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.

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.

Republicans Want to Replace Obamacare with…Obamacare-Lite?

Americans Trust Democrats Over Republicans on Health CareEver since Barack Obama signed the Affordable Care Act on March 23, 2010, the Republicans in Congress have tried to repeal it. This week’s vote was their 50th attempt.

And yet, despite their unyielding opposition, their earnestness rings hollow to most Americans for the simple reason that they have not offered an alternative path to health care reform. Even the party’s own strategists have chastised it for its negative approach, for failing to offer a plan of their own, for obstructing rather than leading.

Finally, their pleas have been answered — in the form of the Patient Choice, Affordability, Responsibility, and Empowerment Act, or “PCEREA,” sponsored by Republican Senators Orrin Hatch, Tom Coburn, and Richard Burr.

At long last, we can answer the simple question that Democrats have been asking Republicans since March 23, 2010: You got a better idea?

Unfortunately, the answer is a disappointing “no.”

The ACA, better known as “Obamacare,” has four major provisions: (1) a ban on price discrimination against sick people, (2) an “individual mandate” requiring everyone to purchase health insurance or pay a fine to the IRS, (3) tax credits for Americans who cannot afford to purchase insurance, and (4) a Medicaid expansion for the poorest Americans who don’t pay enough taxes to qualify for the tax credits.

The PCEREA does away with the first provision right off the bat. The most popular feature of Obamacare, the one that appeals to our basic sense of fairness, is the rule prohibiting insurers from charging different prices to different consumers based on health status. The Republicans would erase this rule, once again making insurance least affordable for the people who need it the most.

With the first provision gone, there isn’t much need for the second one. This is what most people have trouble grasping about the individual mandate: As unpopular as it is, it’s necessary in order to sustain the most popular part of the law. Without an individual mandate, a ban on price discrimination will simply result in insurers charging high rates to everyone, driving all but the sickest consumers out of the market. Insurers can only afford to charge reasonable rates across the board if healthy people are required to buy in.

The PCEREA replaces these two provisions with two new provisions called “continuous coverage” and “auto-enrollment.”

Under “continuous coverage,” Americans would be given a one-time opportunity to buy insurance at prices that aren’t based on health status. So long as they keep this insurance plan for the rest of their lives, they’ll never be discriminated against. If they miss this opportunity — say, by being born after the window passes — they can be discriminated against. If they lose their plan — say, because they change jobs — they can be discriminated against. Basically, “continuous coverage” is a con, a “first come, first serve” lottery that doles out the right to fairness like it’s a privilege, a prize in some twisted game, and then snatches it out from your hands if you fall on hard times or dare to exercise your freedom of choice.

Under “auto-enrollment,” states can sign you up for insurance without your consent, but you can opt out. Basically, the Republicans are assuming that the problem with the insurance market is that Americans are so stupid that they aren’t signing up for insurance that they need and can afford.

Astonishingly, the Republicans have simply taken the provisions of Obamacare and made them temporary — and called it “reform”! We’ll give you fair prices, but only for a little while. We’ll require you to sign up for insurance, but only until you back out.

The third provision confirms this ploy. Just like the ACA, the PCEREA offers tax credits to Americans who purchase insurance on the individual market. The only difference is that the Republicans’ tax credits are far less generous, helping far fewer people.

Finally, the PCEREA addresses Medicaid by restricting its availability to only certain types of Americans, apparently the ones whom the Republicans deem worthy: pregnant women, children, the disabled — but not, for example, working parents. It would also change Medicaid into a block grant program, where it would get a chunk of money every year regardless of how much it needs, leaving most states with tremendous shortfalls during recessions and leaving patients out in the cold when they need help the most.

This last provision is just cruel, but the Republicans can slip it into the bill because the rest of the proposal looks so thoughtful and measured that they’re hoping you won’t notice that it will do almost nothing to address the serious problems ailing our health care system. It is little better than the status quo that existed before Obamacare — and in that sense, they haven’t really offered an alternative after all.

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This op-ed was published in the Huffington Post, and an abbreviated version was published in the South Florida Sun-Sentinel.

Yes, Obamacare Critics, Health Insurance Does Make You Healthier

Michael Barone and Charles Krauthammer have some medical advice for you: Don’t get health insurance, they say. It won’t make you healthier. It’s a waste of money.

Obamacare Enrollment SurgeThey must be desperate. They don’t want to admit that they’ve run out of criticisms of Obamacare. The website is working, enrollments are surging, and millions of Americans are getting affordablehigh-quality health insurance. They couldn’t deny these facts, so they needed a new argument to discredit the law — and they found it tucked away in the New England Journal of Medicine.

In 2008, Oregon conducted an experiment. They held a random lottery. They picked 20,745 names out of a waiting list of 90,000 low-income adults who wanted to sign up for Medicaid. Of the winners, half received Medicaid, and half did not. After two years, they compared the two groups to see if the ones who had Medicaid were any better off.

Barone and Krauthammer claim that the Medicaid group did not have better health than the uninsured group, proving the futility of health insurance, but their conclusion is based on a very narrow, selective reading of the evidence.

It’s true that the individuals on Medicaid did not fare any better than their uninsured counterparts on blood tests for cholesterol, blood sugar, and blood pressure. But it’s also true that the Medicaid patients scored higher on the mental quality-of-life test, experienced significantly lower rates of depression, and reported that they felt healthier.

The Medicaid patients also experienced significantly less financial strain. They were 25 percent less likely to have an unpaid medical bill sent to a collection agency.

In other words, health insurance has significant mental and financial benefits.

In this study, the physical benefits are less clear, but that’s not surprising, given that it only lasted two years and it only measured three simple blood levels. Fortunately, other researchers have measured more than just cholesterol.

A 2008 study in the prestigious medical journal The Lancet, for example, revealed that uninsured patients were significantly more likely to develop advanced-stage cancer because they didn’t receive early screening to detect it.

A year later, Harvard researchers published a study in the Annals of Surgery showing that uninsured patients who arrived at the emergency room with traumatic injuries were almost twice as likely to die in the hospital as patients with insurance, even if they had the same race, gender, age, and severity of injury. Later that year, a similar study was conducted at the Boston Children’s Hospital and published in the Journal of Pediatric Surgery. It found that uninsured children were more than three times as likely to die from traumatic injuries as children with commercial insurance.

And if all that wasn’t enough to convince you, the American Journal of Public Health published a study that same year comparing the death rates of the insured and the uninsured when they had the same education, income, weight, rates of smoking and drinking, etc. They concluded that 44,789 Americans die every year simply because they don’t have health insurance.

That is the bottom line we should be talking about.

If the Oregon experiment were carried out beyond two years, the differences between the insured and the uninsured would accumulate. They found that the Medicaid patients were 70 percent more likely to visit the doctor, 20 percent more likely to have their cholesterol monitored, and for the women, 60 percent more likely to get a mammogram. Those kinds of preventive measures don’t make a huge impact in two years, but in the long run, they can mean the difference between life and death.

Health insurance is so beneficial to your health, in fact, that its effects spillover and benefit those of us around you. Studies have shown, for instance, that companies that offer health insurance are more productive because insured workers take 52 percent fewer “sick days” than their uninsured co-workers.

I have to wonder if Barone and Krauthammer have ever even met anyone on Medicaid. I wonder if they know the terrible fear that uninsured Americans feel when they get sick and they’re forced to choose between astronomical medical bills and untreated illness.

I think they should find out. If they’re so confident that health insurance doesn’t affect your health, then I would like to issue this challenge to them: Give up your own health insurance. Don’t waste another penny on it. Join the ranks of the uninsured.

If not, if they’re unwilling to follow their own advice, then they should stop giving it. They should stop spreading misinformation that can hurt millions of Americans who read their op-ed columns and who depend on the access to lifesaving medical care that only health insurance can provide.

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This op-ed was published in today’s Huffington Post. An abbreviated version was published in the South Florida Sun-Sentinel.