Herb Schaunaman served from from 1973 to 1997 in the U.S. Air Force. He visits the current clinic for physicals and eye exams. He knows that other clinics across the country have had their problems handling veterans’ issues, but he doesn’t see that in Aberdeen, calling himself and his fellow vets fortunate.
“There’s a bunch of us that are real happy with the clinic,” Schaunaman said. “I can’t even think of an example where I’ve had a problem. The people have been super. I feel very comfortable there in person.”
He said there have been days he’s gone in and the waiting room has been nearly full, but he estimates he’s never waited longer than 15 minutes [Kelda J.L. Pharris, “New VA Clinic for Aberdeen in Preliminary Stages,” Aberdeen American News, 2017.09.09].
According to Pharris’s report, the Aberdeen VA clinic has seen a marked increase in patients in recent years. Visits increased from 2,190 in 2010 to 2,574 last year and this year have already reached 2,583.
Schaunaman is one of 2,679 veterans in Brown County who can get super, low-wait health care from Uncle Sam at the Aberdeen VA outpatient clinic. The clinic serves Brown and five other South Dakota counties with a veteran population of 4,516, plus probably a few hundred more in Dickey County across the border.
An eager reader sends me this CNBC article comparing Canadian and American taxes. The article includes this great chart showing that total per capita taxation in our two countries has remained close to the OECD average (that’s the 35 countries of the Organization for Economic Cooperation and Development).
Senator Marion Michael Rounds is hosting not one but two public meetings next week—Chamberlain Wednesday, August 16, 3:30 p.m. Central; Deadwood Thursday, August 17, 3:30 p.m. Mountain.
Instead of razzing Rounds for his craven cowardice before Il Duce, perhaps we should all thank him for changing course—maybe not 180°, but at least 90°—on the Affordable Care Act. Back in 2014 (when there was no chance it would actually happen), Rounds campaigned on his repeatedly promised to repeal ObamaCare. Now that his party controls the White House and Congress (though “control” exaggerates whatever Donald Trump thinks he’s doing in the Executive Branch, and the failure of three ACA repeals in one week in the Senate shows Republican control is more mathematical than effective), Rounds is promising constituents that he’ll protect huge components of ObamaCare, including the indestructible Tomi Lahren clause:
During these ongoing discussions, I will continue to advocate for the guaranteed renewal of coverage, portability of coverage, no lifetime limits, the permanent reauthorization of the Indian Health Care Improvement Act, no exclusions on pre-existing conditions if you are currently insured and the ability for children to remain on their families’ health care plans until the age of 26 [Senator M. Michael Rounds, e-mail to constituent, 2017.08.09].
Ah, we knew all along that Mike Rounds loves ObamaCare, right, Stace?
The goal should be to get people off of Medicaid. The goal should be to get people in jobs and working and raise their incomes so they can have their own insurance plans, and that’s really what the bill that I voted for does [Rep. Kristi Noem, transcribed from audio, “Noem Says People Did Not Get All the Facts on ACA Repeal,” Hub City Radio, 2017.07.31].
Senator Marion Michael Rounds, like all Trump enablers, had a really bad week. Senator Rounds caps off his really bad week by writing a really bad column. “Government-Run Health Care Does Not Work,” moans Senator Rounds, after seven months in which he and his Republican majority haven’t really worked.
If you read no other response to Senator Rounds’s sniveling horsehockey, read this:
No Democrat I know of is advocating “government-run health care.” No one is saying we should nationalize every hospital, make every doctor a government employee, and submit everyone’s diagnosis and treatment to a vote of Congress.
Following recent votes in the Senate, it’s clear that reforming our health care system is no easy task [Rounds, 2017.07.28].
You and your party sure thought health care reform was easy during seven years of shouting, “Repeal ObamaCare!” Only “following recent votes” does the difficulty of the task become clear to you? Unlike you and your Dear Leader, Barack Obama and the Democratic Party knew that health care could be so complicated, and when they took over in 2009, they spent over a year crafting a workable plan that is helping Americans today.
However, I remain committed to working with my colleagues toward a solution. We believe affordable health care is best achieved through a competitive, market-based system that allows for innovation, competition and optionality [Rounds, 2017.07.28].
“Competitive, market-based system” is at the core of every plan your party has put to a vote this year, and every one of those plans failed to win enough Republican votes to pass. “Competitive, market-based system” was also at the core of the part of the health care system prior to the ACA (and Medicaid, and Medicare) that failed to deliver coverage and care for poor, old, and sick Americans. Your “competitive, market-based system” does not work in health care.
In the quest to address Obamacare’s failures, some have been advocating for a single-payer, government-run health care system in which health care is provided for every single citizen for free and financed by taxes [Rounds, 2017.07.28].
Wrong—see above: government-paid, not government-run. Also, single-payer does not make care free. We all pay, through our taxes, just like we all pay now through insurance. We just pay a lot less.
Care is rationed, and citizens cede their health care decisions to a central government bureaucracy [Rounds, 2017.07.28].
Additionally, the cost makes it unsustainable for future generations. Either taxes – which are already too high – will continue to skyrocket in order to pay for universal care, our debt will spiral even further out of control, or both [Rounds, 2017.07.28].
Wrong—single-payer is cheaper than private insurance, so single-payer is more sustainable than the current system.
Our ability to make decisions for ourselves and our families will suffer. Bureaucrats don’t like taking advice [Rounds, 2017.07.28].
Do Grandma and Grandpa’s ability to make decisions suffer under Medicare? And how much advice do the profit-driven agents at your family insurance agency like to take from patients?
And we have many examples to substantiate this: In the U.S., California and Vermont recently tried to implement universal health care at the state level; both were abandoned as quickly as they were enacted due to its cost [Rounds, 2017.07.28].
However, a report by professors at the University of Massachusetts Amherst, commissioned in part by National Nurses United, estimated that after taking in the savings of single-payer, such as lower administrative costs and prices of pharmaceuticals, the actual cost of the plan would end up at around $331 billion. And, because 70 percent of the state’s current health care spending is covered by public programs like Medicare and Medi-Cal, California would only need to come up with $106 billion in new revenue, which researchers proposed could be done through two new taxes (a 2.3 percent gross receipts and sales tax), with exemptions for small businesses and tax credits to offset costs for low-income families. In exchange, nearly all of Californians’ medical expenses would be covered, doing away with premiums, copays, and deductibles [Clio Chang, “What Killed Single-Payer in California?” New Republic, 2017.06.30].
That exchange—taxes go up but premiums, copays, and deductibles go bye-bye—turns out to be a good deal:
But let’s say they’re right and the cost is closer to $400 billion overall, and that $100 billion in new revenues is needed (the high end of their $50b-$100b scale). That would pencil out to a monthly cost to each Californian of $208. ($100 billion / 40 million = $2500, which is the annual sum; divide that by 12 and you’re at $208.)
The average monthly premium for a Californian, as of 2016, was just under $600. For a household, it’s just above $1600.
In other words, even assuming the fiscally conservative analysis of the Senate Appropriations Committee and spreading the cost evenly across every Californian, single-payer would cost a third of what it currently costs Californians – just for health insurance alone. And unlike the present system, this would mean Californians don’t have to pay anything else beyond that $208/mo. No copays. No co-insurance. No out of pocket costs (at least within the Golden State). The ultimate savings would therefore be even greater. Californians could wind up paying just a quarter of what they pay now, if not less [“Single-Payer Would Cost a Third of Current Health Care Costs Per Family,” Health California, 2017.05.26].
…even [Governor Peter] Shumlin’s projections indicated that the plan would reduce Vermont’s overall health spending and lower costs for the 90% of Vermont families with household incomes under $150,000. Despite differing projections, all three studies showed that single payer was economically feasible [John E. McDonough, “The Demise Of Vermont’s Single-Payer Plan,” New England Journal of Medicine, 2015.04.23].
Now back to Senator Rounds:
In Canada, long wait times in their single-payer system are the norm.According to a Fraser Institute report, British Columbia residents have to wait up to six months just to get an MRI. Ontario’s own Ministry of Health and Long-Term Care states that residents may have to wait up to 11 months for hip replacement surgery [Rounds, 2017.07.28].
Sure, Canada’s wait times exceed the international average, but…
Overall, then, that’s about 0.13 percent of Canadians and 0.08 percent of Americans who flee their countries for health care. Those are pretty similar numbers. The only real difference is the reason for leaving. Canadians mostly cite wait times for elective surgery. Americans mostly cite the high cost of medical treatment [Kevin Drum, “Americans Flee America for Overseas Health Care Just Like Canadians,” Mother Jones, 2017.02.08].
Thus destroyed on the Canadian comparison, Senator Rounds flees to Europe:
Across Europe, where universal health care is prevalent, the cost to governments for this care is exploding, contributing to rising national debts. But instead of increasing taxes, which oftentimes are already over 50 percent of one’s income, governments are slowing down care to curb the cost, and innovation is stymied [Rounds, 2017.07.28].
While there are good employees in South Dakota at both agencies, nationwide these programs have been plagued with decades of long wait times, bureaucratic mismanagement, corruption and – most importantly – providing inadequate quality of care to Americans. In some cases, patients have even died waiting for care. Meanwhile, administrative costs have skyrocketed, wasting countless taxpayer dollars on paperwork instead of focusing on patient care [Rounds, 2017.07.28].
The IHS is chronically underfunded. It receives a set amount of money each year to take care of 2.2 million native people — no matter how much care they may need. On the reservation, IHS facilities often don’t have services that people elsewhere expect, such as emergency departments or MRI machines. And those limited facilities can be hours away by car. In town, reaching care is easier, but clinics also don’t have enough funding to meet all of the health needs of the community. And people can’t get the free medication they are entitled to through the IHS anywhere but an IHS facility.
…In 2013, Indian Health Service spending for patient health services was $2,849 a person, compared with $7,717 for health care spending nationally, according to a report from the National Congress of American Indians. That despite the fact that Native Americans typically have more serious health problems than the general public, including higher rates of diabetes, liver disease and unintentional injuries [Misha Friedman, “For Native Americans Health Care Is a Long, Hard Road Away,” NPR, 2016.04.13].
A set amount of money each year—that’s exactly what Senator Rounds wanted to do to Medicaid. Senator Rounds would have ignored the care the poor actually need, just as he ignores the care American Indians under IHS actually need.
I wholeheartedly believe that everyone should have access to quality health care if they want it. No one should be priced out of health insurance for themselves or their families [Rounds, 2017.07.28].
But forcing all Americans onto a costly, ineffective system that will reduce the quality of care and making them surrender all control of their health care decisions to the federal government is not the answer [Rounds, 2017.07.28].
The Republican plans you voted for, Senator Rounds, would have forced millions to pay more for insurance policies that cover less than their current plans. And no one under the ACA, the Canada Health Act, the UK National Health Service, or Australian Medicare has “surrender[ed] all control of their health care decisions to the federal government.” You’re not criticizing a real policy alternative here, Senator Rounds. You’re crying “Dragon!” to distract us from what you’re trying to burn down.
America is home to the best health care providers in the world, due to a free market system that allows for innovation and competition. Replacing Obamacare with a competitive, free-market system that actually controls costs, allows for innovation and focuses on the patient will allow us to continue our proud tradition of being the world’s health leader [Rounds, 2017.07.28].
Nothing in your three votes directly provided for more innovation, cost control, or focus on patients. Your votes just would have made health insurance unaffordable for millions of Americans.
* * *
That’s every word of Senator Rounds’s column on “government-run health care,” and darn near every word is wrong.
Unable to win on the facts, unable to persuade a majority in the Senate away from Barack Obama’s so-far successful Affordable Care Act, Senator Mike Rounds resorts to fiction to win an argument no one is making. We don’t want government-run health care. We just want a more efficient way to pay the bills. Toward that end, Senator Rounds has offered nothing of substance. Nothing.
Brown County Welfare Director Cliff Rhodes said losing the Affordable Care Act would mean the county would be faced with higher expenses for indigent claims.
“The deal is that under South Dakota law, in order for people to be eligible for hospitalization expenses through the county, one of the tests they have to meet is that they were unable to get insurance on their own,” Rhodes said. “If they were able to get insurance on their own, but they failed to do so, then they’re called indigent by design. If they’re indigent by design, they don’t quality for county assistance.”
Prior to the Affordable Care Act, Rhodes said, the county saw a lot of claims from people who couldn’t get coverage because they had pre-existing conditions. Now, he said, those folks qualify for insurance.
“So as a result, we denied a lot of the claims that we used to pay,” Rhodes said. “Depending on what happens with the repeal, if Obamacare is repealed, it will definitely have a big impact on the county budget” [Elisa Sand and Shannon Marvel, “GOP Vote Had No Effect on Health Coverage,” Aberdeen American News, 2017.07.27].
AAN had to bury that politically problematic statement at the end of the article, off the front page and out of the strangely momentary and diversionary headline. But Brown County’s explanation of where many of those millions (16 million under “skinny repeal“) of newly uninsured Americans will turn for coverage—local county services—should be on top of the stack of policy briefs Thune and Rounds should be reading this week.
Having captured McCain’s vote today on opening debate on repealing and replacing the Affordable Care Act in the Senate, President Trump now calls Senator McCain “a very brave man” who “made a tough trip” from Arizona to Washington, D.C.
Of course, practically, Thune and Rounds simply voted to forge ahead with debate on a bill that has not yet taken shape, that has not been through the normal committee process, and that has not been scored by the CBO or any other reliable agency to give us a reasonable estimate of the fiscal, economic, and public health impacts that their wild amendment mystery meat may produce.
This is not good policy-making. This is not humanitarian politics. This is not open, transparent government. The only guiding principle at work in this health care redeform process is Trumpublicans overriding mania for erasing anything with Barack Obama’s name on it.
University of Missouri law professor Frank O. Bowman continues to believe that the impeachment of Donald Trump is extremely unlikely. However, he acknowledges that the “humiliation” Republicans are suffering on health care increase the chance that Republican members of Congress could abandon a President who is, as Bowman says, neither a conservative, an evangelical Christian, or even a Republican, but only an opportunist who isn’t providing Republicans with the opportunity he promised:
What the healthcare debacle makes clear is that, in addition to his manifold personal deficiencies, Mr. Trump has no talent for crafting policy, jawboning legislative coalitions, or selling hard policy choices to the public. Instead, his performance throughout this year’s healthcare debate has been vintage bad Trump — uninformed and essentially uninterested in the actual substance of legislation, alternatively blustering, threatening, or fawning, always preening and self-absorbed, wildly inconsistent, and ultimately petulant. In the hard business of governance, he is anything but a “winner” [Frank O. Bowman, “The Republican Health Care Bill & Impeachment,” Impeachable Offenses? 2017.07.18].
Lacking the skills necessary to craft and pass health care policy isn’t an impeachable offense, but it does make it easier to Republicans to boot a Republican President who does something impeachable:
But Trump’s catastrophically inept performance in the healthcare debate may — and I emphasize may — be the first step toward a moment when, if presented with incontrovertible evidence that Mr. Trump has committed acts traditionally viewed as impeachable, Republicans will vote to rid themselves and the country of their accidental messiah [Bowman, 2017.07.18].
If Donald Trump can’t deliver politically for the Republicans who compromised their principles to elect him President, Republicans may rediscover their principles (and the Emoluments Clause) and make Mike Pence President.
Troy Jones takes the SDGOP spin blog mic and calls for primary challenges against Senators Capito, Collins, Flake, Lee, and Paul for their opposition to the GOP Senate bill:
From this day forward, they are Obamacare Republicans, liberal co-conspirators, and deserving of being aggressively opposed in primaries. I support the rumored Trump recruitment of primary opponents [Troy Jones, “‘If It Looks Like a Rat…,” Dakota War College, 2017.07.19].
Troy’s going to have a long wait: only Flake is up in 2018. Capito and Collins are up in 2020 (by which year Ladbrokes says there is a 48% chance that there will be no President Trump on whose coattails primary insurgents could ride); Lee and Paul are up in 2022.
Troy is also risking his loyal Republican Party member card by advocating primaries against incumbents. Consider NPR’s discussion of Trump’s push to primary Flake:
CORNISH: And then the other Arizona senator, Republican Jeff Flake, is also in the news today for different reasons. Politico reported that the White House has met with potential Republican primary challengers to run against Flake next year. How unusual is this?
DAVIS: It is highly unusual, and I can tell you Mitch McConnell does not support this kind of infighting. You know, a couple – earlier this year, a Trump-aligned super PAC also planned to target Nevada Republican Senator Dean Heller with an ad campaign. He’s undecided on the health care bill. And that made Senate Republicans very unhappy. At a meeting at the White House last month, they personally appealed to the president not to use these kind of hardball tactics. The group eventually did announce they weren’t going to run the ads.
I think you can expect a similar pushback in Flake’s defense. It is the official policy of the Senate Republican Campaign Committee to back incumbents in primaries. There are no exceptions to this rule. But I think with Flake, it’s also a bit personal. It’s not just about health care. As you recall, he was a very frequent critic of the president during the campaign [Audie Cornish and Susan Davis, “Sen. McCain’s Recovery from Blood Clot Surgery Threatens GOP Health Care Vote,” NPR: All Things Considered, 2017.07.17].
Rule #11 of the Republican National Committee prohibits the RNC from giving any support to any candidate in a primary. I’ll be interested to see if Troy’s comments draw any response from the Republican Senator who sponsors that blog and is required by his own rules to oppose any such call for a primary against an incumbent colleague.
Enacted seven years ago this month, the Affordable Care Act includes ten separate titles (similar to chapters in a book), each addressing a distinct subject matter. Four of the ACA’s titles involve Medicaid and commercial health insurance market reforms. These provisions comprise what is now commonly referred to as “ObamaCare.”
The ACA’s remaining six titles, which total 525 pages, address healthcare payment and delivery system reforms. It is here you will find the legislative mandates for the Medicare value-based purchasing programs (e.g., Hospital Readmission Reduction Program, Medicare Shared Savings Program), as well as funding for the Center for Medicare and Medicaid Innovation (CMMI).
The American Health Care Act deals almost exclusively with ObamaCare. With one exception, the bill does not repeal any provision in the ACA’s six titles addressing payment and delivery system reforms. The exception is Section 4002, which appropriates $2 billion each year to fund prevention and public health initiatives; that funding would end in 2018 under the proposed legislation. Other ACA appropriations, including funding for CMMI, remain untouched [Martie Ross, “The American Health Care Act: What’s Not There, and Why It Matters,” PYA Healthcare Blog, 2017.03.09].
The original GOP “repeal” plan left 524 of the ACA’s 974 pages untouched. That’s 53.8%. Each iteration of the GOP repeal effort has left in place more of the ACA. The Republican Congress is thus acknowledging that the bulk of the Affordable Care Act is good policy.
Among the Affordable Care Act’s successes is the Hospital Readmissions Reduction Program, a key part of the health care reforms President Barack Obama said we needed in 2009 to save money for Medicare:
Second, we need to use Medicare reimbursements to reduce preventable hospital readmissions. Right now, almost 20 percent of Medicare patients discharged from hospitals are readmitted within a month, often because they’re not getting the comprehensive care that they need. This puts people at risk; it drives up cost. By changing how Medicare reimburses hospitals, we can discourage them from acting in a way that boosts profits but drives up costs for everyone else. That will save us $25 billion over the next decade [President Barack Obama, address to American Medical Association, 2009.06.15].
The HRRP was established by a provision in the Affordable Care Act (ACA) requiring Medicare to reduce payments to hospitals with relatively high readmission rates for patients in traditional Medicare. Starting in 2013 as a permanent component of Medicare’s inpatient hospital payment system (i.e., not a temporary demonstration project), the HRRP applies to most acute care hospitals. Exempt hospitals include psychiatric, rehabilitation, long term care, children’s, cancer, and critical access hospitals, as well as all hospitals in Maryland.4
Under the HRRP, hospitals with readmission rates that exceed the national average are penalized by a reduction in payments across all of their Medicare admissions—not just those which resulted in readmissions. Before comparing a hospital’s readmission rate to the national average, CMS adjusts for certain demographic characteristics of both the patients being readmitted and each hospital’s patient population (such as age and illness severity). After these adjustments, CMS calculates a rate of “excess” readmissions, which links directly to the hospital’s readmission penalty—the greater each hospital’s rate of excess readmissions, the higher its penalty. Each year, CMS releases each hospital’s penalty for the upcoming year in the Federal Register and posts this information on its Medicare website [Cristina Boccuti and Giselle Casillas, “Aiming for Fewer Hospital U-Turns: The Medicare Hospital Readmission Reduction Program,” Kaiser Family Foundation, 2017.03.10].
After studying more than 6 million hospitalizations from over 5,000 hospitals over a seven-year period, we found no evidence that the reduction in hospital readmissions resulted in greater risk of dying for patients recently discharged.
In fact, hospitals that reduced readmissions the most were, if anything, more likely to reduce mortality after hospitalization. These findings held even for patients with heart failure, who had rising mortality over time as the least sick patients were increasingly treated as outpatients.
How did this happen? To lower readmissions, hospitals needed to better prepare patients and families for discharge and improve the integration and coordination of care from hospital to home. These interventions likely also reduced the risk of death.
The Hospital Readmission Reduction Program is Obamacare saving money and saving lives. That’s why Republicans who voted for clean ACA repeal under veto-certain Obama won’t vote for it under reckless Trump: they can’t really justify getting rid of a program that works.