Our Editorial in the New York Times: “We Stand For Access”

As a member of the American Society of Law, Medicine & Ethics, I’m proud to add my name to this letter to the editor in the New York Times:

To the Editor:

We, many of the nation’s health law and health policy professors from law, medical, public health and graduate schools across the United States, write to address one of the most fundamental issues impacting our country: the potential repeal and replacement of the “Affordable Care Act” (“Obamacare”). It is clear that the House-passed “American Health Care Act,” as well as the legislation likely to be considered by the Senate, will cause severe, lasting harm to all of us, especially our society’s most vulnerable and middle class.

Today we raise our voices to oppose these proposals. While the Affordable Care Act has its shortcomings that should be fixed, the current proposals are merely “repeal,” with no effective “replace.” These proposals are wrong, and must be rejected. At a time when we are seeing significant declines in the number of uninsured and inadequately insured in our country, the House and Senate proposals represent a giant step backward. By cutting Medicaid funding, eliminating federal assistance for families securing private coverage, and encouraging individuals to either not purchase insurance or to buy barebones coverage, these proposals will result in a less equitable, less accessible system of health care. Ultimately, the public’s health will decline as needed care is forestalled or not sought, and costs will rise as a shrinking pool of Americans with “good” insurance pay more to subsidize those without.

Given the many health care challenges that we face— an aging population needing an increasing amount of health care services; a young and middle age population facing growing rates of obesity, heart disease, and other chronic conditions; a rapidly expanding “gig” economy of independent contractors needing to secure insurance without employer subsidies; and a rising number of individuals addicted to new and more prevalent illegal drugs— reducing access to health care services simply cannot be an acceptable policy option.

We also are deeply concerned about what this new legislation portends for women and children. Currently, the United States leads the developed world in maternal mortality. More women die during childbirth in the United States than in any other Western nation. Despite the urgency to protect women’s health and strive for better outcomes, lawmakers have specifically targeted maternal health coverage for cuts.

The same is true for infants in the U.S, whose health care is also at risk with these proposals. Our nation ranks 50th in the world on infant mortality. By shifting more families off of Medicaid, and creating a larger uninsured and under-insured population, children’s access to health care services will decline.

The Affordable Care Act protects all Americans from discrimination based on preexisting conditions, expands coverage for mental health treatment and drug addiction, and fosters preventive care. Millions of Americans have health insurance for the first time, and we are at an all-time low in the percentage of citizens who lack coverage. The reform legislation under development proposes to wipe away these essential gains, returning Americans to the pre-Affordable Care Act era of coverage limitations and exclusions thwarting the provision of essential health care services.

In 1966, Dr. Martin Luther King explained to a group of health providers, “Of all the forms of inequality, injustice in health is the most shocking and inhumane.” We agree.

Letter to a Trump Supporter #1: Undocumented Immigration

We will all remember this election. Our children and grandchildren will read about it. They will ask us what it was like to live through it. They will want to know what we did, where we stood, how we voted.

This is the record I will leave behind.

Throughout this election season, I have been corresponding with a family friend who supports Donald Trump. I have explained, point by point, why I oppose Mr. Trump and why I see the country so differently than he does. In this final month leading up to Election Day, I will publish these “Letters to a Trump Supporter” on this blog.

I will begin with the issue that started it all: undocumented immigration.

He sent me this video as an argument in favor of Mr. Trump’s rhetoric on this issue. Below is my response.

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Dear Mr. ——,

Thank you for sending this video. It’s interesting to see the fears that people have about undocumented immigration.

Hopefully, it’ll comfort you to learn that most of those fears are unwarranted.

First and most importantly, the undocumented immigrant population is shrinking. It peaked in 2007 at 12.2 million people. Now, there are only 11.1 million. So, contrary to all the accusations in this video, undocumented immigrants have been leaving more than they’ve been coming here during the Obama administration.

Contrast that with the Bush administration, during which the population grew from 8 to 12 million…a 50 percent increase!

Second, President Obama never said that he welcomed undocumented immigrants to cross the border. Notice that they never show him saying such a thing. That’s because such a video doesn’t exist. He never said it.

Third, immigrants actually commit fewer crimes than native-born American citizens. This shouldn’t be surprising, when you consider the fact that violent crime rates have plummeted nationally over the past couple decades when undocumented immigration has been rising. What this video is doing is pure racism, assuming that foreigners are more “dangerous” when the facts say the exact opposite.

They’re trying to scare you. Don’t be fooled.

Fourth, there are very, very few undocumented immigrants who are granted asylum on the border. In 2013, for example, only 155 Mexican immigrants were granted “defensive asylum.” The numbers from other Central American countries are even lower.

That shouldn’t be surprising, since it’s not nearly as easy as this video alleges. The Border Patrol has no control over it, and neither does the President. The asylum-seeker has to prove their case before an immigration judge.

Fifth, it is not true that immigrants run to the Border Patrol. On the contrary, the Border Patrol is regularly accused of using excessive force, to the point that it “has normalized policing practices that would be considered patently unconstitutional if carried out by local police.”

Sixth, undocumented immigrants cannot receive “free heart surgery.” The Affordable Care Act (a.k.a. Obamacare) explicitly prohibited undocumented immigrants from receiving subsidized health insurance. Some community clinics provide charity care, but they do not do expensive operations. Even those options are few, however, and too underfunded to serve most of the undocumented population.

Finally, I want to point out how this is a classic case of biased, unprofessional journalism. Notice that he only presents one side of the case: He only interviews Border Patrol workers. He never interviews a single undocumented immigrant!

This presentation would fail even the most basic journalism class. It’s not news. It’s propaganda.

Best regards,
Anthony

Our Kids Aren’t the Only Ones Suffering From Inequality. We’re Failing Our Parents Too!

You wouldn’t know it to read the news these days, but the Baby Boomers are in trouble.

Rarely does a day go by that the Baby Boomers aren’t blamed for something. They’re bankrupting Social Security. They caused the Great Recession. They’re hogging all the money.

Well, I’m here to tell you that you’ve got the wrong culprit. Most Baby Boomers don’t have nearly as much money as you think they do. You’re rounding up the many to prosecute the few. That’s just bad police work.

This is a plea for the parents out there. They raised us and fed us, they taught us and nursed us, they brought us into this world, and for the most part, they tried to make it better for us. And we are failing them.

We are failing our parents.

We have a strange sense of obligation in this country. We talk a lot about what we owe our children but very little about what we owe our parents. The future is sacrosanct; the past quickly forgotten.

And we should talk about our children. Because we’re failing them too.

Pick up a copy of Robert Putnam’s new book Our Kids, and you’ll see all the ways we’re failing them:

  • More and more kids are growing up with one parent instead of two. The single parent is less likely to find a job. They have less time to spend with their kids. As a result, their children perform worse in school, exhibit more behavioral problems, and experience more anxiety and depression.
  • More and more kids aren’t eating dinner with their family. They aren’t having conversations with their parents. They don’t know the alphabet when they start school. And they never catch up!
  • More and more kids are living below or near the poverty line, where they “experience severe or chronic stress,” making it harder to concentrate, “cope with adversity, and organize their lives.” They are more likely to be neglected, discouraged, abused, and traumatized. And they have permanent brain damage!
  • More and more families can’t keep up with the rising cost of childcare. They send their kids to low-quality daycare. They have less time available to spend with their kids. And when they do spend time with them, their financial worries make it harder for them to be patient, focus, and nurture.
  • More and more students are falling behind their peers in school. Their parents don’t have the time or knowledge to help them. Their schools don’t have the fundraising capability to make up the difference. Their teachers are demoralized. Their classmates are disruptive, discouraging, and even violent. Extracurricular activities are either unavailable or too expensive to participate in. College is even more expensive. And if they do make it to college, it’s one with lower graduation rates and a future of higher unemployment and lower earnings.
  • More and more kids don’t trust people. They don’t have mentors to teach them about life. They don’t have youth organizations to keep them safe and healthy. They don’t have programs to show them how to apply for college or budget their money. They don’t have contacts to help them find a job. And they think their vote doesn’t matter, so the problem just keeps getting worse!

For Putnam, this is where the story ends. And who can blame him? Kids are an easy sell. No one can blame them for their lot in life.

But what happens when they become adults? We don’t like to talk about that part. Affordable housing, food stamps, incarceration, labor unions, mandated health insurance, Medicaid, Medicare, the minimum wage, paid leave, progressive taxation, public jobs, Social Security, unemployment insurance, welfare — that’s the controversial stuff. Better not to touch those subjects. Kids deserve a helping hand, but adults? We’re not so sure.

The problem is, those adults were kids once upon a time too, and when they were, many of them had it just as bad. And now, after heaping disadvantage upon disadvantage on them for twenty years, they’re expected to compete on the same playing field as everyone else. It’s as if they were running a race, and their peers were given a twenty-year head start — and we criticize them for not catching up!

These adults deserve equalizing policies every bit as much as their kids.

Long-Term Unemployment by AgeThe young and the old aren’t so different after all. It’s the wrong contrast. Even if we wanted to take money from the old and give it to the young, it wouldn’t work because they don’t have it!

The Baby Boomers are trillions of dollars short of the wealth they need to retire without a “drastic lifestyle change.” Over half of them will get most of their income from Social Security, and one in four will have nothing but Social Security. For those who got laid off during the Great Recession, they’re having a much harder time getting rehired than younger generations. And because they were the ones who were holding mortgages when the bubble popped, their homeownership rate has nosedived so badly that Trulia’s chief economist Jed Kolko calls them “the lost generation of homeowners.”

Clearly, inequality affects Americans of every age — and that is why you cannot cure what ails the children without treating the parents, for the ailment is not generational. It is economic, and it perpetuates itself down through the generations.

So, yes, by all means, let’s talk about inequality of opportunity for our kids because that’s where it all starts. But let’s also remember that those kids grow up, and when they do, it doesn’t get easier. The scars of childhood last a lifetime.

We tend to overlook those scars and place blame on those who have fallen behind in the race. But for those of us who have been given a head start and don’t reach back to offer them a hand, the real failure rests with us.

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This op-ed was originally published on the Huffington Post.

New Data Settles the Debate: Obamacare Is Making Health Insurance More Affordable, Not Less

Change in Obamacare Premiums, 2014-2015

It’s that time of year again.

No, not the holiday season. I’m talking about Obamacare season.

In the second year of our new annual tradition, the exchanges are open for enrollment, which begs the question: What have we learned since last time? Were the naysayers proven right, or did Obamacare really make health insurance more affordable, as was intended?

With a new year of data to answer these questions, once more into the breach we go…

At this time last year, the inaugural enrollment period was not going well. The website was malfunctioning, people were losing plans they wanted to keep, and the media was running scare stories about “sticker shock.” I argued, on the contrary, that the website would get fixed in a hurry, most people were getting better plans, and the exchanges were actually reducing the cost of health insurance.

The first prediction was clearly vindicated. The website got fixed, and 8 million Americans enrolled.

The second prediction was also a victory for Obamacare. Before the exchanges opened, 16.4 percent of Americans were uninsured. A year later, only 11.3 percent were uninsured.

And this isn’t only due to the Medicaid expansion. In states that did not expand Medicaid, the uninsured rate fell from 18.2 percent to 13.8 percent. Clearly, the exchanges didn’t just replace old plans. They created new ones for people who didn’t have any.

They didn’t reduce coverage. They expanded it.

And according to the latest Gallup poll, the people who got that coverage are just as happy with it as the people with non-exchange insurance — and the people on the exchange are actually happier with their costs than everyone else.

Which brings us to the third prediction. This one was more controversial.

Earlier this year, I analyzed the many studies of pre- and post-Obamacare costs and came to the conclusion: “On average, Obamacare clearly lowered the cost of health insurance.”

Two of the experts who wrote one of those studies, Paul Howard and Yevgeniy Feyman, disagreed with me. They argued that I misinterpreted their estimates by comparing Kaiser’s estimate for all ages to their estimate for 27-year-olds. But they’re the ones who made the mistake. Apparently, they misread the Kaiser estimate I cited, which referred to 18-to-34-year-olds, not all age groups. I chose this estimate specifically because it was comparable to theirs.

Then, they cited other studies that used the same faulty methodology that they used, and they claimed that I “ignored” those studies — when in fact I explained exactly why those kinds of studies were inaccurate.

Finally, they suggested that I was conflating premiums before subsidies with the cost after subsidies, overlooking the price paid by taxpayers. At this point, I was wondering whether they even read my original article, where I made a clear distinction between the two. The evidence suggested, I wrote, that the average premium increase before subsidies was small — maybe zero. And even if it did increase, that increase was due to people buying more generous plans because now they could afford them. And the point of the subsidies was to make health insurance costs go down for the people who needed it the most — which is exactly what happened.

Whew. You can see what I meant when I said it was controversial.

The good news is, now we have a second year of data to settle the debate, and this data is better because we can compare the same level of plans with the same amount of coverage on the same exchanges, apples-to-apples, as opposed to the pre-Obamacare plans, which were all over the map. Literally.

The nonpartisan Kaiser Family Foundation has examined the “benchmark” silver plans in major cities in all 50 states, and they’ve found that the monthly premiums have increased 2 percent, on average, since last year. That is slower than health insurance premiums have grown in any year since we’ve started recording the data. Only a couple years ago, health insurance costs were growing 5 percent per year. During the Bush administration, they were growing more than 10 percent per year. Two percent is unheard of.

And that’s only the average. In nearly half of those cities, premiums are falling on the exchanges. That’s unprecedented. Health insurance premiums almost never fall. And when you compare premiums after subsidies, 90 percent of cities are paying less than they did last year!

Now, maybe you still don’t like Obamacare. Maybe you’d prefer a simpler, cheaper system. (Who wouldn’t?) But there is one thing you simply cannot deny: Over the past year, health insurance has become more affordable for the non-group market, and the result will be better health care for millions of Americans who need it and wouldn’t have it if Obamacare didn’t exist.

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This op-ed was originally published in today’s Huffington Post.

Finally! Someone Explains What All Those Obamacare Numbers Mean!

You’re going to hear a lot about Obamacare this fall, especially from Republicans. They’ll try to convince you that it was a bad deal. They’ll throw numbers at you to make you think that the cost of health insurance is spiraling out of control. In all likelihood, those numbers will be wrong, but how will you know? There are so many numbers flying around out there that even the experts are having trouble keeping track.

That’s why it’s time for a math lesson. After reading this article, you’ll know what the numbers mean — and which ones you should trust. No candidate will be able to fool you.

Millian Medical Index

And you won’t even need a calculator.

First of all, you have to understand that we’re only talking about the individual market, where people buy insurance if they’re not covered by their employer or a government program. That means the “individual mandate” and the “government-run exchanges” only affect 7 percent of the population. For the majority of the population covered by their employer, the cost of health insurance rose less in 2014 than it had in any year since the Milliman Medical Index started keeping track. We can probably thank Obamacare’s cost control provisions for some of that achievement, but that’s a conversation for another day.

For now, let’s focus on the individual market. Before Obamacare, insurers charged low rates to healthy people and high rates to sick people, making insurance unaffordable for the people who needed it the most. Obamacare banned discrimination against sick people and mandated that all people must purchase insurance. Without that mandate, insurers would have raised rates to cover the new sick customers, and healthy people would have refused to pay the new high rates, driving rates up even higher as the population became sicker on average.

When the law was passed, the Congressional Budget Office predicted that premiums would increase 10 to 13 percent, but only because people would be receiving more generous coverage. Obamacare required every health insurance plan to meet basic minimum standards. Additionally, by making it more affordable, more people would want to buy more generous coverage. If you compared plans with the same level of coverage, the CBO predicted that premiums would actually go down.

When states started announcing the premiums for their new “exchanges,” you probably started hearing about “sticker shock.” By comparing the new premiums to old quotes from health insurance websites, Obamacare critics claimed that the law had drastically raised prices. The problem with their argument was that the quotes on the old websites were very unreliable. They rarely reflected what insurers would actually charge you, once they factored in your medical history, age, gender, etc. In fact, many Americans would be denied coverage altogether. Anyone who knew anything about health insurance knew that the website quotes were lowballing the cost.

State governments like California countered by making a more reasonable comparison. They argued that the new exchange premiums were actually lower than premiums for small group coverage, for which they had better data. Obamacare critics weren’t satisfied. Small group plans may have been more expensive than the plans on the new exchange, but that’s because they offered more generous coverage.

The Manhattan Institute, led by conservative health expert Avik Roy, tried to find a middle ground by adjusting the quotes on the health insurance websites, raising the estimates for people who were “surcharged” or denied, and finding that Obamacare increased prices by 41 percent.

The problem with Roy’s analysis was that his adjusted numbers didn’t match reality. Before Obamacare, Roy suggested that 27-year-olds — the ones who were being hit the hardest, he argued — paid between $1,596 (men) and $1,980 (women) in average annual premiums. But the Kaiser Family Foundation conducted a survey in 2010 and found that they were actually paying closer to $2,630. Across the board, Roy had underestimated the pre-Obamacare cost of health insurance, and he wasn’t including costs that consumers paid out of their own pockets.

Last month, three Wharton economists used the Current Population Survey to calculate a more accurate estimate of the average pre-Obamacare premium. They found that it was basically identical to the lowest-cost plan available on the Obamacare exchanges. Compared to more expensive plans, of course, it was cheaper, but when they factored in out-of-pocket costs, they found that the new plans were 14 to 28 percent more expensive than the old ones, only slightly higher than the CBO’s original predictions.

Monthly Subsidized Premiums on Federal Exchange

But wait. The Wharton study only counted people who purchased insurance, not people who were denied or who refused because the insurer’s quote was too expensive. We’ll never know what that quote was, but we can assume it would significantly raise our estimate of the average premium. To ignore those people — and there were millions of them — is to say that they don’t matter, even though Obamacare was designed specifically with them in mind.

The Wharton study also doesn’t include the tax credits that the federal government uses to subsidize low-to-middle income buyers on the exchanges. Last month, the government announced that 87 percent of shoppers received a subsidy on the federal exchange, bringing their average monthly premium down from $346 to only $82!

That’s a 76 percent reduction, and it more than makes up for the 14 to 28 percent premium increase, which may not be much of an increase after all if you include people who didn’t buy insurance in the past.

Bottom line: On average, Obamacare clearly lowered the cost of health insurance.

Sure, some people will pay higher rates, but you have to remember that those people only paid low rates in the past because insurers were discriminating against sick people. The new market is much fairer and more affordable for more people — a fact that you might want to point out to Republicans on the campaign trail this fall.

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Similar versions of this op-ed were published in today’s South Florida Sun-Sentinel and Huffington Post.