The legacy of Obamacare: A five percent increase in heart patient deaths

15 November 2017

When one individual inflicts bodily injury upon another such that death results, we call the deed manslaughter; when the assailant knew in advance that the injury would be fatal, we call his deed murder. But when society places hundreds of proletarians in such a position that they inevitably meet a too early and an unnatural death, one which is quite as much a death by violence as that by the sword or bullet  murder it remains. (Friedrich Engels, The Condition of the Working Class in England, 1845)

* * *

A US government program supposedly devised both to improve medical care and cut costs has, predictably, succeeded in the latter while undermining the former. Research published Sunday in JAMA Cardiology (Journal of the American Medical Association) shows that an initiative introduced five years ago under the Affordable Care Act (ACA) to induce hospitals to reduce Medicare readmissions for heart patients has resulted in an increase in mortality rates among those studied.

Under the ACA’s Hospital Readmissions Reduction Program (HRRP), hospitals were penalized financially when heart failure patients were readmitted within a month. While the program has succeeded in reducing the number of 30-day readmissions, the number of patients who died within a year rose by 5 percentage points. According to one of the study’s senior authors, these findings could account for an additional 5,000 to 10,000 deaths annually across the US due directly to the program.

For the American ruling elite, HRRP and other schemes devised by bureaucrats at the Centers for Medicare and Medicaid Services (CMS) are part of an agenda that is as deliberate as it is ruthless: Men and women in the US are living too long into old age and measures must be taken to cut costs associated with their medical care and shorten their life expectancy. This is the deadly price that must be paid to prop up a society that is one of the most socially unequal both in terms of income and the delivery of health care.

The statistics do not lie. Study researchers analyzed 115,245 patients at 416 hospitals in the American Heart Association’s Get With the Guidelines-Heart Failure registry from January 2006 to December 2014. They examined readmission and death rates before and after the program began in 2012.

* Readmission rates within one month fell from 20 percent before HRRP penalties to 18.4 percent after HRRP (down 1.6 percent). Mortality rates, however, rose by almost the same rate, from 7.2 percent before HRRP to 8.6 percent after (up 1.4 percent).

* Statistics for readmission and mortality within one year were even more damning. Readmission within one year fell by only about 1 percent, from 57.2 percent before HRRP to 56.3 percent after. But the mortality rate within one year rose from 31.3 percent before HRRP to 36.3 percent after—a shocking 5 percent increase. These figures show that there is a direct correlation between implementation of the Obamacare policy and preventable deaths.

HRRP penalizes hospitals up to 3 percent of every Medicare dollar for “excessive” repeat hospital stays. That is 15 times more than the 0.2 percent penalty levied against hospitals with high mortality rates. In other words, while hospitals with higher rates of mortality face a minimal fine, hospitals are being substantially penalized for failure to comply with a program that is resulting in increased deaths.

Compounding the misery, financial penalties from HRRP have been shown to fall disproportionately on academic medical centers and “safety-net” hospitals where “higher readmission rates are associated with the higher case-mix complexity and lower socioeconomic status,” according to the study, i.e., those treating poorer and sicker patients. In such settings, hospitals are incentivized to “game” the system by delaying admissions, increasing observation stays or shifting inpatient-type care to emergency departments, to the detriment of patient welfare.

The US mortality rate rose in 2015 in the first year-over-year increase since 2005, with life expectancy falling between 2014 and 2015 from 85.8 years to 85.6 years for men, and from 87.8 years to 87.6 years for women. According to the Centers for Disease Control and Prevention, this decline was due to an increase in eight of the 10 leading causes of death in the US, including heart disease, stroke, Alzheimer’s disease and suicide.

With heart disease rising, there is no other way to interpret the penalties imposed by the ACA for early readmission of heart patients than a deliberate effort to see more men and women die. US corporations are already reaping a grim dividend from this downward trend, with at least 12 major corporations reporting this summer that they have reduced their estimates for how much they could owe in pension and other retirement obligations by a combined $9.7 billion due to shorter life spans.

It is fitting that the health care overhaul known as Obamacare was the instigator of HRRP, an irrefutable demonstration that the ACA was the first major volley in the bipartisan drive to restrict access to affordable health care and sharply reduce the length of workers’ lives.

As the World Socialist Web Site explained as early at 2009, the Obama administration’s health care “reform” established a framework for the insurers, the corporations and the government to drastically reduce the health benefits available to low- and middle-income individuals and families. The aim is to limit the amount that the government must pay out for health care and Social Security payments, as well as what corporations must pay in pensions and other retirement benefits.

Health care in the Obamacare era has nothing in common with quality, near-universal health care, as Obama initially pledged. It is based entirely on the for-profit health care system in America, including the insurance companies, giant hospitals, health care chains and pharmaceutical companies. Any repeal of the ACA—and its replacement with “Trumpcare” or any other legislation—will maintain the class-based delivery of health care and undoubtedly worsen it for the majority of Americans.

The empirical proof provided by research published in JAMA Cardiology that an ACA program has predictably caused increased deaths should serve as a stark warning to the working class. This Obamacare program is of a piece with the bipartisan attack on jobs and living standards, the attack on immigrants and democratic rights, and the drive to war.

This assault will inevitably provoke enormous social opposition among workers and young people. This opposition must be channeled into the fight for a progressive overhaul of the health care system that takes as its starting point an end to privately owned health care corporations and medicine-for-profit and the establishment of socialized medicine, democratically administered by a workers’ government, providing free, high-quality health care for all.

Kate Randall

http://www.wsws.org/en/articles/2017/11/15/pers-n15.html

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Will Trump’s sabotage wreck your health care?

Christopher Baum explains what Trump’s executive orders on health care will mean–and why no one should settle for the Democrats’ bipartisan “compromise.”

Donald Trump signs an executive order on health care (Andrea Hanks | WhiteHouse.gov)

Donald Trump signs an executive order on health care (Andrea Hanks | WhiteHouse.gov)

“OBAMACARE IS finished,” Donald Trump told reporters on October 16. “It’s dead. It’s gone. You shouldn’t even mention it. It’s gone. There is no such thing as Obamacare anymore.”

Just saying the same thing over and over doesn’t make it true. But Trump has certainly been busy trying to turn these words into reality.

This summer, Senate Republicans failed three times to “repeal and replace” the Obama administration’s Affordable Care Act (ACA), thus denying Trump the victory he’s been promising to his right-wing base since last year’s election campaign.

But Trump has the power to do a lot of harm on his own, without any help from Congress. In October, he kicked his sabotage efforts into high gear–first by dismantling the ACA’s contraceptive mandate and then with a pair of orders that threaten to undermine the insurance markets established under the ACA.

A bipartisan pair of senators, Lamar Alexander of Tennessee and Patty Murray of Washington, are proposing a bill that they say will stop the Obamacare system from crashing because of Trump’s unaccountable orders.

But predictably, the bill is tailored to the concerns of the insurance companies threatened with a loss of federal government money to cover premium subsidies for poor and working-class Americans, rather than the problems so many millions of people face because of the ACA–and there’s no guarantee that Trump will support the bipartisan deal, or that the GOP-controlled House will pass it, anyway.

So Trump’s executive actions do represent a further threat to access to health care for millions of people. But even if Trump accepts the bipartisan “compromise” to temporarily prop up one aspect of Obamacare, the ACA status quo is breaking down as a result of a wider crisis, which includes sabotage on the part of the insurance industry itself.

We need to oppose the right-wing assault on our health care in any form–whether the outright “repeal and replace” proposals that would demolish the government’s Medicaid health care system for the poor or Trump’s whittling away at the ACA provisions that help ordinary people.

But the grassroots uprising that helped defeat Trumpcare this summer can’t be diverted by Democrats claiming their bipartisan compromises are enough to solve the worst of the problems.

The health care status quo built on Obamacare won’t do. We need a whole new system: a single-payer system that guarantees free comprehensive health care for all.

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TRUMP’S LATEST wave of attacks came in a one-two punch on October 12.

First, Trump issued an executive order directing his administration to “consider proposing regulations or revising guidance” in some key areas regarding the ACA.

These include association health plans (AHPs), which essentially allow small businesses to band together and thereby obtain more favorable pricing from insurers; and short-term limited duration insurance (STLDI), which provides limited coverage for a defined period for people who are in between jobs or otherwise need “gap” coverage while looking for a more permanent solution.

In both these areas, Trump called for expanded access and availability–which in effect means deregulation.

AHPs, for instance, offer tantalizing prospects to those who find Obamacare’s regulations on what health insurance policies must cover excessive.

The ACA essentially recognizes three types of insurance plans: individual plans, small group plans (covering two to 50 employees), and large group plans (covering 51 or more employees).

Some of the most important protections under Obamacare–such as the requirement that all plans cover a defined list of essential health benefits–apply only to individual and small group plans.

Large group plans can, for example, “avoid covering essential services like mental health care and substance use disorder treatment and, although they technically are not supposed to exclude pre-existing conditions or charge higher rates to people with them, they are in fact less constrained in doing so,” Timothy Jost wrote at the HealthAffairsBlog.com.

Trump’s idea, then, is to find ways to allow small groups–and perhaps even individuals–to band together into AHPs and get the same exemptions as large groups. As Jost goes on to write:

If association health plans could market health coverage claiming to be self-insured large group plans…they could be free from state regulation and could market plans with skimpy benefits and find it easier to cherry pick healthy enrollees and avoid unhealthy ones.

As for the short-term policies known as STLDI, Trump’s order instructs federal agencies to consider lengthening the coverage period and making the policies renewable–meaning that people could choose STLDI, as a more or less permanent option for health care coverage.

This appeals to the Trump administration because, as the executive order notes, STLDI is “exempt from the onerous and expensive insurance mandates and regulations” of Obamacare. Freed from the requirement that such policies be temporary, STLDI could be offered cheaply to young, healthy people who don’t anticipate having significant health care expenses.

Thus, Trump’s objective is clearly to expand the availability of insurance plans that aren’t subject to the full scope of the ACA’s patient protection requirements. As Jonathan Cohn wrote at Huffington Post, the order could allow “a proliferation of cheaper, less comprehensive plans that would undermine rules about who and what insurers must cover.”

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TRUMP’S SECOND order would end reimbursements to insurance companies for the cost-saving reductions (CSRs) they are required by law to make for low-income policyholders. These payments are estimated to total $7 billion in 2017.

Trump and Republicans have deceptively characterized these payments as “handouts” to the insurance industry. But CSR payments are the means that the Obama administration came up with to provide help for low-income consumers who have to purchase health insurance under the ACA rules.

Under the ACA, individuals and families with incomes up to 250 percent of the federal poverty line who buy insurance through state or federal markets are eligible for a reduction in premium payments and out-of-pocket costs. The ACA also requires that the federal government pay insurers to offset this reduction.

But because the law doesn’t explicitly require the government to appropriate funds to cover the CSR payments–and Congress didn’t pass a separate measure to fund them–the Republicans claimed that the CSR violated the constitution because the administration was making the payments without the sanction of Congress.

In 2016, a federal judge ruled in favor of the GOP in a lawsuit against the Obama administration, but immediately stayed her order blocking the payments in order to let the appeals process play out.

Ever since Trump took office, his administration has been threatening to use the court decision as a pretext for cutting off CSR payments.

The requirement that insurance companies continue to offer rate reductions to lower-income people remains in effect, whether or not they get CSR payments from the Feds. So the question is how the insurers will respond.

One danger is that more insurance companies will abandon the state and federal marketplaces for selling policies under the ACA–a trend that has been accelerating already over the last several years. Others might use the cutoff as an excuse to stop offering reduced rates as required, and wait to see how the Trump administration responds.

For insurers that remain in the ACA marketplace, another approach would be to raise premiums to offset the lost reimbursement from the federal government.

In August, the Congressional Budget Office (CBO) studied this possible outcome and concluded that most of the negative effects arising from higher premiums would be offset by corresponding increases in the premium tax credit (PTC), another Obamacare subsidy. In other words, the tax credit would increase for people paying higher premiums.

But this conclusion relies on the rather massive assumption that the PTC itself will remain intact.

The CBO estimates that with CSR payments to insurers eliminated, the cost of increased PTCs over the next 10 years in reduced tax revenue to the federal government would be a net of $247 billion.

Republicans in Congress have already demonstrated with every health care proposal they’ve tried to pass this year that they believe too much is being spent on subsidizing health care for the needy. What are they odds they’ll stand for such an increase?

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TO THE extent that a rise in premiums isn’t offset by tax credits or other means, the result will be higher costs, fewer plan options and reduced access to health care. And if enough insurers decide to exit the market, many people may find themselves with no health insurance options whatsoever.

But this–or at least the threat of this–is precisely what Trump wants.

“Now, we’re going to get the health care done,” Trump told reporters on October 16. “In my opinion, what’s happening is, as we meet–Republicans are meeting with Democrats because of what I did with the CSR, because I cut off the gravy train. If I didn’t cut the CSRs, they wouldn’t be meeting.”

As we have seen, the CSR is no “gravy train.” And however much Trump may flatter himself that his destructive behavior is just a clever maneuver, the only thing he’s truly demonstrated is his willingness to destroy anything or anybody to get what he wants.

Whether he is threatening health care subsidies desperately needed by millions of low-income people, or using the possibility of deportation for nearly a million DACA participants as a bargaining chip to get his beloved border wall, Trump’s message is the same: I’m going to get my way, or I’ll blow the whole thing up.

So it’s anybody’s guess whether Trump will support the deal worked out by Sens. Lamar Alexander and Patty Murray, which would fund CSR payments to insurers through 2019.

Although the response from congressional Republicans was lukewarm at best, Democrats were, of course, enthusiastic. Speaking to the press last week, Senate Minority Leader Chuck Schumer spoke of the “growing consensus that in the short term we need stability in the markets,” and praised the Alexander-Murray proposal for providing that–along with “some very significant anti-sabotage provisions,” although he didn’t elaborate on what these might be.

This was in keeping with the Democratic talking points that legislation is needed to “stabilize markets and lower premiums,” as Schumer said last month–and then Obamacare will be just fine.

But insurance markets won’t be “stable” unless they are profitable for insurance companies. If the insurers aren’t happy, they can simply leave.

This is why, for all their talk of serving the health care needs of ordinary people, the Democrats are only willing to pursue this goal to the extent that it is compatible with keeping the insurers happy.

Trump didn’t create this problem. Major insurers were leaving the ACA marketplaces, or threatening to do so, long before he took office. UnitedHealth, for instance, made the decision to exit in mid-2016–not because the insurance giant was losing money, but because profit margins weren’t high enough for its liking.

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THE REAL problem with Obamacare is that it depends on the voluntary participation of for-profit insurance companies–and as a result, it’s at the mercy of those companies.

No “anti-sabotage measures” are going to change this. If insurers decide they aren’t making enough money or if they’re unhappy for any other reason, they can simply take their ball and go home.

This must be kept in mind when considering the other major element that Democratic leaders claim they want to address. It’s fine to talk about lowering premiums, but again, the market must remain profitable for insurers. The usual tradeoff is between premiums and deductibles: the lower the one, the higher the other.

If you truly want to talk about “affordable health care,” both numbers need to be brought down. Otherwise, consumers may have a lower monthly payment–but if they actually need care, they will find themselves paying a ruinously high portion of the bill out of their own pocket before any insurance kicks in.

But the truth is that “affordable health care” is simply the wrong goal. As long as the objective is “affordability,” access to health care will remain a matter not of what people need, but of what they can afford.

The consequences of this are all around us: people who are sick and can’t pay for medication; people who are bankrupted by their medical bills, even though they have insurance; people who don’t get care because the cheap policy they bought doesn’t cover the treatment they need; and on and on.

There is only one way out of this–by providing comprehensive health care to all people, free of charge, without the for-profit insurance companies involved.

What we need, in other words, is a universal single-payer health care system.

As with all the Republicans’ earlier attacks on the ACA, this latest assault must be opposed–but we can’t stop there. No one should be lulled into thinking that all we need to do is tweak Obamacare here and there. Obamacare isn’t just broken; in its reliance on for-profit insurance companies, it is fatally flawed. It can never be the health care solution that every person living in this country needs and deserves.

We must demand single-payer, and fight for it with everything we have. The stakes are too high to settle for anything less.

https://socialistworker.org/2017/10/23/will-trumps-sabotage-wreck-your-health-care

Following Trump executive orders, Democrats offer Obamacare “fix”

A new stage in the bipartisan health care counterrevolution

14 October 2017

The last 10 days have marked an escalation of the bipartisan conspiracy against the health care rights of working class Americans. After Congressional Republicans’ numerous failed attempts in recent months to “repeal and replace” the Affordable Care Act (ACA), the Trump administration has issued a series of executive orders aimed at undercutting the legislation popularly known as Obamacare.

The president’s first order expanded exemptions for employers who claim moral or religious objections from requirements under the ACA to provide their workers with no-cost birth control.

Next, Trump finalized an executive order to allow “association health plans” an exemption from the ACA’s requirements to provide 10 essential services in their insurance coverage.

Finally, the administration announced that, beginning next Wednesday, it would be scrapping cost-sharing reduction payments (CSRs) to private insurers that help low-income Americans purchase health coverage.

Trump made clear that he is seeking to reach out to congressional Democrats to make a deal on health care “reform,” that is, changes to Obamacare to further reduce health care coverage. In a post on Twitter Friday morning, he said, “The Democrats[’] ObamaCare is imploding. Massive subsidy payments to their pet insurance companies has stopped. Dems should call me to fix!” He went on to call the law “a broken mess.”

All of Trump’s orders will have the effect of raising insurance premiums, particularly for older, poorer and unhealthy people, and denying access to basic medical services for millions. But this is not what concerns the Democrats in Congress.

House Minority Leader Nancy Pelosi and Senate Minority Leader Chuck Schumer issued a demagogic statement Friday night scolding Trump for stopping the CSRs, stating in part: “[I]t seems President Trump will single-handedly hike Americans’ health premiums. It is a spiteful act of vast, pointless sabotage leveled at working families and the middle class in every corner of America.”

But the Democratic leaders concluded with their real point, which was to chastise the president if his actions meant he “is walking away from the good faith, bipartisan Alexander-Murray negotiations and risking the health care of millions of Americans.”

Earlier this month, following the Republicans’ failed repeal and replace attempts, Trump tweeted, “I called Chuck Schumer yesterday to see if the Dems want to do a great HealthCare Bill.” Schumer responded: “If he wants to work together to improve the existing health care system, we Democrats are open to his suggestions. A good place to start might be the Alexander-Murray negotiations that would stabilize the system and lower costs.”

Schumer is referring to the health care talks being led by Senators Lamar Alexander (Republican of Tennessee) and Patty Murray (Democrat of Washington). These bipartisan negotiations have nothing to do with expanding medical coverage to the 28 million Americans who remain uninsured, improving the already hopelessly inadequate benefits of many, or in any way reining in the profiteering and power of the insurance and pharmaceutical monopolies.

Instead, their “fixing” of Obamacare involves shoring up the insurance industry by means of various payouts. The Democrats have also agreed to a “compromise” allowing insurers to skirt the Obamacare regulations requiring insurance companies to offer a set of essential benefits by offering “skinny” plans, as well as to dodge ACA protections for individuals with preexisting conditions.

Any “compromise” between the Democrats and Republicans on health care reform is by its very nature a conspiracy against the working class. It is entirely premised on the subordination of the need for health care to the profits of the corporations and the functioning of the capitalist market.

Ohio Governor John Kasich was more transparent on what a bipartisan deal on health care would look like, stating this summer, “After two failed [Republican] attempts at reform, the next step is clear: Congress should first focus on fixing the Obamacare exchanges before it takes on Medicaid. … Once we see these repairs taking hold, Congress should then take up needed improvements to Medicaid as part of comprehensive entitlement reform.”

All of the failed Republican versions of Obamacare repeal and replace cut hundreds of billions of dollars from Medicaid, the government health insurance program for the poor, elderly, the disabled and pregnant women. They posed the virtual end of the program as a guaranteed entitlement program, by imposing block-granting and per-capita caps to the states, which would force states to deny benefits to people who qualify.

Through these measures, Medicaid would be starved of funds on the road to privatizing and ultimately dismantling the program. There have been no clear statements from leading Democrats opposing in principle the termination of Medicaid, which everyone in the political and media establishment knows is the first step to dismantling and privatizing Medicare, the government insurance program for the elderly, and Social Security, the government pension system.

The bipartisan plans to “fix” Obamacare in the interests of the insurance companies—further slashing benefits and raising premiums for working families, while cutting costs for the government and corporations—are not at odds with the spirit of Obamacare. In fact, they reflect its essence and objective: that workers are living too long into retirement, receiving costly and “unnecessary treatments,” and that something must be done to curb costs in the interest of corporate profit.

As early as 2009, the year before the ACA was signed into law, the World Socialist Web Site wrote:

“[Barack Obama’s] drive for an overhaul of the health care system, far from representing a reform designed to provide universal coverage and increased access to quality care, marks an unprecedented attack on health care for the working population. …

“Obama’s health care counterrevolution is of a piece with his entire domestic agenda. It parallels the multi-trillion-dollar bailout of the banks, the imposition of mass layoffs and wage and benefits cuts in the auto industry, and a stepped-up attack on public education and on teachers.”

The Democrats’ policies on health care reform are no alternative to Trump’s. Both will lead to untold suffering, misery and preventable deaths. The defense of basic social needs such as health care requires a fight against capitalism, which in its advanced stage of crisis is incompatible with basic democratic and social rights.

A fight in defense of health care requires a fight for socialism. The health care industry must be removed from private hands and placed under public ownership and the democratic control of the working class. This is not an unrealistic pipe dream but the only rational solution to a health care system dominated by profit and defended by an outmoded ruling elite.

Kate Randall

http://www.wsws.org/en/articles/2017/10/14/pers-o14.html

Trump administration limits access to birth control under ACA

By Trévon Austin
7 October 2017

The Trump administration has announced plans to revoke the federal requirement for employers to include birth control coverage in health insurance plans. The new policy would expand exemptions under the Affordable Care Act (ACA) for employers who claim moral or religious objections to contraception.

Under the previous mandate, more than 55 million women employees had access to no-cost birth control. According to the Kaiser Family Foundation, the percentage of women employees that pay with their own money for birth control fell from 21 percent to 3 percent after contraception became a covered preventive benefit.

The new exemptions will be available to for-profit companies, nonprofit organizations and colleges and universities that provide health care to students and employees.

Hundreds of thousands of women could potentially lose access to benefits they receive at no cost. The Trump administration itself estimated that some 200 employers who have already voiced opposition to the Obama-era mandate would qualify for exemption, and that 120,000 women would be affected.

In expanding the exemption for employers, the Trump administration claims there are “dozens of programs that subsidize contraception for the low-income women” and various alternative sources for birth control exist.

The administration also cites health risks that it says are correlated with the use of certain types of contraceptives, and claims the previous mandate that required employers to cover birth control could promote “risky sexual behavior” among teenagers and young adults.

In contrast, many obstetricians and gynecologists say contraceptives have been and are generally beneficial for women’s health.

Dr. Haywood L. Brown, the president of the American College of Obstetricians and Gynecologists, expressed concern for consequences on women’s health. “Affordable contraception for women saves lives,” he said. “It prevents pregnancies. It improves maternal mortality. It prevents adolescent pregnancies.”

The Trump administration cites the Religious Freedom Restoration Act, a 1993 law protecting religious liberty, as legal reasoning for the new mandate. The administration admits that moral objections are not protected by the law, but states: “Congress has a consistent history of supporting conscience protections for moral convictions alongside protections for religious beliefs.”

Attorney General Jeff Sessions announced the Department of Justice would take steps to protect the new policy and stated, “President Trump promised that this administration would ‘lead by example on religious liberty,’ and he is delivering on that promise.”

The new policy is expected to face a large number of lawsuits. The National Women’s Law Center, a nonprofit advocacy group, has been preparing a lawsuit since last spring. Brigitte Amiri, a senior attorney for the ACLU, said, “We are preparing to see the government in court.”

In addition, Massachusetts Attorney General Maura Healey and California Attorney General Xavier Becerra announced plans to file a suit against the new mandate.

Trump’s new policy is an obvious attempt to win support from religious groups and conservatives, such as Speaker of the House Paul Ryan, who claimed today is “a landmark day for religious liberty.”

A group supportive of the administration’s action is the Little Sisters of the Poor, an order of Roman Catholic nuns who said that being required to cover contraception would make them “morally complicit in grave sin.” The organization sued the government, despite an already existing exemption for churches and other religious employers to opt out by notifying the government.

During his 2016 presidential bid, Trump promised that he would “make absolutely certain religious orders like the Little Sisters of the Poor are not bullied by the federal government because of their religious beliefs.” At a Rose Garden ceremony in May, he told the religious order, “Your long ordeal will soon be over.”

The Trump administration’s mandate sets a dangerous precedent for working women’s health. In 2014, in the case Burwell v. Hobby Lobby, the Supreme Court ruled that the ACA violated the religious liberty of Hobby Lobby, and stated that corporations could object to the birth control coverage mandate on religious grounds. Under Trump’s mandate, corporations could deny women employees access to no-cost birth control simply based on “moral objections.”

The new policy sets a precedent for corporations to deny other health coverage to employees under conditions in which the state of women’s health in the United States is already dire. The US holds the highest maternal mortality rate among industrialized nations, and a lack of access to birth control will potentially exacerbate the problem.

The new policy goes into effect immediately.

http://www.wsws.org/en/articles/2017/10/07/birt-o07.html

Health Care in America: Where is the Socialist Solution?

Photo by Molly Adams | CC BY 2.0

The introduction of the Republican legislation to “repeal and replace” Obamacare is no more than latest scrimmage in the ongoing one-sided war against the poor and working class. The “Affordable Care Act” (ACA, better known as Obamacare) proved to be both unaffordable and unable to provide comprehensive care for millions. Nevertheless, with the ACA being one of the only tangible “victories” Democrats could claim for an administration with a dismal record of noteworthy accomplishments, neoliberal Democrats and the party’s liberal base led by Bernie Sanders are now coalesced around the ACA and have vowed to defend it to the bitter end.

Yet, camouflaged by the hot rhetoric of confrontation and the diversionary struggle of the duopoly, the common agenda and objective interests being protected in this healthcare battle are quite clear. No matter what version of the healthcare bill passes or if the ACA remains in place, it will be a win for the market-based, for-profit beneficiaries of the U.S. system. As long as healthcare remains privatized, the real winners of healthcare reform will continue to be the insurance companies, hospital corporations and pharmaceutical and medical device companies.

That commitment to the interests of the insurance/medical complex ensures that the interests of healthcare consumers, the uninsured, the elderly and the sick will continue to be sacrificed to maintain a healthcare delivery system in which thousands suffer premature deaths from inadequate preventative treatment, millions are unable to afford coverage and millions who have private insurance fear using it because of prohibitive co-pays and deductibles.

That is why during the current debate the insurance companies have been largely silent. There is no need to engage in public debate because having largely written the ACA they are again deeply involved in the construction of the current legislation. Their interests will be protected even if it means forcing Republicans to embrace policies that are at odds with their professed philosophies – like including government subsidies for low-income people to purchase insurance. In fact, the only comments from insurance companies in this debate were related to their supposed concern that the Senate bill might not provide enough assistance to those who need help to pay for healthcare. They want what is being called a “stabilization fund” to reduce the numbers of people who might opt out of coverage because they can’t afford it.

The Senate bill provides those funds, but they are temporary and are scheduled to end after 2019. Which means that people will be forced to make an unpalatable decision after that – purchasing insurance with higher out-of-pocket costs like $10,000 deductibles or electing to go without insurance altogether. If history is a guide, many will opt out. In fact, the Congressional Budget Office predicts that the current bill will push 22 million people back into the ranks of the uninsured with the potential loss of millions of customers and potential profits for healthcare corporations.

But the companies have a plan should those funds prove inadequate to hold substantial numbers in the system: Increase individual premiums by at least 20 percent more than the double-digit increases already under consideration.

Coming to the aid of the Insurance/Medical complex: Ted Cruz and the Consumer Freedom Amendment

Insurers need large numbers of healthy people on the rolls, as their premiums help defray the cost of care for those who are sick. Because insurance companies are for-profit operations they set rates based on the risk pool in a market. With the potential loss of customers if the government does not provide adequate long-term subsidies, middle-class consumers who earn too much to qualify for temporary premium assistance will bear the brunt of any premium increases.

The Cruz amendment to the legislation has a solution to the possible increase in premiums and healthcare costs in general. The so-called “Consumer Freedom Amendment” represents the typical extreme individualism and anti-social sentiments of the right wing. It essentially advocates for reducing the burden on healthy consumers paying into system to help cover higher-risk fellow citizens.

The Washington Post’s analysis of the Cruz amendment suggests:

“Under Senator Cruz’s plan, insurers could sell cheaper, stripped-down plans free of Obamacare coverage requirements like essential health benefits or even a guarantee of coverage. These sparser plans would appeal to the healthiest Americans, who would gladly exchange fewer benefits for lower monthly premiums.

But insurers would also have to sell one ACA-compliant plan. The sickest patients would flock to these more expansive and expensive plans because they need more care and medications covered on a day-to-day basis. As a result, premiums for people with expensive and serious medical conditions like diabetes or cancer would skyrocket because all those with such serious conditions would be pooled together.”

And how would the elderly and people with pre-existing conditions pay for the increased premiums that they would face under the current Senate bill and Cruz’s amendment? “The $100 billion stabilization fund for states could help cover costs for the resulting pricier coverage for those with preexisting conditions under this amendment.”

In an ironic twist that both exposes the class interests of this initiative and its hypocritical approach to the question of the role of the government, Cruz’s amendment affirms that role in the form of subsidies for the sickest citizens and calls for an expansion of government resources to cover them.

The Cruz plan would segment the insurance market into healthier and higher-risk segments. High risk individuals along with the already-sick and the elderly would be pushed out of the market because those premiums would soar even with state subsidies, since insurance companies would still set premium rates to maximize profits.

Given the lose-lose options for consumers now being debated in Congress, the only rational objective for the majority of the people in the U.S. is to move toward the complete elimination of the for-profit healthcare system.

Socialization of Healthcare: The Only Solution

The ideological and political opposition to state-provided healthcare is reflected in the ACA and the various repeal-and-replace scenarios. Through mandates, coercion and the transfer of public funds to the insurance industry, the ACA delivered millions of customers to the private sector in what was probably the biggest insurance shams in the history of private capital. And that gift to the insurance companies is only one part of the story. The public monies transferred to the private sector amounted to subsidies for healthcare providers, hospital chains, group physician practices, drug companies and medical device companies and labs as well.

The Republican alternatives to the ACA variably supplement the corporate handouts with more taxpayer-funded giveaways. And once the private sector gains access to billions of dollars provided by the state, they and their elected water-carriers fiercely resist any efforts to roll those subsidies back.

The subsidies coupled with the mergers and acquisitions of hospital corporations and insurance providers over last few years and a general trend toward consolidation of healthcare services in fewer and fewer hands underscored the iron logic of centralization and concentration of capital represented by the ACA and was a welcome development for the biggest players in the healthcare sector. The movement toward a monopolization of the American health-care market means that rather than the reduction in healthcare costs that is supposed to be the result of repeal and replace, the public can instead expect those costs to escalate.

Many on the left have called for a single-payer system similar to those that work well (if not perfectly) in Britain, the Netherlands, Finland and elsewhere in Europe. But even with an “improved Medicare for all” single-payer system, costs will continue to increase in the U.S. because they cannot be completely controlled when all of the linkages in the healthcare system are still firmly in the hands of private capital.

The only way to control the cost of healthcare and provide universal coverage is to eliminate for-profit, market-based healthcare. Take insurance companies completely out of the mix and bring medical device companies, the pharmaceuticals companies and hospitals chains under public control.

The ideological implications of the Cruz amendment are that it reflects a growing public perception both domestically and internationally that healthcare should be viewed as a human right.

Putting people at the center instead of profit results in healthcare systems that can realize healthcare as a human right. This is the lesson of Cuba where the United Nations World Health Organizationdeclared that Cuba’s health care system was an example for all countries of the world.

That is the socialist option, the only option that makes sense and the one that eventually will prevail when the people are ready to fight for it.

Ajamu Baraka is the national organizer of the Black Alliance for Peace and was the 2016 candidate for vice president on the Green Party ticket. He is an editor and contributing columnist for the Black Agenda Report and contributing columnist for Counterpunch magazine. 

US Senate health care bill guts Medicaid, slashes taxes for the wealthy

 

By Kate Randall
23 June 2017

US Senate Republicans unveiled on Thursday the Better Care Reconciliation Act, their version of a plan to “repeal and replace” the Affordable Care Act (ACA), the Obama administration’s signature domestic legislation. The US House passed its own version, the American Health Care Act (AHCA), early last month.

Like the House plan, the Senate version guts Medicaid, the health insurance program for the poor and disabled jointly administered by the federal government and the states, slashing its funding by hundreds of billions of dollars. It would mark the effective end of the program, which currently covers 75 million Americans, as a guaranteed program based on need.

Better Care also repeals virtually all of the ACA’s taxes on wealthy individuals and corporations, effecting one of the largest redistributions of wealth from the poor to rich in US history. These tax cuts would be paid for by slashing health care coverage and raising costs for the vast majority of ordinary Americans, in particular targeting the poor, the elderly, the disabled, and those with preexisting conditions and disabilities.

The plan was drafted in secrecy by a “working group” of 13 senators, a process drawing criticism from both Republican and Democratic senators. As of Thursday evening, a group of four ultra-right Republican senators said they would not sign on to the bill, as it was not draconian enough, while other more moderate Senate Republicans said they needed to study the bill before making a decision.

However, it is likely that Majority Leader Mitch McConnell will be able to garner the votes of 50 out of 52 Republican senators to pass the legislation with a simple majority, counting on the vote of Vice President Mike Pence to break a tie. The bill would then be sent to a conference with the House, where a final version would be agreed, before being sent to President Trump to sign. Senate leaders hope to receive a scoring on the bill from the Congressional Budget Office (CBO) early next week and vote on it before the July 4 recess.

Medicaid

The Senate bill would convert Medicaid to a “per capita cap” funding system, in which states would get a lump sum from the federal government for each enrollee. States could also choose to receive a block grant instead, not tied to the number of Medicaid enrollees. This would effectively end Medicaid as an “entitlement” program, so-called because the funding is expanded automatically as people qualify on the basis of need.

The legislation would also change the way federal payments to Medicaid are calculated. The Senate bill would tether funding growth to the Medical Consumer Price Index plus 1 percentage point through 2025, then change over to the urban Consumer Price Index (CPI). This would amount to a funding cut to Medicaid, as the cost of health care typically goes up faster than the CPI.

The bill would also end the expansion of Medicaid under Obamacare by 2021. This extended coverage to an estimated 14 million people, mainly low-income adults earning below 138 percent of the poverty line (about $15,000 for an individual), in the 31 states plus the District of Columbia that opted to participate in the expansion.

Better Care defunds Planned Parenthood for one year, meaning Medicaid patients could no longer seek treatment of any kind at the nonprofit organization’s clinics. This will result in forgone screenings, less access to contraceptive and abortion services, and more unintended pregnancies, as well as maternal and infant deaths.

CBO scoring of the House bill, which makes similar cuts, estimated it would slash overall funding to Medicaid by $880 billion over a decade. The cutbacks would force states to remove people from Medicaid, reduce the range of services covered, and cut reimbursements to doctors, hospitals and drug companies.

Tax cuts

The Senate bill cuts taxes on net investment income for wealthy people, repeals an ACA Medicare tax on wealthy people, and eliminates taxes on health insurers, medical device companies and tanning salons.

Better Care repeals a 3.8 percent tax on net investment income (capital gains, dividends, etc.) for individuals making more than $200,000 a year or for couples making more than $250,000. In one of the bill’s most brazen giveaways to the rich, this repeal is not only immediate, but retroactive to capital gains made earlier this year.

The Tax Policy Center estimates that around 90 percent of the tax cuts will go to households with more than $700,000 in annual income, the top 1 percent, who will be freed from the 3.8 percent tax, along with a 0.9 percent payroll surtax on their salaries.

Smaller subsidies, skimpier coverage

The bill would make much less generous subsidies available to low- and middle-income people to purchase health insurance (people earning less than 350 percent of the poverty line, compared to the ACA’s 400 percent cutoff). Individuals earning less than $41,580 and families of four making less than $85,050 would be covered. However, the size of the tax credits would be tied to what it takes to purchase insurance with poorer coverage.

Insurance companies would be able to charge older adults not yet eligible for Medicare five times more than younger people, compared to three times more under Obamacare. The bill would also change the definition of “affordable” insurance. For example, a 60-year-old who earns $35,640 a year would be required to spend 16.2 percent of annual income, or $5,773, before receiving any assistance from the government. Overall, working-class families would pay higher premiums, deductibles and out-of-pocket costs for health insurance that covers much less.

Essential benefits and preexisting conditions

The Senate bill would allow states to seek a waiver from ACA requirements for insurers to cover essential benefits, such as maternity care, prescription drugs, substance abuse and mental health services, emergency care, and other vital services.

While Senate Republicans claim their legislation keeps in place protections for those with preexisting conditions, in practice insurers would be able to skirt these protections by simply offering plans that don’t cover a range of preconditions, such as diabetes, cancer, prenatal care, etc.

Such waivers could also affect those with employer-sponsored insurance. For example, large employers in a waiver state could restrict services, impose lifetime limits on health care costs and eliminate out-of-pocket caps from their plans.

Better Care eliminates the individual mandate, which requires those without coverage from their employer or from a government program to purchase insurance or pay a tax penalty. Due to the “reconciliation” process, the bill cannot eliminate the mandate, but it reduces the penalty to zero. Employers with 50 or more employers would also not be penalized if they fail to provide insurance to their workers.

While gutting the mandates, the Senate plan keeps the insurance marketplaces set up under the ACA intact, but insurance will be more expensive and cover less.

While Republicans in both the Senate and House, as well as the Trump administration, have set as their goal repealing and replacing Obamacare, both the AHCA and the Better Care Reconciliation Act keep the ACA’s basic structure in place—all while repealing taxes for the wealthy, gutting Medicaid and raising costs and cutting services for working and middle-class people.

This is in part the result of the procedure chosen for repeal. Lacking the 60 votes to overcome a Senate filibuster, the Republican leadership chose to employ “reconciliation,” which is limited to a single bill each year, and requires only a simple majority. The rules governing reconciliation are arcane, and prevent changes in policy that have no fiscal impact, such as a ban on insurance companies covering abortion, which was dropped from the Senate bill.

But in the final analysis, there was no need to repeal Obamacare outright, since it accomplishes many of the goals agreed on by both capitalist parties. As the WSWS has maintained from the start, Obamacare was aimed at cutting costs for the government and corporations while rationing health care for the vast majority. Whatever version of “Trumpcare” eventually emerges from Congress for the president to sign will take the tendencies already present in the Affordable Care Act, then strip off the limited concessions it offered in the way of Medicaid expansion, essential services and other inadequate protections.

Obamacare took as its starting point the entrenched for-profit system of health care delivery in America, which is based on enriching the insurance companies, the pharmaceutical companies and the giant hospital chains.

With this as its basis, the ACA had as its aim the development of an even more openly class-based health care system than what previously existed, in which workers and their families are left with rising costs, cut-rate care, or no coverage at all, and the super-rich and privileged upper-middle-class layer avail themselves of the best medical care that money can buy.

As we wrote last year, through its tax credit system and marketplace exchanges, “[T]he ACA essentially establishes a voucher system, whereby minimal government subsidies are given to individuals to purchase private health insurance. It thereby serves as a model for the future privatization of the key government programs, Medicare and Medicaid, wrenched from the ruling class through bitter working class struggles in the last century.”

The Democrats have predictably denounced the Senate plan as a boondoggle for the rich, with House Minority Leader Nancy Pelosi and Senate Minority Leader Chuck Schumer railing against the tax breaks for the rich and the millions who stand to lose coverage.

But they have little to offer in way of an alternative, except the maintenance of the Obamacare status quo, or “working with” the Republicans to fix it. That is because they believe in the underlying premise that health care in America must remain at the mercy of the for-profit health care industry, and that the provision of health care must conform to the interests of the capitalist market.

As the WSWS wrote in July 2009, more than six months before the ACA became law, the Obama administration’s “drive for an overhaul of the health care system, far from representing a reform designed to provide universal coverage and increased access to quality care, marks an unprecedented attack on health care for the working population. It is an effort to roll back social gains associated with the enactment of Medicare in 1965.”

The Republicans’ attack on Medicaid, embodied in both the AHCA and the Better Care bill, marks a further step in this direction.

The Democrats’ fraudulent opposition to Trumpcare

By Kate Randall
21 June 2017

Senate Republicans are working feverishly to pass their version of a bill to “repeal and replace” the Affordable Care Act (ACA), having set themselves an arbitrary deadline of securing its passage before the July 4 congressional recess. Early last month, House Republicans passed the American Health Care Act (AHCA), celebrating in the White House Rose Garden with President Trump, who said of the bill, “It’s a great plan, and I believe it’s going to get better.”

A group of 13 Republicans senators is working behind closed doors on the Senate version of the legislation. Senate Majority Leader Mitch McConnell plans to push the legislation—which concerns one-sixth of the US economy, and which will affect the health and lives of tens of millions of Americans—with no committee hearings, no public mark-up (drafting and editing) of the bill, and only limited debate.

It is no secret that the clandestine nature of the Senate “working group’s” negotiations is due to the AHCA’s wide unpopularity, with a recent poll showing that only 20 percent of Americans approve of it while 57 percent disapprove. The broad opposition is due to its draconian features, particularly the gutting of Medicaid, the social insurance program for the poor jointly funded by the federal government and the states. The AHCA would effectively end Medicaid as a guaranteed benefit based on need by placing a per-capita cap on overall spending.

The AHCA would slash $824 billion from Medicaid and would end the ACA’s expansion of Medicaid to low-income adults, causing 14 million newly insured people to lose their benefits over a decade. All told, the Congressional Budget Office estimates that 23 million people would become uninsured in 10 years under the AHCA. At the same time, the bill would slash taxes for corporations and wealthy individuals, while boosting the already multibillion-dollar profits of the health care industry.

McConnell has an additional reason for secrecy, since any divisions within the Republican caucus threaten passage of the bill, and concessions made to far-right senators like Ted Cruz and Rand Paul could provoke opposition from a group of “moderates” from states with large Medicaid populations, and vice versa.

Under the “reconciliation” process chosen for the health care legislation, the Republican leadership can push through the bill despite holding only a narrow 52-48 majority, providing they lose no more than two Republicans, with Vice President Mike Pence casting a tie-breaking vote.

Senate Democrats profess outrage over the closed-door nature of the Republicans’ deliberations. They staged a talk-a-thon on the Senate floor Monday night, stalling chamber proceedings through a series of parliamentary maneuvers. A few senators live-streamed their “search” for the elusive legislation, driving around the capital. All of these stunts amount to so much hot air. The Democrats are incapable of mounting a true opposition to the Republicans’ vicious assault on the health care of ordinary Americans because they share their class objectives.

Numerous media commentaries have pointed to the Democrats’ “powerless” position to oppose the Republicans’ plan, due to the Republicans’ 52-48 Senate majority. This is only valid in terms of parliamentary arithmetic: the vast majority of the American people oppose the House bill and will oppose the Senate bill once they learn its provisions. But the Democratic Party is unwilling and unable to mobilize this popular opposition.

Every Senate Democrat, including so-called independent and self-professed “democratic socialist” Bernie Sanders, portrays Obamacare as a progressive social reform, or at least a “step in the right direction,” concealing the reactionary and anti-working-class character of the Affordable Care Act.

Obamacare was aimed from the start at cutting costs for the government and corporations while rationing health care for the vast majority. In that sense, the Republicans have invented nothing new. Whatever version of “Trumpcare” eventually passes the Senate will only take the tendencies already present in Obamacare and make them worse: imposing more and more of the cost of health care on individual workers and their families.

The logic of this process, under both Democrats and Republicans, is the development of an openly two-class health care system: the best health care money can buy for the super-rich and a privileged upper-middle-class layer; and for the vast majority of the population, a cut-rate system, starved for funds and personnel, offering inadequate and overpriced care, if any at all.

In response to Trump and the Republicans’ howls that the ACA is “failing” and “imploding”—through rising premiums and deductibles and dwindling networks of insurers—the Democrats beg for a seat at the table to “fix” Obamacare. This is a euphemism for making further concessions to the demands of the insurance companies and other corporate interests by further restricting subsidies for low-income purchasers of insurance plans, cutting business taxes and implementing other regressive measures.

Any health care overhaul hatched in Washington will be based on the for-profit health care system, enriching the insurance companies, drug companies, hospital chains and medical device companies and the CEOs that run them.

Looking beyond the Democrats’ bluster, working people need to actually take stock of what is at stake in the Republicans’ plan. The most fundamental attack is the gutting of Medicaid, one of the last social reforms wrested from the ruling elite through working-class struggle. While limited in nature, Medicaid guaranteed the right to health insurance and medical services for the poor and for children and disabled people, and provided funding for nursing care for the elderly based on need. Medicaid emerged as part of the “Great Society” and “War on Poverty” under the Johnson administration, alongside landmark legislation such as the Civil Rights Act and the Food Stamp Act, both in 1964, and the Voting Rights Act of 1965.

The assault on health care exemplified by the Republicans’ reactionary legislation is of a piece with the ruling elite’s attack on all the social rights of the working class—the right to a job, education, decent housing, a secure retirement, access to the arts and culture, and a healthy and safe environment.

Congressional Democrats have chosen to oppose the Trump administration not over the destruction of social conditions, but over Trump’s alleged “softness” toward Russia. They are working in alliance with the dominant factions of the intelligence apparatus to whip up a war fever against Russia in an attempt to condition the public for an escalation of the wars in the Middle East as well as a military confrontation with Iran and nuclear-armed Russia. Incapable of opposing the most reactionary presidency in US history on anything resembling a progressive or democratic basis, they have positioned themselves to the right of Trump on issues of imperialist foreign policy.

Whatever form it takes, the health care legislation that the Republicans are able to pass through Congress and place on the president’s desk to sign will be one of the most reactionary pieces of legislation in modern history. The ruling elite sees the attack on Medicaid as the first shot in their war on Medicare and Social Security and wants to see all of these social programs privatized or ended outright. In the final analysis, both big-business parties agree that health care must be limited to what is compatible with the profit interests of corporate America.

The working class must fight for its own class interests. The crisis in health care requires a socialist solution, which takes as its point of departure the needs of working people and society as a whole, not the wealth and profits of a tiny minority.

The establishment of a system of universal, free health care for all requires placing the entire health care system—the private insurers, pharmaceuticals, giant health care chains—under public ownership, managed democratically to serve human needs, not profit. Such a fight requires the mobilization of the working class as a revolutionary force, independent of and opposed to both the Democratic and Republican parties.

http://www.wsws.org/en/articles/2017/06/21/medi-j21.html