to more uncompensated care, which will make healthcare more expensive for insurance programs, which will lead to higher premiums.

More sick people not getting the care they need.
More medical bankruptcies.
Fewer providers.


Vox: Tax Bill is Just the Start of the Obamacare Collapse.
WAPO: GOP Eyes Post Tax Cut Changes to Medicare, Social Security
LA Times: After Giving Tax Cuts to the Rich, GOP Will Cut Social Security, Medicare
Forbes: How the GOP Tax Bill Will Blow Up Medicare
NYT: The Tax Bill's Automatic Spending Cuts

Own it and Learn

As a nurse, I hate making mistakes.
I try not to make them, but they sneak up on you despite your best efforts.

Usually, they come when you feel like you're on top of things, like you have it all under control.

Let your guard down.
Fail to do the one thing you always do.
Fail to catch that vital bit of information at that crucial time.
Trust, when you know you shouldn't.

When I do make mistakes, I've learned that there is a professional -- and healthy -- way to cope.

1) Own it. (Admit it to team quickly and openly) Covering up a mistake, or spending time the the denial phase only makes things worse. Errors are compounded by obfuscation and willful ignorance. Admitting it to your team lets them know you made a mistake and gets them on board with helping you correct it. Moreover, it let's them know that you are aware of the error and not a incompetent idiot who can't be trusted.
2) Figure out how I can avoid repeating it. Every error is an opportunity. Figure out how you got fooled, or why you got complacent, and never let it happen again.

3) Share with peers - so they can learn from my mistakes. This is the other half of owning it publicly and will help when confessing your sins. "Man, I learned the hard way, I'll never get burned like that again."

Mistakes haunt me, they make for a long ride home and a hard time sleeping, especially when they have a negative outcome on the patient. Mistakes make me question my place in this profession and all the time I spend teaching others.

I played cornerback in high school football. Playing defensive back is tough because you will get burned for a big play eventually. The receiver knows the route, you don't. The quarterback knows it is a fake, you don't. You are at a disadvantage of knowledge. When you get burned, there's no time to get down on yourself. Pick your jock up off the turf and get back to the line, the next down is coming fast.

I learned to yearn for the next down after getting beaten by a big play. Getting it right was the only way to get the taste of getting it wrong out of my mouth.

Experience builds confidence if you learn along the way. Each experience is a piece of armor as we go into battle against the unknown. You get tougher. You get smarter, faster - you catch some little thing that you overlooked before.

The most important play is the next one - because that's an opportunity to get it right.

We can't be perfect.

But we can get better.



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