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2017-03-24

Trumpcare fails as Trump and Republicans cancel vote; Obamacare remains for now

by John S. James

Congressional Republicans cancelled a vote on the bill to repeal Obamacare, after it became clear that the replacement they proposed could not get enough votes to win.

The bill that failed was almost unanimously opposed by doctors' and other medical organizations - and then made worse to get votes of right-wing Republicans, upsetting moderate Republicans who otherwise would have voted for it. To reduce premiums, the final bill would have allowed health-insurance companies to offer policies without maternity care, emergency care, treatment for mental health or substance abuse disorders, prescription drugs, lab tests, rehabilitation, and four other "essential benefits" required by Obamacare. Many moderate Republicans could not vote for that.

For more news see GOP health-care bill: House Republican leaders abruptly pull their rewrite of the nation’s health-care law. You can also search for news on this (or any other recent news) at news.google.com.

Comment: What's Next

What's driving the problem is the excessive cost of U.S. health care - currently one sixth of the entire U.S. gross domestic product. The U.S. spends far more on healthcare per person than any other country in the world, but is currently #42 in life expectancy at birth (according to the CIA's list,
https://www.cia.gov/library/publications/the-world-factbook/rankorder/2102rank.html).

All the cost-reduction proposals we heard in the huge national debate leading up to the failed Trumpcare bill were either to deny healthcare to the poor, or to sell much-worse policies to the middle class. None dealt with the fundamental reason that U.S. healthcare costs so much.

The reason is that U.S. healthcare is dominated by corporations and individuals that are all about making money, whatever their mission statements may say. Almost all incentives in the system are to charge higher prices. Greed and fear work tolerably well for organizing a stock market; they don't work well for medicine.

For example, drug companies have huge biases toward developing only the most expensive therapies. New antibiotics are not a focus even though resistant infections kill many thousands of people each year in the U.S. alone. Why? Because antibiotics cure too quickly; the companies want drugs that need to be taken for years, ideally for life, so that more money can be extracted.

Combining unscrupulous, predatory, what-the-market-will-bear pricing, with the traditional ideology that human life is priceless, causes market prices to rise toward infinity (especially when there is no competition, due either to patent laws, or to regulatory logjams for generics) - not just drug prices but most prices throughout the complex, non-transparent medical system. Quite commonly one person's medical bills can be half a million dollars or more. Since almost nobody can pay that out of pocket (and they would have to pay extra-high prices if they did, since they don't have the negotiating power than insurance companies do), the idea is that almost everyone will be insured. There is little "market discipline" in this system; insurance companies usually pay if high-status doctors say it's needed. So prices go up and up while profiteers pocket the cash.

The real business model of health insurance is to find excuses not to pay for care - and also to get rid of expensive patients, one way or another (for example, automatic premium payments can go away automatically and silently at the end of the year). Despite their complaints about not being able to make money, health-insurance companies have been remarkably successful in recent years; see Gripes About Obamacare Aside, Health Insurers Are in a Profit Spiral.

And since the poor could not possibly pay the insurance premiums, co-pays, and deductibles, government pays for their care through Medicaid. This is what Republican want to get rid of - let the poor suffer and die without access to medical care. Or they can go to an emergency room when necessary to postpone death - which is not comprehensive medical care, and costs a median of $1,233 per visit (as of three years ago), according to a study by the National Institutes of Health,
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3584078/.

And more and more of the middle class can't pay for effective insurance either, as costs go up and up. So both political parties propose various subsidies to help them, but ultimately not enough.

The result in an extremely expensive system that burdens the middle class, the poor, and the taxpayers. It has become unsustainable.

But mainstream politicians have avoided the real causes of excessive costs and prices, since talking about this would threaten profiteers who fund their campaigns. So others must take the initiative to get these problems addressed.

If Republicans or Democrats want to help improve Obamacare, they can start by talking with healthcare professionals and finding proposals that working doctors and other health professionals can support. No more schemes that are almost unanimously opposed by the medical community, please.

2017-03-20

Good laptops for about $200: Windows 10, or Chromebook

by John S. James, March 2017

We found a surprisingly good value in an 11.6-inch Windows 10 laptop for $200, and after three weeks of use we are still impressed by what we got for the money. This laptop (ASUS E200HA) travels very well, so is good for working in coffeehouses or libraries, or for out-of-town travel (for home use you might want a larger screen, which of course is less portable).

But before buying Windows you might also consider the Chromebook - designed and programmed by Google but manufactured and sold by various other companies. Chromebooks can cost even less than $200, and are much easier than Windows to set up and use.

Trumpcare in Congress: Quick Overview Now

by John S. James, March 20

This week the House of "Representatives" may vote on the major Republican effort to repeal Obamacare, replacing it with what is increasingly called Trumpcare (though President Trump doesn't want his name on his own main project). The Congressional Budget Office (the most thorough and objective analyst of the plans) predicts that 14 million people will lose healthcare in the first year, rising 24 million by 2026, compared to not changing the law.

Despite strong oppositions by doctors, medical organizations, hospitals, and many others including Trump voters, Republicans are determined to push this through. They have a majority in the House (due to heavy gerrymandering and voter suppression) - and a small majority in the Senate (due to voter suppression but not gerrymandering, since the Senate's election districts are fixed at state borders).

Most or all of the Republican replacements for Obamacare will basically end Medicaid, the Federal program of medical care for the poor, who have no other way to get acceptable healthcare in most cases (federally qualified health centers could help in some areas, but without Medicaid their funding is uncertain - as is their ability to scale up fast enough to treat 14 million more patients next year). And for the middle class, the plans will increase healthcare costs for older individuals, and also increase costs in certain geographic areas (including some that voted heavily for Trump), based on hastily devised formulas. For healthy young people who are unlikely to need much medical care, costs will often decrease, especially in certain areas. Total Federal costs will decrease by many billions of dollars - which Trump already plans to give in tax cuts, mainly to very rich individuals and corporations. (The big war budget comes from huge cuts in other programs, including the National Institutes of Health and other scientific and medical research - when the U.S. already spends about as much for its military as all countries on Earth put together.)

Some Republican plans promise to protect those with pre-existing conditions, but whether and how this will work in practice is not clear. Tax credits under some plans will help middle-class persons pay for insurance or other healthcare expenses; but this will not help much in cases of serious illness if out-of-pocket expenses greatly exceed the person's total federal taxes for the year. U.S. medical care for serious conditions often costs hundreds of thousands of dollars.

If a bill passes the House and the Senate, Trump will almost certainly sign it into law.

When these changes will happen depends on the plan that is finally adopted. Some changes, including the end of the Medicaid entitlement, will likely take place immediately. (The entitlement, which exists now and has existed since President Johnson started Medicaid in the 1960s, means that Medicaid patients have a right to certain healthcare, so they will still get treated even if the program runs out of money; Congress is ultimately responsible for finding enough funds. Without the entitlement, patients' treatment can stop when money runs out for the year.)

The  Medicaid expansion (allowing persons under 65 and with incomes up to 133% of the Federal poverty level to get healthcare through the program - at 65 they become eligible for Medicare instead) may be phased out over several years - or much faster, depending on what replacement plan if any becomes law. (Federal Poverty Level is currently $12,060 for an individual, $16,240 for a family of 2, $20,420 for a family of 3, etc.; see http://www.healthcare.gov/glossary/federal-poverty-level-FPL/  - and multiply by 133% to get eligibility for Medicaid in the 31 states who's governors have accepted the expansion. But be aware that the whole program could go away.)

And what is NOT in the Republican plans? Any serious effort to reduce the greatly inflated costs of U.S. healthcare, except by kicking many millions of people out of medical care entirely. And of course single-payer is nowhere in sight; it could eliminate all sorts of gamesmanship, and endless paperwork and paperlesswork - ending most unnecessary surgeries,  tests, and other procedures, and allowing doctors to focus on providing medical care instead of justifying and processing reimbursements.

Last Week: Trumpcare Got Even Worse

Many "conservative" Republicans don't like Trumpcare, calling it "Obamacare lite." They don't like the concessions that Ryan and Trump made to reduce political opposition - such as saying that they will not allow insurance companies to reject people with pre-existing conditions, and phasing in the end of Medicaid over several years instead of much faster.

So Ryan and Trump sweetened the bill for conservatives by allowing a work requirement for able-bodied adults. The main effect will be dropping many people from Medicaid. It is unlikely to increase employment much, for many reasons - especially lack of jobs for those without special skills and experience, and millions of mostly minority citizens being made unemployable by police records that can hardly be avoided in many U.S. cities. And to the extent that the work requirement does increase employment, it will allow employers to reduce already unlivable wages for probably millions of people.

The other change being talked about is allowing states to get Federal Medicaid support (until it goes away) as a block grant instead of per Medicaid patient - in return for more "flexibility" in how states run their programs, and decide who gets treated and who does not.

Also, almost all complex federal laws have tricky wordings that deliver gifts to insider special interests - without the public, press, or most of Congress that votes for the law knowing what is going on. Keep an eye out for these. They could possibly even include attacks on MediCARE - which is ignored in the original Trumpcare, but some of the other Republican proposals for replacing Obamacare proposed changing Medicare as well. Conservative Republicans have never been happy with the three major entitlement programs, Social Security, Medicare, or Medicaid. They picked Medicaid to attack first for strategic reasons, because it is mostly (though not entirely) for the poor and lower-paid middle class.

For More Information

We are preparing an ongoing list of published articles with reliable information at the time of publication. Be aware that the situation changes very fast, often day to day, so older articles may no longer be correct.