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Health Policy, Healthcare Reform, Medicare, Medicine, Op-eds, Socialized Medicine

Giving Medicare for All a Facelift: the Ugly Is Still There

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By Marilyn M. Singleton, MD, JD

Medicare for All (M4A) retained its prominent place on the stage at the latest Democratic debate. In its purest Bernie Sanders form, concurrent with abolishing private health insurance, U.S. residents would be enrolled in “Medicare.” The program would pay for unlimited “medically necessary” health expenses, including pharmaceuticals, mental health and substance abuse treatment, vision, dental, and hearing services, and long-term care with no out-of-pocket costs. Some supporters were scared off by the $32 trillion over 10 years price tag. Not to be outdone, Elizabeth Warren’s “I’m with Bernie” plan comes with a $52 trillion over 10 years price tag including up to $34 trillion in new government spending. Our country’s entire yearly budget is a mere $3.5 trillion. For perspective, if your salary is $40,000 per year it would take 25 million years to earn 1 trillion dollars. As M4A’s dark side emerged, the candidates distanced themselves from Bernie-care.

Elimination of private insurance? Whoa, Nellie! Over 156 million Americans —half the country—are covered by employer-sponsored health insurance plans and another 23 million have private individual policies. And most of these folks like that arrangement. Then there was pushback from some unions who had excellent health insurance policies for which they had bargained and given up other perks.

In the June debate the candidates raised their hands indicating they would abolish private health insurance. Now Mayor Buttigieg wants to “unify the American people around, creating a version of Medicare, making it available to anybody who wants it, but without the divisive step of ordering people onto it whether they want to or not.” Vice president Biden, noting his desire to keep patient choice stated, “we should build on Obamacare … adding a Medicare option in that plan, and not make people choose.” Of course, Obamacare caused a rise in premiums, a decrease in choice of insurance coverage, and like any large government-run program was prone to mismanagement and waste.

Possible financing mechanisms were screaming for a deep dive. One analysis concluded that most Americans would suffer financially if M4A were implemented as proposed. An analysis by a bipartisan think tank estimated a 32 per cent increase in payroll taxes would be needed to fund M4A. Everyone—even the working poor—would have more payroll taxes extracted from their paycheck. The analysis concluded that most households would pay more in new taxes than they would save by eliminating their current spending on private health insurance and out-of-pocket medical expenses.

Senator Warren tries to hide the ugly truth by railing about the evil rich who would be taxed down to their underwear. Take the deceptively worded “2-cent” annual tax for households with more than $50 million in assets. If you have $51 million in assets, most probably tied up in your business, you’d have to cough up (.02)($1,000,000) or $20,000, not 2 cents. The devil’s spawn, aka our 535 billionaires, would be subject to a 6 percent annual tax on their assets. Who will be the next target when the government has driven the assets to a sunny island in the Caribbean? Finally, raising the corporate income tax back up to 35 percent likely would result in businesses paying lower wages to current employees or cutting back on hiring to compensate for the increased tax burden.

During the latest debate, Senator Warren retreated from her “all-in” approach, asserting she would first provide Medicare at no cost to “everybody under the age of 18, everybody who has a family of four income less than $50,000”—about 135 million people. Second, she would lower the Medicare age to 50 and expand Medicare coverage to include vision, dental, and long-term care. In the third year, “when people have had a chance to feel it and taste it and live with it, we’re going to vote and we’re going to want Medicare for all.”

Senator Sanders owns that payroll taxes would be doubled or tripled and proposes a 4 percent surtax on families earning more than $29,000. So if you earn $60,000, you’d have to pay (.04)($31,000) or $1,240, enough for a whole year’s membership in a private Direct Primary Care plan. Senator Sanders, staying true to his principles, is sticking with unadulterated Medicare for All with its financial warts.

Even those who are numb to government over-spending can see the broader problem of inviting Uncle Sam into their lives in exchange for a Medicare card in their wallet. Any remaining privacy is erased. Our medical records would be furnished to the Department of Health and Human Services and the National Coordinator for Health Information Technology. Physicians and patients would be robbed of their autonomy and choice by medical care policies set by the government monopoly. Lack of competition leads to lower quality and fewer services. Coverage becomes an illusion.

Medicare for All’s beauty is only skin deep and its ugly goes to the bone.

Bio: Dr. Singleton is a board-certified anesthesiologist. She is Immediate Past President of the Association of American Physicians and Surgeons (AAPS). She graduated from Stanford and earned her MD at UCSF Medical School.  Dr. Singleton completed 2 years of Surgery residency at UCSF, then her Anesthesia residency at Harvard’s Beth Israel Hospital. While still working in the operating room, she attended UC Berkeley Law School, focusing on constitutional law and administrative law.  She interned at the National Health Law Project and practiced insurance and health law. She teaches classes in the recognition of elder abuse and constitutional law for non-lawyers. 

Culture & Society, Health Policy, Healthcare Reform, Law, Medicare, Medicine, Op-eds, Socialized Medicine

The Healthcare Revolution: More Choices, Not More Taxes

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By Marilyn M. Singleton, MD, JD

Paris is in flames over a fuel tax increase that would pile 30 cents onto the $7.06 per gallon price paid by citizens whose average monthly salary is $2,753.This burdensome “carbon tax” on the middle class is intended to help meet Europe’s commitment to reduce carbon dioxide emissions and thereby halt global warming or climate change. It appears that the 21st century French Revolution has begun. This time, Brussels is sending in tanks to protect the new elite and its agenda.

Back in the states, some well-heeled, presumably well-intentioned Medicare-for-All advocates from California, New York, and New Jersey are grousing about how “Trump took away my homeowners tax deduction!” The Tax Cuts and Jobs Act now caps the previously unlimited federal tax itemized deductions for the combined state, local and property taxes at $10,000. The portion of a mortgage on which interest can be deducted is limited to $750,000, down from the current limit of $1 million.

Folks with million-dollar homes who continue to vote for legislators who impose high state taxes to finance their pet social programs are less sympathetic than the French Yellow Vests—especially when these same elitists want to take away the “crumbs” from the 80 percent of taxpayers who are receiving some relief from the near doubling of the standard deduction.

But everyone will face still more taxes to fund Medicare-for-All. Bernie Sanders’s financing plan would “limit tax deductions for the wealthy,” defined as $250,000 per household. Sanders also proposes eliminating health savings accounts (HSAs), which allow patients to take charge of their own care. And it won’t stop there—or at the equivalent of 30 cents per gallon.

It’s not just the taxes: it’s the loss of the freedom to choose. The M4A bills prohibit virtually all private health insurance. M4A promises “free” access to “willing healthcare providers”—but robs us of choice. Even existing Medicare offers 11 supplemental insurance programs with options for different premium structures. Purchasers can decide to pay a little more now for a stable premium price as they age, or pay quite a bit less and anticipate the age-related increase over the years. But, you say there would be no premiums with M4A. Wrong. The “premiums” are increased taxes. And taxes are not optional. You must obey.

We should take a cue from the French (minus the fires and looting). We need a middle-class medical care revolt against the elitists and politicians who think more government through high taxes is The Answer while ignoring community solutions. For example, We Do Better, a humanitarian movement, seeks out solutions to social problems based not on a particular political ideology or lobbyist’s effort, but on what works. In Southern California eight Clinica Mi Pueblo (CMP) clinics accept only cash, have transparent pricing on their website, and their services cost less than half of the price set by third parties. Where the average charge for an X-ray is between $260 and $460, CMP charges only $80. Utah’s Maliheh Free Clinic (MFC) serves low income and uninsured residents who are ineligible for Medicare, Medicaid, or any government subsidized healthcare. The MFC provided free healthcare to more than 15,000 patients in 2016 at an average cost of only $56 per patient, and 95% of donations to MFC go to providing medical services. New Jersey’s Zarephath Health Center is a volunteer-run and funded facility for patients who cannot find care “in the system.” Here it costs $15 to see a patient, versus $160-$280 at the Federally Qualified Health Center down the street.

Another increasingly popular model is direct primary care (DPC). Here, patients pay a monthly subscription fee to the practice (between $40 and $100 depending on age and family size), which covers all primary care services, certain laboratory tests, and at-cost pharmaceuticals at as much as 15 times less than the price at the pharmacy. The personal relationship with a physician enhances the care to patients with chronic conditions, reducing costly hospitalizations. Catastrophic insurance can cover major medical expenses. St. Luke’s Family Practice in Modesto, California is a DPC non-profit organization. Here, “benefactors” pay the fees for the “recipients” – those who cannot afford the fees.

Then there are many health care sharing ministries where members engage in voluntary sharing of costs for its members’ health needs. One such model, the Christian Healthcare Ministries (CHM), has plans that cost half as much as ACA Marketplace plans. It has more than 279,000 members, and has covered more than $1 billion in medical bills since 1981.

Americans want authority over our own lives. Our innovative spirit and generosity have created and will continue to create ways to deliver medical care to the most people without sacrificing choice—and at a more affordable cost.

Dr. Singleton is a board-certified anesthesiologist. She is also a Board-of-Directors member and President of the Association of American Physicians and Surgeons (AAPS). She graduated from Stanford and earned her MD at UCSF Medical School.  Dr. Singleton completed 2 years of Surgery residency at UCSF, then her Anesthesia residency at Harvard’s Beth Israel Hospital. While still working in the operating room, she attended UC Berkeley Law School, focusing on constitutional law and administrative law.  She interned at the National Health Law Project and practiced insurance and health law.  She teaches classes in the recognition of elder abuse and constitutional law for non-lawyers.

Culture & Society, Health Policy, Healthcare Reform, Law, Medicare, Socialized Medicine, Uncategorized

Mission Possible: Saving Freedom in Medical Care

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by Marilyn M. Singleton, MD, JD

In the original Mission: Impossible series, against all odds, through brilliant strategizing the good guys thwart stealth communist plots to undermine democracies. In trying to provide affordable, quality, personalized medical care, independent physicians face seemingly insurmountable obstacles: digging out from under piles of electronic paperwork, breaking free of third-party red tape, dodging hospital buyouts, and shielding patients from data mining and privacy intrusions.

But the biggest obstacle to great medical care is the socialist brigade rallying around Medicare for All, the proposed federally financed program that boasts no premiums, deductibles or copays, and medical, dental, vision and hearing benefits. What could possibly go wrong? As they say, show me the money. The Congressional Budget Office estimates the federal government will spend about $1 trillion on healthcare programs in 2018. A detailed Mercatus Center analysis concluded that Medicare-for-All would add $32.6 trillion to federal expenditures during its first 10 years.

Currently, payroll taxes and income tax on Social Security benefits fund Medicare’s Part A Hospital Insurance Trust Fund. The Centers for Medicare and Medicaid (CMS) estimates this fund will be depleted in 2026. General tax revenues and beneficiary premiums fund medical services coverage (Part B). Medicare for All would be financed by current Medicare funds – minus the insurance premiums – and would be supplemented by the ever-popular “taxing the rich.” Beware: the definition of “the rich” will be ratcheted down to encompass more taxpayers.

Then there is the coercive nature of Medicare. A beneficiary’s opting out of Medicare Part A means forfeiting all past and future Social Security benefits. Medicare for All makes it clear that no straying from the herd is allowed: neither private insurers nor employers can offer insurance that competes with the government.

Fortunately, more choices are becoming available for potential patients. The House of Representatives recently passed two packages of expansions of Health Savings Accounts (HSAs) (H.R. 6199, H.R. 6311). To name a few benefits, the contribution limit for an HSA nearly doubled to $6,650 for individuals and to $13,300 for families. HSAs would be allowed to pay for direct primary care (DPC) monthly fees. Best yet, anyone would be able to purchase a lower-premium catastrophic plan — removing the ACA’s under age 30 restriction. And purchasers of “bronze” and catastrophic (“copper”) plans would be able to contribute to an HSA.

Improving HSAs is not a trivial goal. HSAs are portable. HSA contributions reduce taxable income, money in the account grows tax-free, and money can be withdrawn tax-free to cover qualified medical expenses. The Employee Benefits Institute estimates that a person saving in an HSA for 40 years, assuming a 2.5% return, could accumulate up to $360,000.

The Executive Branch acted on CMS’s report that lower-cost alternatives were necessary given the rising premiums responsible for the decline in the purchase of unsubsidized ACA plans. The Administration created new rules for short-term limited duration (STLD) insurance policies, which are not bound by the ACA’s restrictive mandates.

STLD plans, defined by the Obama administration as less than three-months duration, can be up to 12 months duration and can include an option for guaranteed renewal up to 36 months. Californians may be out of luck if the proposed consumer protection legislation prohibiting STLD policies makes it to the governor’s desk.

According to CMS, in the fourth quarter of 2016 the average monthly premium for individuals for a STLD policy was approximately $124, compared with $393 for an unsubsidized ACA-compliant plan with comparable $5,000 deductibles. That is an annual savings of $3,228. Even adding $50 per month for a direct primary care practice, an individual saves $2,628 a year. With DPC, all primary care services, including chronic disease management and access to low-priced commonly used medications are included in the upfront price.

The HSA bills and the new STLD rules are an antidote to the erosion of our freedom to contract under the guise of protecting us from “junk” insurance. Medicare-for-All is not the cure for health care ills. Once the central planners lure the masses into dependence on “free” stuff, abuse of power ensues. Voluntary participation by physicians becomes mandatory. When the money tree withers, the non-negotiable provider payments are slashed, and services to patients are rationed.

To mitigate the unacceptable, sometimes fatal wait times in the Veterans Administration health system a bipartisan Congress looked to the backbone of great medicine: private practice physicians. Independent medical practices will lead the way to achieving great affordable medical care through competition and consumer choice.

Dr. Marilyn M. Singleton, MD, JD is a board-certified anesthesiologist and member of the Association of American Physicians and Surgeons (AAPS).

Dr. Marilyn Singleton ran for Congress in California’s 13th District in 2012, fighting to give its 700,000 citizens the right to control their own lives.

While still working in the operating room, Dr. Marilyn Singleton attended UC Berkeley Law School, focusing on constitutional law and administrative law. She also interned at the National Health Law Program and has practiced both insurance and health law.

Dr. Marilyn Singleton has taught specialized classes dealing with issues such as the recognition of elder abuse and constitutional law for non-lawyers. She also speaks out about her concerns with Obamacare, the apology law and death panels.

Congressional candidate Dr. Marilyn Singleton presented her views on challenging the political elite to physicians at the Association of American Physicians and Surgeons annual meeting in 2012.

Follow Dr. Marilyn Singleton on Twitter @MSingletonMDJD

More info about Dr. Marilyn Singleton

Culture & Society, Doctors, Healthcare Reform, Medical Ethics, Medicine, Op-eds

The Expendables: There’s More to Life than Death

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By Marilyn M. Singleton, M.D., J.D

April 16th begins a week of National Healthcare Decisions Day. Hopefully this week will encourage honest discussions not only about a so-called “good death” but the value of an individual’s life. I am not optimistic, given the trend toward consciously or unconsciously steering patients toward “death with dignity” rather than focusing on the dignity of life. Indeed, a recent documentary video of an Oregon couple’s dual physician-assisted suicide received positive reactions.

One Affordable Care Act program to promote “quality care” through financial incentives for attaining high performance scores (and penalties for low scores) contains a metric that is fraught with moral hazard. Hospitals with higher numbers of pneumonia, heart failure, or heart attack patients who die within 30 days of discharge receive a lower score. But if patients are designated for hospice (palliative) care during the first 24 hours of their hospital stay, and then die within 30 days of discharge, they are not counted against the hospital’s score. In order to improve its quality-of-care score, one Veterans Administration hospital disclosed that it used an “inappropriate admissions system” where sicker patients were turned away against the physicians’ recommendations.

As the Affordable Care Act continues its painful death, many are seduced by the promises of government-sponsored single payer healthcare. Given the federal government’s 2017 healthcare expenditures of $1.14 trillion, politicians and policymakers ponder how to pay for such a massive program. Patients wonder whether they will pay with their pocketbooks (taxes) or their lives (rationing).

The fallback solution of raising everyone’s taxes is unpalatable to most. Aware that providing fewer services saves money but fearing public outrage, politicians have shunned efforts to explicitly ration health. Thus, policymakers promote programs that reduce waste and inefficiency. For example, frugality is encouraged by reimbursing a set dollar amount for a course of treatment that includes all inpatient and outpatient care and physician fees (“bundling”). But once the waste and inefficiency are successfully addressed, what is the next step to rein in “overuse” of services?

The British National Health Service’s National Institute for Health and Care Excellence (NICE) supports the use of “quality-adjusted life years” (QALY) to measure the quality and quantity of life added due to a particular medical treatment. One QALY is one year of perfect health. Zero QALY is death. If the cost per QALY gained exceeds a predetermined amount, the government denies payment for that treatment. Touted as more ethical, the “Complete Lives System”—the brainchild of ObamaCare physician architect Ezekiel Emanuel—includes worrisome determinants of who should receive care. The system prioritizes adolescents and persons with “instrumental value,” i.e., individuals with “future usefulness.”

These rationing systems devalue the benefits the disabled, elderly, or others with a lower life expectancy could receive from a given treatment. A study of individuals with late-in-life disabilities found that overall quality-of-life assessments were often positive even as participants described things that made their lives uncomfortable or difficult. Dignity and a sense of control were most closely tied to overall quality of life.

Importantly, health care professionals are not immune to personal bias in presenting the treatment options to patients. And physicians sometimes forget that their notion of quality is not the same as the patient’s.

A nationwide multi-medical center study revealed the inadequacy of written living wills or the generic check-the-box Physician Orders for Life-Sustaining Treatment (POLST). Based solely on these documents, physicians reached a consensus (95 percent agreement) on code status and resuscitation decisions in only two out of nine clinical scenarios. Viewing a patient’s video statement produced statistically significant improvement in physician agreement in interpreting the patients’ wishes in seven scenarios. Moreover, in five of the seven scenarios, physicians were more likely to choose full aggressive treatment.

It seems the best way to be your own best advocate is jump into the 21st century and make a video. Ensure that in a critical moment you are seen as not merely a medical condition but a person. If you want no medical intervention, say so in your own unambiguous words. If you want the full court press, be clear and explicit. Tell your doctors to treat you as aggressively as 92 year-old Jimmy Carter was treated for his metastatic malignant melanoma. And NO, a former president is not more important than you are.

And to my fellow physicians: ask yourself what you would recommend to the parents of a 19 month old deaf and blind toddler who needed extensive intensive care. Helen Keller’s parents have the answer.

Dr. Marilyn M. Singleton, MD, JD is a board-certified anesthesiologist and member of the Association of American Physicians and Surgeons (AAPS).

Dr. Marilyn Singleton ran for Congress in California’s 13th District in 2012, fighting to give its 700,000 citizens the right to control their own lives.

While still working in the operating room, Dr. Marilyn Singleton attended UC Berkeley Law School, focusing on constitutional law and administrative law. She also interned at the National Health Law Program and has practiced both insurance and health law.

Dr. Marilyn Singleton has taught specialized classes dealing with issues such as the recognition of elder abuse and constitutional law for non-lawyers. She also speaks out about her concerns with Obamacare, the apology law and death panels.

Congressional candidate Dr. Marilyn Singleton presented her views on challenging the political elite to physicians at the Association of American Physicians and Surgeons annual meeting in 2012.

Follow Dr. Marilyn Singleton on Twitter @MSingletonMDJD

More info about Dr. Marilyn Singleton

Health Policy, Healthcare Reform, Medicine, Op-eds, Politics, Socialized Medicine

California’s Very Expensive Free Lunch

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By Marilyn M. Singleton, M.D., J.D.

California’s state senate’s unipartisan passing of a sweeping single-payer health care bill, the Healthy California Act, has drawn attention to single payer as a solution to the decaying Affordable Care Act. The ACA decreased competition and plan availability in health insurance and leaves patients holding the bag of unaffordable premiums, deductibles, and copays. It’s no surprise that a majority of state residents polled were in favor of universal, government-run health care — as long as it doesn’t raise their taxes.

The unrealistic bill provides that every California resident, regardless of age, employment, or immigration status, would be eligible for coverage with no premiums, copayments, or deductibles. Additionally, patients could see any “willing” provider without a referral and receive any service deemed medically appropriate, including chiropractic, vision, dental, ancillary health or social services, and National Institutes of Health-approved alternative therapies. Insurers are only allowed to offer coverage for services that are not offered by the state.

“Providers” would be paid on a fee-for-service basis unless and until the Healthy California board establishes another payment methodology. The government thus has the unilateral ability to fix prices and payment methods – including State IOUs.

Were discussions about health care rational rather than political, the bill would have died in committee. Instead, it is moving on to the assembly. According to the California senate’s own study, the estimated cost of the single-payer program is $400 billion, while California’s total budget for 2018 is $179.5 billion. The bill naively or slyly makes no mention of funding. The top contenders are (of course) a 15 percent employer tax, a 2.3 percent sales tax increase, a 2.3 percent gross receipts tax, and existing healthcare-directed federal, state, and local funds.

California’s default funding method is fleecing the taxpayers and then redirecting targeted tax revenues. Recently, voters approved California’s 2016 Healthcare, Research and Prevention Tobacco Tax Act, which added a $2 per pack tax because the funds would go to physician training, disease prevention, medical research, Medi-Cal, and tobacco-use prevention and reduction. Gov. Brown now plans to shift some of the revenue to the general fund. And to solve a $32 million budget shortfall, Oakland’s mayor wants to divert to the general fund the soda tax money which was to be used for health programs.

Another glaring drawback that the legislators failed to address is the lure of the Golden Bear. The Supreme Court ruled in Memorial Hospital v. Maricopa County [Arizona] that the one-year residence requirement to receive free non-emergency medical services from the county violated the Equal Protection Clause by creating an “invidious classification” that impinges on the right of interstate travel by denying newcomers “basic necessities of life.” California is a large state with three border states and a large border country. If the Supreme Court has their say, the law could cover every soul who has a foot on California’s golden soil. Who will pay for the free-riders after the middle class has been taxed out of the state?

Let’s face it. Why would we trust the government to manage our medical care? The obvious example is the Veterans Health Administration. Congress has introduced a staggering 1,440 bills relating to veterans’ health since January 1, 2017. Several of these bills are directed toward the ability to fire demonstrably incompetent or rule-breaking employees by changing an appeals process that has allowed bad employees to remain on the job for years and receive pensions and bonuses.

The real tragedy is that the call for single payer ignores what patients really want. Deloitte’s 2016 Consumer Priorities in Health Care Survey found that patients overwhelmingly wanted “personalized provider interactions”. Of course, with a universal, government-run system comes universal privacy eradication and intrusion into our medical records. Secondly, people wanted “economically rational coverage.” They did not say free; they just want value for their dollar. They want convenient access. None of these things will be found in a government-run health care factory staffed by “willing” providers.

In truth, single payer is not a cure for a broken system, but another manifestation of the attempt to depersonalize patients and doctors and convert them to obedient participants trapped in a system with no exit. They will have no choice but to ignore the reality that when the government runs out of money and the taxpayers are drained dry, payments and services will be reduced.

 We need to think local. Tap into physicians love and joy in delivering charity care, and use insurance for its intended purpose: major unexpected expenses. Most importantly, ensure that patients and physicians can always deal directly with one another in an atmosphere of a trusting personal relationship.

Losing the hallmarks of good medicine is not worth the cost of free single payer.

Dr. Marilyn M. Singleton, MD, JD is a board-certified anesthesiologist and member of the Association of American Physicians and Surgeons (AAPS).

Dr. Marilyn Singleton ran for Congress in California’s 13th District in 2012, fighting to give its 700,000 citizens the right to control their own lives.

While still working in the operating room, Dr. Marilyn Singleton attended UC Berkeley Law School, focusing on constitutional law and administrative law. She also interned at the National Health Law Program and has practiced both insurance and health law.

Dr. Marilyn Singleton has taught specialized classes dealing with issues such as the recognition of elder abuse and constitutional law for non-lawyers. She also speaks out about her concerns with Obamacare, the apology law and death panels.

Congressional candidate Dr. Marilyn Singleton presented her views on challenging the political elite to physicians at the Association of American Physicians and Surgeons annual meeting in 2012.

Follow Dr. Marilyn Singleton on Twitter @MSingletonMDJD

More info about Dr. Marilyn Singleton

Featured, Health Policy, Healthcare Reform, Law, Politics

Legislative Update: AHCA edition

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In this edition of Legislative Update, Marilyn Singleton, MD, JD dissects AHCA. We know what’s in the House version, but what will the Senate come up with?

The American Health Care Act, H.R. 1628—passed by the House with one vote to spare on May 4—is a budget reconciliation bill that is part of the 2017 federal budget process. It lowers both government spending and tax revenue. Reconciliation status means it can avoid filibuster in the Senate and pass with a simple majority of votes.

Please be advised: the Senate has promised to change this bill and is already looking to side-step major provisions of AHCA, claiming they might not meet requirements for reconciliation. “What we have to do is build a consensus … to get to a compromise we can agree to,” stated Senate Majority Whip John Cornyn, a member of a 12-person Senate “working group” said to be developing an alternate bill.

Some argue that the bill was put together too quickly without conferring with stakeholders while Obamacare was drafted and discussed for over a year. Of course, I don’t recall the Obama administration contacting AAPS for our opinion.

It seems to me, the Republicans have had a solid 6 years to horse-trade and come up with something that should have been ready on day one for a vote.

There were not enough votes to pass the bill at the end of March. The centrist Tuesday Group and the Freedom Caucus kissed and made up with the MacArthur Amendment and the Upton Amendment at the end of April. The MacArthur amendment allows states to apply for a waiver allowing insurers to further increase the ratio of premiums charged to enrollees in their 50s and early 60s versus younger enrollees. It also allows states to waive essential health benefits and certain sections of the community rating program that would permit insurers to charge people significantly more if they have a pre-existing condition, as long as the state creates a program to ameliorate the costs to enrollees and/or insurers. The Upton Amendment adds an additional $8 billion in assistance to lower costs for enrollees with pre-existing conditions.

The bill has equal opportunity opposition: AARP, AMA, American Hospital Association, Association of American Medical Colleges, among others. Additional critics include Heritage Action, the Cato Institute, Americans for Prosperity, FreedomWorks, Tea Party Patriots, MoveOn.org, and the Center for American Progress and many other liberal groups.

What Was “Repealed”

  • The AHCA eliminates (by reducing to $0) the individual mandate penalty for not having ACA-qualified “coverage.”
  • The AHCA reverses the ACA’s Medicaid expansion in 2020 (32 states opted in). Anyone enrolled prior to 2020 would stay enrolled.
  • The AHCA eliminates the ACA’s expanded required benefits mental health and addiction benefits under Medicaid.
  • The AHCA eliminates fines for large employers who don’t provide health plans
  • Under current law, state Medicaid programs are guaranteed federal matching funds for qualifying expenditures. The bill establishes targeted spending caps for each state, on federal funding for state Medicaid programs beginning in 2020 based on 2016 Medicaid expenditures. States could also choose a block grant and institute work requirements for Medicaid enrollees.
  • Small business tax credits end in 2020.
  • Health insurance premium limits are adjusted. Under the ACA, older persons could be changed up to three times that of younger folks. This is changed to to five times.
  • The platinum, silver and bronze levels are eliminated.
  • Taxes are eliminated: 3.8% tax on investment income and 0.9% additional Medicare tax on high income folks. Also, the 10% tanning services and 2.3% medical device tax.
  • The 40% Cadillac tax is suspended until 2024.
  • The threshold for receiving a tax deduction form medical expenses is returned to 7.5% of adjusted gross income from the ACA’s 10%.

Added by last minute amendment:

  • States may opt-out of providing the ACA’s essential health benefits. (This requirement was already dropped in the bill for Medicaid but not for the individual market.)
  • Pre-existing conditions: States may opt-out of requiring premiums to be the same for all people of the same age, so while individuals with pre-existing conditions must be offered health insurance there is no limit on the cost of that insurance. New funds would help lower premiums for these individuals.
  • States may opt-out of limiting premium differences based on age. The 3 to 1 limit is changed to 5:1 federally. States may apply for a waiver to choose a different ratio above 5:1.

Keepers

  • Guaranteed issue
  • The AHCA would keep the ACA’s requirement that dependents can stay on their parents’ plan until they are 26.
  • The ACA’s federal and state-run exchanges which listed individual and small business health insurance plans, would continue unchanged.
  • The AHCA would continue to provide subsidies for premiums that are based on income although the formula would be completely different and the subsidy would likely be much less for young, low-income Americans.
  • Although the individual mandate is reduced to $0 (essentially repealing it), the AHCA would instead impose a 30% surcharge when purchasing a policy after a lapse in coverage.

Expanded Benefits

  • Increased contributions to Health Savings Accounts. Increase annual tax free contribution limit to equal the limit on out-of-pocket cost sharing under qualified high deductible health plans ($6,550 for self only coverage, $13,100 for family coverage in 2017, indexed for inflation). – Tax penalty for HSA withdrawals used for non-qualified expenses is reduced from 20% to 10%.
  • Federal subsidies can assist with premiums for insurance purchased off the exchanges (but not grandfathered plans).
  • $123 Billion authorized for various state-based initiatives to “to improve affordability and access to coverage.”

Additional resources:

Full text bill (126 pages) and amendments: https://rules.house.gov/bill/115/hr-1628

Congressional Research Service Summary: https://www.govtrack.us/congress/bills/115/hr1628/summary#libraryofcongress

Kaiser Family Foundation Summary: http://files.kff.org/attachment/Proposals-to-Replace-the-Affordable-Care-Act-Summary-of-the-American-Health-Care-Act

CBO Scoring: https://www.cbo.gov/publication/52486

AAPS White Paper on Repeal and Replace: http://aapsonline.org/white-paper-repealreplacement-affordable-care-act/

Health Policy, Healthcare Reform, Law, Politics

Legislative Update – March 15, 2017

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“Beware of the Ides of March as both parties slowly kill us all off!” ~Marilyn Singleton, MD, JD reports on the latest battles in health care legislation on Capitol Hill.

Revisions to the ACA
Revisions to the ACA continued to pile in even as the “repeal and replace” was in progress. What was on their minds? These bills seem like an exercise in futility while negotiations over a major health care “system” overhaul are occurring. These revisions will likely be ignored while our congresspersons mull over the American Health Care Act (AHCA). At least these bills will be written when nothing happens to the ACA and we are still stuck with it.
I include some alternative bill to the American Health Care Act since they, like the AHCA, maintain provisions of the ACA.

 

The American Health Care Act (AHCA – working bill; no official bill yet)
The bill would repeal and replace various tax-related provisions of the ACA. Rep. Paul Ryan indicates that this bill is designed as the first phase of a three-step process. By focusing on taxes, the bill can be introduced using the reconciliation process. (Reconciliation allows for expedited consideration of certain tax, spending, and debt limit legislation. In the Senate, reconciliation bills aren’t subject to filibuster and the scope of amendments is limited). This summary is based on the House Ways and Means Committee majority summary. The bulk of the proposed bill repeals and replaces health-related tax policy:

(1) Recapture Excess Advance Payments Of Premium Tax Credits
The amount a household is required to pay towards their premiums is based on income. If a household’s income increases during the tax year, excess premium tax credits may result. Under the ACA, for households with incomes less than 400 percent of the federal poverty level there are certain limits on the amount the household is required to repay the federal government for the excess premium tax credits. For tax years 2018 and 2019, any individual who was overpaid in premium tax credits must repay the entire excess amount, regardless of income.

(2) Additional Modifications To Premium Tax Credit
Under the ACA, qualified health plans must meet certain requirements for households to be eligible for the premium tax credit. This section: (a) amends those requirements to make available premium tax credits for the purchase of “catastrophic-only” qualified health plans and certain qualified plans not offered through an Exchange; (b) prohibits premium tax credits from being used to purchase plans that offer elective abortion coverage; (c) revises the schedule under which an individual’s or family’s share of premiums is determined by adjusting for household income and the age of the individual or family members.

(3) Premium Tax Credit
This section repeals the ACA’s premium tax credit beginning in 2020.

(4) Small Business Tax Credit
This section repeals the ACA’s small business tax credit beginning in 2020. Between 2018 and 2020, under the proposal, the small business tax credit generally is not available with respect to a qualified health plan that provides coverage relating to elective abortions.

(5) Individual Mandate
This section would reduce the penalty to zero for failure to maintain minimum essential coverage. The bill would provide retroactive relief to those impacted by the penalty in 2016.

(6) Employer Mandate
This section would reduce the penalty to zero for failure to provide minimum essential coverage. The bill would provide retroactive relief to those impacted by the penalty in 2016.

(7) Repeal Of The Tax On Employee Health Insurance Premiums And Health Plan Benefits
The ACA imposed a 40 percent excise tax on high cost employer-sponsored health coverage (“Cadillac plans”). The tax will go into effect in 2020. This section changes the effective date of the tax until December 31, 2024.

(8) Repeal Of The Tax On Over-The-Counter Medications
This section repeals the ACA exclusion of over-the-counter medications from the definition of qualified medical expenses.

(9) Repeal Of Increase Of Tax On Health Savings Accounts
Distributions from an HSA or Archer MSA that are used for qualified medical expenses are excludible from gross income. Distributions that are not used for qualified medical expenses are includible in income and are generally subject to an additional tax. The ACA increased the percentage of the tax on distributions that are not used for qualified medical expenses to 20 percent. This section lowers the rate to pre-ACA percentages, effective for distributions after December 31, 2017.

(10) Repeal Of Limitations On Contributions To Flexible Savings Accounts
This section repeals the ACA limits the amount an employer or individual may contribute to a health Flexible Spending Account (FSA) to $2,500, indexed for cost-of-living adjustments, effective December 31, 2017.

(11) Repeal Of Medical Device Tax
This section repeals the ACA’s 2.3 percent medical device excise tax beginning after December 31, 2017.

(12) Repeal Of Elimination Of Deduction For Expenses Allocable To Medicare Part D Subsidy
This section re-instates the pre-ACA business-expense deduction for retiree prescription drug costs without reduction by the amount of any federal subsidy, beginning after December 31, 2017.

(13) Repeal Of Increase In Income Threshold For Medical Expense Deduction
The ACA increased the AGI percentage threshold from 7.5 percent to 10 percent if the taxpayer or spouse was aged 65 or older. This section restores the pre-ACA AGI percentage threshold to 7.5-percent for all taxpayers beginning in 2018 and extends the special rule for those aged 65 or older through this year.

(14) Repeal of Medicare Tax Increase
This section repeals the ACA’s Medicare Hospital Insurance (HI) surtax based on income at a rate equal to 0.9 percent of an employee’s wages or a self-employed individual’s self-employment income, beginning in 2018.

(15) NEW: Refundable Tax Credit For Health Insurance
This section creates an advanceable, refundable tax credit for the purchase of state-approved, major medical health insurance and unsubsidized COBRA coverage. To be eligible, generally, an individual must not have access to government health insurance programs or an offer from any employer; and be a citizen, national or qualified alien of the United States, and not incarcerated. The credits are adjusted by age, increasing from $2,000 for those under age 30 to $4,000 to those over age 60. The credits are additive for a family and capped at $14,000.

(16) Increase Maximum Contribution Limit To Health Savings Accounts
This section increases the basic limit on aggregate Health Savings Account contributions for a year to equal the maximum on the sum of the annual deductible and out-of-pocket expenses permitted under a high deductible health plan. Thus, the basic limit will be at least $6,550 in the case of self-only coverage and $13,100 in the case of family coverage beginning in 2018.

(17) Allow Both Spouses To Make Catch-Up Contributions
This section would effectively allow both spouses to make catch-up contributions to one HSA beginning in 2018.

(18) Special Rule for Certain Medical Expenses Incurred Before Establishment of HSA
This section sets forth certain circumstances under which HSA withdrawals can be used to pay qualified medical expenses incurred before the HSA was established. Starting in 2018, if an HSA is established during the 60-day period beginning on the date that an individual’s coverage under a high deductible health plan begins, then the HSA is treated as having been established on the date coverage under the high deductible health plan begins for purposes of determining if an expense incurred is a qualified medical expense.

Other Provisions
*Repeal of ACA’s 10% indoor Tanning Tax, beginning 2018.

*Repeal Of ACA’s Net Investment Tax
This section repeals the ACA’s 3.8% net investment tax on individuals, estates, and trusts with incomes above certain amounts, starting in 2018.

*Remuneration From Certain Insurers – While this marks a return to free capitalism, it is also a gift to the insurers who appear to be driving all health care “reform.”
Generally, employers may deduct the remuneration paid to employees as “ordinary and necessary” business expenses. The ACA added a limitation for certain health insurance providers that exceeds $500,000 paid to an officer, director, or employee. This section repeals the limit on the deduction of a covered health insurance provider for compensation attributable to services performed by an applicable individual starting in 2018.

*Repeal of Tax on Prescription Medications
This section repeals the ACA’s annual fee (tax) on brand pharmaceutical manufacturers such that the tax would not apply for years beginning after December 31, 2017.

*Repeal Of Health Insurance Tax
This section repeals the ACA’s annual fee (tax) on health insurers beginning after December 31, 2017.

Full text: http://www.foxnews.com/politics/interactive/2017/03/06/text-american-health-care-act/

 

Other ACA “Replacements”:

On January 23, 2017, S. 191, the Patient Freedom Act of 2017,(73 pages) was introduced by Sen. Bill Cassidy, MD (R-LA) and referred to the Senate Finance Committee. The legislation aims to shift the question of repeal to states by allowing them to continue to use the ACA as is or move to state-specific plans that rely on health savings accounts and decreased financial support from the federal government.

The bill eliminated from the ACA:
(1) the individual mandate, the employer mandate
(2) mandated benefit packages

The bill maintains the ACA’s:
(1) rules allowing children to stay on their parents’ health insurance plans until age 26
(2) preventing denial of coverage based upon pre-existing conditions
(3) prohibiting both annual and lifetime limits by health insurance companies.

Each state would have one of three choices:
(1) re-adopt the ACA on a state level,
(2) create a new state-designed plan with federal assistance but less money than the ACA provided, or
(3) create a new state-designed plan with no federal assistance at all.

An article in The Federalist, “4 Ways the Patient Freedom Act Is Worse Than Obamacare,” notes that the bill would expand taxpayer funding for abortions (by providing federal funding for states as a workaround to the ban on federally funding abortions), could increase total federal expenditures by increasing Medicaid funding even for states choosing not to expand the program, perpetuates government-mandated price controls, and creates a “big government” automatic enrollment program.

Full text: https://www.govtrack.us/congress/bills/115/s191/text.

 

On January 24, 2017, S. 222, the Obamacare Replacement Act (149 pages) was introduced by Sen. Rand Paul, MD (R-KY) and referred to the Senate Finance Committee. While the American Health Care Act is what is on the table, Rand Paul is fighting for his proposals. The basis for his proposals are personal freedom saving money for individuals and the federal government. But it does not repeal the ACA, leaves many taxes in place, and
The bill eliminates many of the parts of the ACA:
(1) the employer mandate, the individual mandate, Medicaid expansion.
(2) most of federal regulations that mandate what health plans are required to cover, mandatory birth control coverage, community rating.
(3) ban on insurer discrimination on the basis of a patient’s preexisting condition. Sen. Paul’s bill returns to pre-ACA rules from HIPAA which provides that individuals cannot be denied eligibility or benefits based on certain “health factors” when enrolling in a health plan. Additionally, they may not be charged more than similarly situated individuals based on any health factors.
The bill adds new provisions which would:
(3) allow insurance to be sold across state lines
(4) encourages health savings accounts (HSAs) by providing a tax credit of up to $5,000 (vs the current $3,400 per individual).
(5)provide uncapped deduction for individual-provided health insurance.
(5) provide refundable tax credit for health insurance premiums, but the refundable portion of the credit only applies up to the limit of an individual’s payroll taxes paid.
(6) allow the IRS to give doctors a tax deduction equal to the amount they would otherwise charge for charity care, up to 10 percent of a doctor’s income for the year.

Full text: https://www.govtrack.us/congress/bills/115/s222/text.

 

Repeal the IPAB
On February 1, 2017, S. 260, the Protecting Seniors’ Access to Medicare Act of 2017, was introduced by Sen. John Cornyn (R-TX) and referred to the Senate Finance Committee. This bill repeals the Independent Payment Advisory Board (IPAB) and any provision of law amended by such sections is hereby restored as if such sections had not been enacted into law.
Full text: https://www.govtrack.us/congress/bills/115/s260/text.

On February 1, 2017, S. 251, the Protecting Medicare from Executive Action Act of 2017, was introduced by Sen. Ron Wyden (D-OR) and referred to the Senate Finance Committee. The bill repeals section 3403 of the Affordable Care Act – the IPAB – and any provision of law amended by such sections is hereby restored as if such sections had not been enacted into law.

Full text: https://www.govtrack.us/congress/bills/115/s251/text.

 

Repeal of Other Tax-Related ACA Provisions
On February 14, 2017, H.R. 1051, the Halt Tax Increases on the Middle Class and Seniors Act, was introduced by Rep. Martha McSally (R-AZ) and referred to the House Ways and Means Committee. The bill would amend the Internal Revenue Code to roll back the increased income threshold for determining the amount of the tax deduction for medical expenses. Currently, individual taxpayers may only deduct those medical expenses that exceed 10% of their adjusted gross income. This bill reduces that percentage to 7.5%.

Full text: https://www.govtrack.us/congress/bills/115/hr1051/text.

On February 16, 2017, H.R. 1150, Tanning Tax Repeal Act of 2017, was introduced by Rep. George Holding (R-NC) and referred to the House Ways and Means Committee. The bill would amend the Internal Revenue Code to repeal the 10% excise tax on indoor tanning services.

Full text: https://www.govtrack.us/congress/bills/115/hr1150/text.

On February 17, 2017, H.R. 1204, the Responsible Additions and Increases to Sustain Employee Health Benefits Act of 2017, was introduced by Rep, Steve Stivers (R-OH) and referred to the House Ways and Means Committee. The bill would amend the Internal Revenue Code, with respect to the tax exclusion for distributions from health flexible spending arrangements provided under a cafeteria plan, to: (1) increase the annual limit on employee salary reduction contributions to $5,000, with an additional $500 for each additional employee dependent above two dependents that has not been taken into account by another person for the year; (2) revise the adjustment for inflation after 2017; and (3) allow a carryforward into the next year for unused amounts in such plans.

Full text: https://www.govtrack.us/congress/bills/115/hr1204/text.

 

Expansion of Religious Exemptions
On February 17, 2017, H.R. 1201, the Equitable Access to Care and Health Act (EACH Act), was introduced by Rep. Rodney Davis (R-IL) and referred to the House Ways and Means Committee. The bill would amend the Internal Revenue Code to expand the religious conscience exemption under the Patient Protection and Affordable Care Act to exempt individuals who rely solely on a religious method of healing and for whom the acceptance of medical health services would be inconsistent with their religious beliefs from the requirement to purchase and maintain minimum essential health care coverage.

Full text: https://www.govtrack.us/congress/bills/115/hr1201/text.

 

Physician Practice Issues

On February 2, 2017, S. 284, the End Surprise Billing Act of 2017, was introduced by Sen. Sherrod Brown (D-OH) and referred to the Senate Finance Committee. Its sister bill, H.R. 817, introduced by Rep. Lloyd Doggett (D-TX). This bill amends the Medicare law to require a critical access hospital or other hospital to comply, as a condition of participation in Medicare, with certain requirements related to billing for out-of-network services. The justification for the bill is that the ACA does not limit what emergency-care providers may balance bill patients beyond the amounts that health plans allow. To fully protect patients, federal law should prohibit any balance billing by providers for emergency services, also including ambulance services. In addition, a comprehensive solution should cover the totality of a patient’s treatment after coming to the emergency room, including any care during an ensuing hospital admission (either at the same or a transfer hospital). This requirement could be imposed, similar to EMTALA, as a condition of providers participating in Medicare.

With respect to an individual who has health benefits coverage and is seeking services, a hospital must provide notice to individuals with any type of health insurance as to:
(1) whether the hospital, or any of the providers furnishing services to the individual at the hospital, is not within the health care provider network or otherwise a participating provider with respect to the individual’s health care coverage; and
(2) if so, the estimated out-of-pocket costs of the services to the individual.
At least 24 hours prior to providing those services, the hospital must document that the individual: (1) has been provided with the required notice, and (2) consents to be furnished with the services and charged an amount approximate to the estimate provided. Otherwise, the hospital may not charge the individual more than the individual would have been required to pay if the services had been furnished by an in-network or participating provider.
With respect to such an individual who is seeking same-day emergency services, a hospital may not charge more than the individual would be required to pay for such services furnished by an in-network or participating provider.

Full text (Senate): https://www.govtrack.us/congress/bills/115/s284/text.
Full text (House): https://www.govtrack.us/congress/bills/115/hr817/text.

Medical Education
On February 16, 2017, H.R. 1167, Enhancing Opportunities for Medical Doctors Act of 2017 was introduced by Rep. Mia Love and referred to the House Energy and Commerce and Ways and Means Committees. The bill would amend the Medicare law to redistribute unused residency positions for which graduate medical education costs are paid under Medicare. Specifically, the Centers for Medicare & Medicaid Services must: (1) reduce a hospital’s resident limit by a specified amount if the hospital has unused residency positions and is not a rural hospital with fewer than 250 acute care inpatient beds, and (2) increase the resident limit for each qualifying hospital that applies for an increase. In aggregate, the number of increased positions shall equal the number of reduced positions.

Full text: https://www.govtrack.us/congress/bills/115/hr1167/text.

Use of Unapproved Medical Products by Patients with a Terminal Illness
On January 24, 2017, S. 204, the Trickett Wendler Right to Try Act of 2017, was introduced by Sen. Ron Johnson (R-WI) and referred to the Senate Health, Education, Labor, and Pensions Committee. This bill requires the federal government to allow unrestricted manufacturing, distribution, prescribing, and dispensing of experimental drugs, biological products, and medical devices that are: (1) intended to treat a patient who has been diagnosed with a terminal illness, and (2) authorized by state law. The federal government must allow unrestricted possession and use of such treatments by patients certified by a physician as having exhausted all other treatment options.
A manufacturer, distributor, prescriber, dispenser, possessor, or user of such a treatment has no liability regarding the treatment.

The outcome of manufacture, distribution, prescribing, dispensing, possession, or use of such a treatment may not be used by a federal agency to adversely impact review or approval of the treatment.

The treatment must: (1) have successfully completed a phase 1 (initial, small scale) clinical trial; (2) remain under investigation in a clinical trial approved by the Food and Drug Administration; and (3) not be approved, licensed, or cleared for sale under the Federal Food, Drug, or Cosmetic Act or the Public Health Service Act.

Full text: https://www.govtrack.us/congress/bills/115/s204/text.

Expansion of duties of Mid-levels
On February 16, 2017, H.R. 1155 was introduced by Rep. Lynn Jenkins (R-KS) ad referred to the House Energy and Commerce and on Ways and Means Committees. The bill would amend the Medicare law to allow physician assistants, nurse practitioners, and clinical nurse specialists to supervise cardiac, intensive cardiac, and pulmonary rehabilitation programs.

Full text: https://www.govtrack.us/congress/bills/115/hr1155/text.

Will Physicians Be On the List?
On February 15, 2017, H.J. Res. 42, introduced by Kevin Brady (R-TX), passed the House (236 – 189). The resolution disapproves and nullifies the rule issued by the Department of Labor on August 1, 2016, defining the occupations eligible for drug testing of unemployment compensation applicants. “Occupations” listed by the Department that may regularly require drug testing are only jobs that require carrying a firearm, aviation flight crews, air traffic controllers, commercial drivers, railroad crews, pipeline crew members, and commercial maritime crew members. This list is considered too narrow and the rule generally considered too prescriptive and overly constraining of states.
Full text: https://www.govtrack.us/congress/bills/115/hjres42/text.

On February 16, 2017, S.J. Res. 23, a joint resolution disapproving the rule submitted by the Department of Labor relating to drug testing of unemployment compensation applications, was introduced by Sen. Ted Cruz (R-TX) and referred to the Senate Committee on Finance Committee.

Full text: https://www.govtrack.us/congress/bills/115/sjres23/text.

 

Abortion-Related Bills

On January 30, 2017, S. 241, the Protect Funding for Women’s Health Care Act, was introduced by Sen. Joni Ernst (R-IA) and referred to the Senate Health, Education, Labor, and Pensions Committee. This bill prohibits federal funding of Planned Parenthood Federation of America or its affiliates, subsidiaries, successors, or clinics.

Full text: https://www.govtrack.us/congress/bills/115/s241/text.

On January 31, 2017, H.R. 771, the Equal Access to Abortion Coverage in Health Insurance (EACH Woman) Act of 2017, was introduced by Rep. Barbara Lee (D-CA) and referred to House Energy and Commerce and Oversight and Government Reform Committees. This bill is in response to H.R. 7, the No Taxpayer Funding for Abortion and Abortion Insurance Full Disclosure Act passed by the House in February 2017. That bill made permanent the ban of federal funding for abortions as set forth in the Hyde Amendment which Congress has passed every year since 1976.

This bill, H.R. 771, requires the federal government: (1) to ensure coverage for abortion care in public health insurance programs including Medicaid, Medicare, and the Children’s Health Insurance Program (CHIP); (2) as an employer or health plan sponsor, to ensure coverage for abortion care for participants and beneficiaries; and (3) as a provider of health services, to ensure that abortion care is made available to individuals who are eligible to receive services.
The federal government may not prohibit, restrict, or otherwise inhibit insurance coverage of abortion care by state or local governments or by private health plans. State and local governments may not prohibit, restrict, or otherwise inhibit insurance coverage of abortion care by private health plans.

Full text: https://www.govtrack.us/congress/bills/115/hr771/text.

Health Policy, Healthcare Reform, Law, Politics

They’re Baaack! Legislative Update – October 7, 2016

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Marilyn Singleton, MD, JD summarizes recent healthcare-related legislative activity on Capitol Hill.

It was a slow summer as our Congresspersons took their highly coveted 7-week vacation.

Even as premiums skyrocket and ACA co-ops fail, health care reform has been below the fold during much of this presidential campaign.

Thanks to Bill Clinton, the ACA is gaining the attention it deserves. The former president while shilling for his wife in Flint, Michigan, called Obamacare “the craziest thing in the world.”  He said, “you’ve got this crazy system where all of a sudden 25 million more people have health care and then the people who are out there busting it, sometimes 60 hours a week, wind up with their premiums doubled and their coverage cut in half.”

He continued, “on the other hand, the current system works fine if you’re eligible for Medicaid, if you’re a lower-income working person; if you’re already on Medicare, or if you get enough subsidies on a modest income that you can afford your health care. . . But the people that are getting killed in this deal are small business people and individuals who make just a little too much to get any of these subsidies.”

For example, the largest approved premium hikes on individual market plans for 2017 are: (1) Tennessee, Blue Cross, Blue Shield, 62%; (2) Kentucky, Golden Rule Insurance Co., 47%; (3) Iowa, Wellmark, 42%; (4) Nebraska, Medica, 39%; (5) Maryland, CareFirst, Blue Cross, Blue Shield, 31%.

 

More Fixes to the ACA

The CO-OP Consumer Protection Act, H.R. 954 which was introduced by Rep. Adrian Smith (R-NE) in February 2016, passed the House on September 22nd. The legislation was in response to the fact that only 6 of the 23 ACA Co-ops have not failed. This bill temporarily exempts from penalties for failing to purchase and maintain minimum essential health care coverage (i.e., individual mandate penalty) individuals whose coverage under a plan offered by a qualified nonprofit health insurance issuer receiving funds through the Consumer Operated and Oriented Plan program was terminated or otherwise discontinued.

Full text: https://www.govtrack.us/congress/bills/114/hr954/text.

 

On September 13, 2016, H.R. 6019, the Relief from Obamacare Mandate Act of 2016 was introduced by Rep. Todd Young (R-IN) and referred to the House Ways and Means Committee. The bill would to provide an exemption to the individual mandate to maintain health coverage for certain individuals whose premium has increased by more than 10 percent.

Full text: https://www.govtrack.us/congress/bills/114/hr6019/text.

 

On September 14, 2016, S. 3322 was introduced by Sen. Jeff Flake (R-AZ) and referred to the Senate Finance Committee. The bill would modify the ACA’s hardship exemption to the individual mandate to maintain health coverage for certain individuals residing in service areas with no health insurance issuers offering plans on an Exchange.

Full text: https://www.govtrack.us/congress/bills/114/s3322/text.

 

On September 15, 2016, H.R. 6049, the Protection from Insurance Exchange Monopolies Act was introduced by Rep. Joseph Heck (R-NV) and referred to the House Ways and Means Committee. This bill amends the Internal Revenue Code to exempt from the requirement to maintain minimum essential health coverage any individual residing in a county with fewer than two health insurance issuers offering qualified health plans on an exchange.

Full text: https://www.govtrack.us/congress/bills/114/hr6049/text.

 

On September 19, 2016, H.R. 6067, the Relief from Obamacare Exchange Failures Act was introduced by Rep. Diane Black (R-TN) and referred to the House Ways and Means Committee. The bill would amend the Internal Revenue Code to provide an exemption from the individual mandate for certain individuals without access to Exchange coverage.

Full text: https://www.govtrack.us/congress/bills/114/hr6067/text.

 

On July 6, 2016, H.R. 1270, the Restoring Access to Medication Act of 2015 was passed in the House and was sent to the Senate for consideration. This bill repeals provisions of the Internal Revenue Code, added by the Patient Protection and Affordable Care Act, that limit payments for medications from health savings accounts, medical savings accounts, and health flexible spending arrangements to only prescription drugs or insulin (thus allowing distributions from such accounts for over-the-counter drugs).

Full text: https://www.govtrack.us/congress/bills/114/hr1270/text.

 

On May 25, 2016, H.R. 5324, Health Savings Account Expansion Act of 2016 was introduced by Rep. Dave Brat (R-VA) and referred to the House Ways and Means Committee. This bill amends the Internal Revenue Code to modify the requirements for health savings accounts (HSAs) to:

increase the maximum contribution amounts, permit the use of HSAs to pay health insurance premiums and direct primary care expenses, repeal the ACA’s restriction on using HSAs for over-the-counter medications, eliminate the requirement that a participant in an HSA be enrolled in a high deductible health care plan, and decrease the additional tax for HSA distributions not used for qualified medical expenses.

Full text (House): https://www.govtrack.us/congress/bills/114/hr5324/text.
Full text (identical Senate): https://www.govtrack.us/congress/bills/114/s2980/text.

 

On Sep 15, 2016 Senate Resolution 561, a resolution supporting efforts to increase competition and accountability in the health insurance marketplace, and to extend accessible, quality, affordable health coverage to every American through the choice of a public option, was introduced by Sen. Jeff Merkley (D-OR) and referred to the Senate Health, Education, Labor, and Pensions Committee.

This resolution expresses support for efforts to build on the ACA by adding the public option. The resolution posits that the public option would (1) lead to increased competition and reduced premiums; (2) cut wasteful spending on administration, marketing, and executive pay; and (3) ensure that consumers have the affordable choices they deserve; and (4) save taxpayers billions of dollars according to the Congressional Budget Office.

Full text: https://www.govtrack.us/congress/bills/114/sres561/text

 

Tax Relief for Consumers

On Jun 29, 2016, S. 3111, the Seniors Tax Hike Prevention Act of 2016 was introduced by Sen. Rob Portman (R-OH) and referred to the Senate Finance Committee. This bill amends the Internal Revenue Code to extend through 2018, the rule that permits individuals who are 65 and older to deduct certain medical expenses that exceed 7.5% of adjusted gross income. (Under current law, the rule that reduces the 10% threshold for the medical expense deduction to 7.5% if a taxpayer or a taxpayer’s spouse is 65 or older expires at the end of 2016.)

Full text: https://www.govtrack.us/congress/bills/114/s3111/text.

 

Support for Direct Pay Practices

On September 13, 2016, H.R. 6015, the Primary Care Enhancement Act was introduced by Rep. Erik Paulson (R-MN) and referred to the House Ways and Means Committee. (Identical bill in Senate, S 1989). This bill amends the Internal Revenue Code to: (1) permit an individual to pay primary care service arrangement costs from a health savings account; (2) allow an eligible taxpayer enrolled in a high-deductible health plan to take a tax deduction for cash paid into a health savings account, even if the taxpayer is simultaneously enrolled in a primary care service arrangement; and (3) for purposes of certain tax-deductible expenses for medical care, expand the definition of “medical care” to include periodic provider fees and pre-paid services. A “primary care service arrangement” is an exchange of ongoing primary care services for a fixed periodic fee which is not billed to any third party on a fee-for-service basis.

The bill also amends title XI of the Social Security Act to require the Center for Medicare and Medicaid Innovation (CMI) to test a primary care medical home model for payment and service delivery. Under this type of model, qualified direct primary care medical home practices are reimbursed a periodic fee for serving Medicare enrollees. In selecting qualified direct primary care medical home practices to participate, CMI shall give priority to practices seeking to enroll dual-eligible individuals.

Full text House version: https://www.govtrack.us/congress/bills/114/hr6015/text.
Full text Senate version: https://www.govtrack.us/congress/bills/114/s1989/text.

 

Pro-Physician Volunteer Legislation

On June 27, 2016, S. 3101, the Good Samaritan Health Professionals Act of 2016 was introduced by Sen. Bill Cassidy (R-LA) and referred to the Senate Health, Education, Labor, and Pensions Committee. This bill amends the Public Health Service Act to shield a health care professional from liability under federal or state law for harm caused by any act or omission if: (1) the professional is serving as a volunteer in response to a disaster; and (2) the act or omission occurs during the period of the disaster, in the professional’s capacity as a volunteer, and in a good faith belief that the individual being treated is in need of health care services.

This protection from liability does not apply if: (1) the harm was caused by an act or omission constituting willful or criminal misconduct, gross negligence, reckless misconduct, or a conscious flagrant indifference to the rights or safety of the individual harmed; or (2) the professional rendered the health care services under the influence of alcohol or an intoxicating drug.

Full text: https://www.govtrack.us/congress/bills/114/s3101/text

 

More Control Over Physicians as Part of the Opiate Wars

On July 13, 2016, S. 3209, the Prescription Drug Monitoring Act of 2016 was introduced by Sen. Amy Klobuchar (D-MN) and referred to the Senate Health, Education, Labor, and Pensions Committee. The bill would require the use of prescription drug monitoring programs and to facilitate information sharing among States.

Full text: https://www.govtrack.us/congress/bills/114/s3209/text.

 

Legalized Physician Assisted Suicide Is On the March

Attempting to join Washington, Oregon, Vermont, Montana, California, on October 4, 2016, a Washington, D.C. city council panel voted 3-2 to advance a bill allowing physician-assisted suicide. One of the dissenters said she feared low-income people who have less access to health care would be pushed to end their lives early. Another felt this should be done through a ballot initiative to give voters their say.

 

And Why Do We Need Laws to Mandate Administrative Common Sense

On September 22, 2016, H.R. 5320, the Social Security Must Avert Identity Loss (MAIL) Act of 2016 passed the House by 414-0. This bill directs the Social Security Administration to ensure that no document it sends by mail includes a complete Social Security account number unless necessary.

Full text: https://www.govtrack.us/congress/bills/114/hr5320/text.

 

On July 14, 2016, H.R. 5880 was introduced by Rep. Cedric Richmond (D-LA) and referred to the House Ways and Means Committee. This bill directs the Department of Health and Human Services to establish cost-effective procedures to ensure that a Social Security account number (or a derivative) is not displayed, coded, or embedded on Medicare cards. If you remember, 20 years ago HIPAA mandated that insurance cards would not have Social Security numbers, but Medicare could not figure out how to do it.

Full text: https://www.govtrack.us/congress/bills/114/hr5880/text.

 

On September 13, 2016, H.R. 6011, the ACA Premium Verification Act, was introduced by Rep. Gus Bilirakis (R-FL) and referred to the House Energy and Commerce and Ways and Means Committees. To require that the Centers for Medicare & Medicaid Services has in place adequate verification procedures to ensure that advance payments under the Patient Protection and Affordable Care Act are made for only enrollees under qualified health plans who have paid their premiums

Full text: https://www.govtrack.us/congress/bills/114/hr6011/text.

Health Policy, Healthcare Reform, Law, Medicine, Politics

Jonathan Gruber – Stupidity, Lies, and Videotape

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By Marilyn M. Singleton, MD, JD

Lies and promises have been a staple of politics since its inception. As Plato observed, “propaganda, that is, ‘enticing people into a change of opinion by promises of pleasure’ and deceit always go together.”

ObamaCare’s empty promises have become not-so-funny household jokes: health law negotiations would be live on C-SPAN, if you like your doctor you can keep your doctor, the law will not add a single dime to the deficits, the average family will save $2,500 on their premiums, and on and on and on. Now the deceit has been exposed.

My heartfelt thanks go to Jonathan Gruber, Ph.D., MIT economics professor and a developer of the Affordable Care Act for speaking the ugly truth. The miracle of the internet has provided undeniable proof that the ACA was a scam perpetrated on the American public.

Gruber’s speeches in various venues confirm what many of us already knew: the ACA is a flawed, unreadable, misleading bill that garnered support based on propaganda and clever but false talking points.

Gruber’s Washington University of St. Louis lecture on October 4, 2013 to college students was a real eye-opener. In discussing how subsidies were critical to the success of health reform, Gruber revealed, “the dirty secret” that RomneyCare was paid for by the federal government to the tune of $450 million a year.

Since there was no other government coffer to tap to finance the ACA’s subsidies, multiple taxes are included in the law to generate revenue.

There is no question that we need a discussion and reform of inconsistencies in the tax code regarding employer versus individual payment of health insurance premiums. However, Gruber settled on imposing a 40 percent tax on high benefit Cadillac health plans.

Why? Because “Americans are too stupid to understand the difference” between a tax break and a tax.

Gruber crystallized his jaded views during a panel discussion at the Annual Health Economics Conference at the University of Pennsylvania’s Leonard Davis Institute of Health Economics on October 17, 2013 Gruber said,

This bill was written in a tortured way to make sure CBO did not score the mandate as taxes. If CBO scored the mandate as taxes, the bill dies… In terms of risk rated subsidies, if you had a law which made explicit healthy people pay in and sick people get money, it would not have passed…

Lack of transparency is a huge political advantage. And basically, call it the stupidity of the American voter or whatever, but basically that was really critical for the thing to pass.

Speaking at the University of Rhode Island on November 1, 2012, Gruber proudly said, “It’s a very clever, you know, basic exploitation of the lack of economic understanding of the American voter.” Gruber’s comments are reminiscent of another arrogant bully, Adolph Hitler: “The receptivity of the masses is very limited, their intelligence is small.”

And then the denials from the White House and the pro-ACA folks came in. House minority leader Nancy Pelosi said, “I don’t know who he is; he didn’t help write our bill.” However on November 5, 2009, she publicly referred to Gruber’s expertise while claiming the ACA would insure 36 million people and would bring down insurance rates.

President Obama dodged the question of whether he had met with Gruber by saying that Gruber was “some advisor who never worked on our staff.” His advice came with a $400,000 price tag.

In a June 13, 2012 PBS Frontline interview Gruber said, “I then worked with the Obama administration and Congress to help develop the Affordable Care Act, or Obamacare. . . The next time I see him [Obama] is summer 2009… We had a meeting in the Oval Office with several experts.” At the Washington University lecture, Gruber unambiguously stated, “I helped write the law.”

In Washington, D.C. truth has become a veritable unicorn. Brazen disrespect by elitist know-it-alls has become the norm. Let your congresspersons know you are not stupid. Ask them to repeal the ACA and support strategies that focus on patient choice and transparency of costs.

Dr. Marilyn SingletonDr. Marilyn M. Singleton, MD, JD is a board-certified anesthesiologist and member of the Association of American Physicians and Surgeons (AAPS).

Dr. Marilyn Singleton ran for Congress in California’s 13th District in 2012, fighting to give its 700,000 citizens the right to control their own lives.

While still working in the operating room, Dr. Marilyn Singleton attended UC Berkeley Law School, focusing on constitutional law and administrative law. She also interned at the National Health Law Program and has practiced both insurance and health law.

Dr. Marilyn Singleton has taught specialized classes dealing with issues such as the recognition of elder abuse and constitutional law for non-lawyers. She also speaks out about her concerns with Obamacare, the apology law and death panels.

Congressional candidate Dr. Marilyn Singleton presented her views on challenging the political elite to physicians at the Association of American Physicians and Surgeons annual meeting in 2012.

Follow Dr. Marilyn Singleton on Twitter @MSingletonMDJD

More info about Dr. Marilyn Singleton

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