Trumpcare=No Care

Via Kevin Drum, we see how well Donald Trump and Republicans have prepared for the elimination of Obamacare:

Congressional Republicans, despite pledging to quickly repeal the Affordable Care Act, are struggling with what parts of the law to roll back and how to lock up the votes they will need, particularly in the Senate, to push their ambitious plans.

Thirty-one states, including many with Republican governors, have expanded Medicaid through Obamacare and could lose billions of dollars if the law is cut back.

In Washington, Republicans are also struggling to figure out what to do with Obamacare insurance marketplaces that Republicans worked for years to dismantle. In a reversal, GOP leaders now are trying to figure out how to prevent their collapse, which would jeopardize coverage for millions more Americans.

Insurance experts, including leading industry officials, have repeatedly warned Republicans over the past several months that repealing the health law without a replacement risks destabilizing insurance markets and will push many insurers to simply stop selling health plans.

So, not only will the repeal likely lead to tens of millions of people losing their health insurance it might actually wreck the entire individual health insurance market. Things would be even worse than before the ACA was passed:

But when the time came to pay up for risk reduction in the Obamacare exchanges, Congress reneged and paid only 12% of what was owed to the insurers. So, on top of the fact that the companies had to bear the risk of unknown costs and utilization in the startup years, which turned out to be higher than they expected, insurers had to absorb legislative uncertainty of whether the rules would be rewritten.

And now comes the reality of the “repeal and replace” initiatives from the Republicans. If the uncertainty of this market was large before with the ACA, it is almost unknowable under whatever comes next. Thus the initial exit of some latecomers, including United Healthcare, and undercapitalized minor entrants, such as nonprofit co-ops, is almost certain to become a flood of firms leaving the exchanges. They have little choice since the risks are too large and the actuarially appropriate rates are still not obvious given the political turmoil and changing rules.

Some in Congress seem to think that passing the “repeal” part immediately but delaying its implementation for two or three years will somehow leave everything as it is now. But this naive notion misses the fact that the riskiness of the Obamacare individual insurance exchange markets will have been ramped up to such a level that continuing makes no sense.

How does the Trump administration plan to deal with this?

The budget legislation gives congressional committees until Jan. 27 — a blink of an eye for lawmakers — to write legislation repealing major parts of the health care law. Likely targets include the law’s tax penalties for people who don’t obtain insurance, its requirement that many companies cover workers and tax increases on higher-earning individuals and many health care firms.

Aware they have no chance of quickly agreeing on replacement legislation, Republicans plan to delay when their repeal would actually take effect. A range of 18 months to three years — perhaps longer — has been under discussion.

Trump has provided few specifics about how he would revamp the nation’s $3 trillion-a-year health care system. Steps he and congressional Republicans have mentioned include greater reliance on tax credits to help people afford coverage.

Republicans don’t want to abruptly end health care coverage for millions of voters who live in GOP-represented districts and states, or cause chaos in health care markets and prompt insurance companies to stop selling policies. So they are considering including provisions in their repeal bill to protect consumers and insurers during the transition period.

Sen. John Thune, R-S.D., a member of the GOP Senate leadership, said that could include money to temporarily continue helping people afford to buy coverage and language letting the Department of Health and Human Services help stabilize insurance markets.

A few things:

  • Republicans have been talking about repealing the ACA since it was passed and they have no plan to replace it yet? Obviously they have never really planned a real replacement.
  • Given the above discussion, it’s very possible that the repeal of the ACA will crash the individual insurance market so it won’t matter if there are subsidies since there will be no companies willing to participate in the market. Why would a company participate in a market they know will be gone in a few years and which depends on Congress supporting them to break even–knowing that Congress reneged the last time such a promise was made?
  • Given all the complexities, they are going to write the repeal legislation very quickly. I’m sure they will be very well written and carefully vetted.

Donald Trump, being Donald Trump, is trying to get out the lie that any failure will be the fault of Democrats:

massive increases of ObamaCare will take place this year and Dems are to blame for the mess. It will fall of its own weight – be careful!

Sorry Donald, this will all be on you and the Republicans. You will be responsible for tens of millions of Americans losing health insurance.

Trump will screw Trump states

Kevin Drum put this up:

Once Obamacare’s subsidies are repealed, it’s likely that 3 million people with expensive pre-existing conditions will be instantly tossed out of the health care system, unable to get insurance and unable to afford proper care.

He’s using the numbers from here. If you look at the chart in Kevin Drum’s post you notice that the states with the highest percent of people with pre-existing conditions voted for Trump. In fact, there are 23 states that are at or above the US average of 27% with pre-existing conditions–of these 4 voted for Clinton including Maine which split electoral votes (3 for Clinton, 1 for Trump). And all 11 with 30% or higher voted strongly for Trump (Clinton got less than 40% of the vote in all those states).

Hey, here’s a scatterplot (DC is the one in the upper left):

pre-exist

Donald Trump has said he wants to keep the ban on people being denied health insurance if the have pre-existing conditions but the health insurance companies will go bankrupt unless they’re allowed to charge them much more and/or force almost everyone to have insurance. Since the mandate to have insurance is not one of the things Trump wants to keep, health insurance will become unaffordable to a good chunk of these people which is why Kevin Drum says that 3 million of these people will be instantly tossed out of the health care system.

Trump voters really know how to stick it to themselves.

Mylan and the EpiPen

Heather Bresch and Mylan Pharmaceuticals are both clever and stupid. Mylan is the company that makes the EpiPen, you might have heard about this. They were clever enough to spread their increases over many years:

Since 2009, Mylan has jacked up the price of the lifesaving allergy treatment an incredible 15 times. The list price on a two-pack of EpiPens is $609, up 400% from seven years ago.

And they mostly tried to hide the price from consumers:

Mylan said the company never intended for patients to pay the full price, expecting insurers would carry the load.

“We recognize the significant burden on patients from continued, rising insurance premiums and being forced increasingly to pay the full list price for medicines at the pharmacy counter,” chief executive Heather Bresch said in a statement.

But they’re also pretty stupid. At some point you can’t hide price hikes if you do it so many times and increase the price too much–they just got too greedy and now a bunch of Senators have sent them a letter noticing that price of the EpiPens has soared as the salary of the CEO has as well:

Reports emerged last week that the company had implemented a series of gradual price increases inflating the price of the drug from $56.64 to $317.82, a 461% increase in cost since Mylan acquired the rights to EpiPen in 2007. During that same time, Heather Bresch, chief executive officer of Mylan, saw her pay rise $2,453,456 to $18,931,068, a 671% increase. Last week, she sold 100,200 of her shares in the company for more than $5m.

What’s their explanation?

“We recognize the significant burden on patients from continued, rising insurance premiums and being forced increasingly to pay the full list price for medicines at the pharmacy counter,” Bresch said in the company’s statement Thursday. “Patients deserve increased price transparency and affordable care, particularly as the system shifts significant costs to them. However, price is only one part of the problem that we are addressing with today’s actions.”

Given that one of the reasons insurance premiums are soaring and copays are increasing is the increased cost of drugs, Heather Bresch is basically blaming herself and her company but pretending otherwise. So far it doesn’t seem to be working. You’ll notice that the prices in the Guardian article are the price Mylan charges the middlemen, so those increases are all on Mylan. Here’s hoping they lose lots of money over their greed.

Conservatives and women

Via here, we get this:

The finding comes from a report, appearing in the September issue of the journal Obstetrics and Gynecology, that the maternal mortality rate in the United States increased between 2000 and 2014, even while the rest of the world succeeded in reducing its rate. Excluding California, where maternal mortality declined, and Texas, where it surged, the estimated number of maternal deaths per 100,000 births rose to 23.8 in 2014 from 18.8 in 2000 – or about 27%.

But the report singled out Texas for special concern, saying the doubling of mortality rates in a two-year period was hard to explain “in the absence of war, natural disaster, or severe economic upheaval”.

From 2000 to the end of 2010, Texas’s estimated maternal mortality rate hovered between 17.7 and 18.6 per 100,000 births. But after 2010, that rate had leaped to 33 deaths per 100,000, and in 2014 it was 35.8. Between 2010 and 2014, more than 600 women died for reasons related to their pregnancies.

No other state saw a comparable increase.

In the wake of the report, reproductive health advocates are blaming the increase on Republican-led budget cuts that decimated the ranks of Texas’s reproductive healthcare clinics. In 2011, just as the spike began, the Texas state legislature cut $73.6m from the state’s family planning budget of $111.5m. The two-thirds cut forced more than 80 family planning clinics to shut down across the state. The remaining clinics managed to provide services – such as low-cost or free birth control, cancer screenings and well-woman exams – to only half as many women as before.

The report is here and its interpretation is much more circumspect:

The Texas data are puzzling in that they show a modest increase in maternal mortality from 2000 to 2010 (slope 0.12) followed by a doubling within a 2year period in the reported maternal mortality rate. In 2006, Texas revised its death certificate, including the addition of the U.S. standard pregnancy question, and also implemented an electronic death certificate. However, the 2006 changes did not appreciably affect the maternal mortality trend after adjustment, and the doubling in the rate occurred in 2011–2012. Texas cause-of-death data, like with data for most states, are coded at the National Center for Health Statistics, and this doubling in the rate was not found for other states. Communications with vital statistics personnel in Texas and at the National Center for Health Statistics did not identify any data processing or coding changes that would account for this rapid increase. There were some changes in the  provision of women’s health services in Texas from 2011 to 2015, including the closing of several women’s health clinics. Still, in the absence of war, natural disaster, or severe economic upheaval, the doubling of a mortality rate within a 2-year period in a state with almost 400,000 annual births seems unlikely. A future study will examine Texas data by race–ethnicity and detailed causes of death to better understand this unusual finding.

The study is actually much more scathing in regards to something much more basic:

It is an international embarrassment that the United States, since 2007, has not been able to provide a national maternal mortality rate to international data repositories such as those run by the Organization for Economic Cooperation and Development.22 This inability reflects the chronic underfunding over the past two decades of state and national vital statistics systems. Indeed, it was primarily a lack of funds that led to delays (of more than a decade in many states) in the adoption of the 2003 revised birth and death certificates. This delay created the complex data comparability problem addressed in this study. The lack of publication of U.S. maternal mortality data since 2007 has also meant that these data have received a lesser degree of scrutiny and quality control when compared with published vital statistics measures such as infant mortality. For example, had the National Center for Health Statistics and the Texas vital statistics office both been publishing annual maternal mortality rates, the unusual findings from Texas for 2011–2014 would certainly have been investigated much sooner and in greater detail. Accurate measurement of maternal mortality is an essential first step in prevention efforts, because it can identify at-risk populations and measure the progress of prevention programs.

The study notes the same thing as the WHO does here, the US is one of the few countries in the world where the mortality rate for pregnant women is going up and it has one of the highest in the developed world (for example it is double that of Canada). That’s pathetic.

 

Government works, part two

Republicans keep saying that Obamacare has been a disaster. Let’s see what a recent study says:

A study published Monday in JAMA Internal Medicine offers another way of looking at the issue. Low-income people in Arkansas and Kentucky, which expanded Medicaid insurance to everyone below a certain income threshold, appear to be healthier than their peers in Texas, which did not expand.

Their survey found people in Arkansas and Kentucky were nearly 5 percent more likely than their peers in Texas to say they were in excellent health in 2015. And that difference was bigger than it had been the year before.

The survey also asked about other subjects. It found that people in the expansion states were more likely to have a doctor and to have a place to go for care. They said they were more likely to have their chronic disease treated, and that they were more likely to have received screening for high cholesterol or high blood sugar, markers for heart disease and diabetes.

On financial measures, the study was in line with some previous studies, finding that people in Kentucky and Arkansas were less likely to postpone care or avoid taking prescribed drugs because of the cost, and that they were less likely to be struggling with a medical bill.

Gee, a government program has made people healthier. That’s going to end civilization as we know it.

Supreme court says no to Texas abortion restrictions

The Supreme Court has struck down abortion restrictions in Texas:

The Supreme Court on Monday struck down Texas abortion restrictions that have been widely duplicated in other states, a resounding win for abortion rights advocates in the court’s most important consideration of the controversial issue in 25 years.

Justice Anthony M. Kennedy joined the court’s liberals in the 5 to 3 decision, which said Texas’s arguments that the clinic restrictions were to protect women’s health were cover for making it more difficult to obtain an abortion.

The challenged Texas provisions required doctors who perform abortions at clinics to have admitting privileges at a nearby hospital and said that clinics must meet hospital-like standards of surgical centers.

Similar restrictions have been passed in other states, and officials say they protect patients. But the court’s majority sided with abortion providers and medical associations who said the rules are unnecessary and so expensive or hard to satisfy that they force clinics to close.

“The decision erodes states’ lawmaking authority to safeguard the health and safety of women and subjects more innocent life to being lost,” Texas Gov. Greg Abbott (R) said in a statement. “Texas’ goal is to protect innocent life, while ensuring the highest health and safety standards for women.”

The Post has an article that looks at that last statement:

A key study published in the journal Obstetrics & Gynecology estimated that the risk of a woman dying after childbirth was 10 times greater than after an abortion. The study estimated that between 1998 and 2005, one woman died in childbirth for every 11,000 babies born. That compares with one in 167,000 women who died of abortion complications. Doctors who perform abortions say the most common complications are not bladder issues or problems with reproductive organs — as some abortion opponents like to emphasize — but mild infection that can be easily treated.

So if Texas makes more women continue their pregnancy more women will die. Even if they just delay the abortion more women will die.

Let’s throw in some data (scroll down to tables 7 or 8):

Among the 38 areas that reported gestational age at the time of abortion for 2012 (Table 7), two-thirds (65.8%) of abortions were performed by ≤8 weeks’ gestation, and 91.4% were performed at ≤13 weeks’ gestation.

and according to here:

The risk of death associated with abortion increases with the length of pregnancy, from 0.3 for every 100,000 abortions at or before eight weeks to 6.7 per 100,000 at 18 weeks or later.

A first-trimester abortion is one of the safest medical procedures and carries minimal risk—less than 0.05%—of major complications that might need hospital care.

The Supreme Court easily figured out that these laws were not about the safety of women and all about restricting abortion.

Another reason to support abortions

Jezebel has the story of a woman who got an abortion at 32 weeks:

I got pregnant on our first try, last July. We were really excited about it. Everything seemed to be fine at first, and then we found out at 10 weeks that there was no heartbeat. That was September 2015, and I had a D&C.

It was around 16 weeks, I think, when we got the scan that looked like his feet were turned in—like club feet. Our doctor said he was OK, that we’d just keep watching it. Then, also around that time, we found out that I had a weird umbilical cord, or velamentous cord insertion. Normally, an umbilical cord is implanted in the center of a placenta; mine was way on the edge. That affects blood flow, affects how blood and nutrients get to the baby, so they put me on rest. And, unrelated, I was also bleeding—these huge bleeds that looked like I was having a heavy period.

Basically, there’s a certain protein that exists inside the fetus, and a tiny bit is supposed to get into the mother’s blood, but very little. I had four times the median of what’s normal.

So they immediately thought about muscular dystrophy, spina bifida, things like that. They rushed me in, did a full scan, measured everything. And they couldn’t find anything. He looked fine. My doctor said all we could do is keep checking.

This baby was unviable, basically. That’s what they say. They say that the baby is “incompatible with life.”

So, she and her husband went through a very bad year. Of course, this being the US, things still weren’t easy:

There are a few doctors in the country—four of them, you interviewed one of them—who will do this. But my doctor had previously referred patients to Dr. Hern, who’s in Boulder. He’s this 78-year-old man who’s been doing this for decades, who developed a lot of the abortion procedures that we know to be the most safe. He’s had 37,000 patients and he’s never lost anyone. And he’s a zealot, but he has to be. There are websites dedicated to offering money to kill him; his practice has four layers of bulletproof glass. They’ve been shot at. He was there during the Roe v. Wade decision. He’s been through it all. And the only other peer he had at his level was Dr. Tiller, who was killed in 2009.

It ended up that she had to fly to Colorado and then fly back because she had brain surgery two years before and could not go through a regular childbirth (since the fetus was so far along, she had to still go through with the ‘birth’). So the politics took a bad situation and made it worse.  And if conservatives had their way it would be even worse. Oh and that whole abortionists do it for the money?

Inside, it feels very much like the ‘70s. There’s wood paneling, wicker furniture, a super-old sonogram machine. They don’t have a lot. The clinic is clean, but it’s old. They try to stretch the money as much as they can. I made friends with a nurse who was from Brooklyn, and she told me that the reason that the procedure is so expensive is because, first, their insurance is so crazy high, and second, the whole staff—the nurses, the front desk—is paid really well because they’re risking their lives to be there.

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