Affordable Care Act

Chris Petersen: GOP wants to bring back 'pre-existing conditions' as a reason to deny health care


For my family, “pre-existing conditions” are more than a technicality. They’re a matter of life or death, of sickness or health.

My wife and I are Iowa family farmers. I have diabetes, and Kristi has a heart murmur. Without the Affordable Care Act (ACA) and its guarantees for people with pre-existing conditions, there’d be nothing standing between us and the insurance corporations.

We know firsthand what happens when insurance corporations can discriminate based on a pre-existing condition. Years ago, I had health coverage through an outside job and was diagnosed with a nickel-sized hernia that didn’t require immediate surgery. 

When farming started looking up, I began to farm full-time and applied for my own insurance. My wife and I disclosed our health conditions and were approved. Each month we religiously paid the $700 premium.

After about a year, I decided to fix the hernia and was pre-approved for surgery. Then the bills started. After months of back-and-forth, my insurer denied the claim, citing a pre-existing condition. They dropped me.

Then my wife had pre-approved tests for her heart, and the insurer dropped her, too. They cited “discrepancies” between medical records and the insurance forms we’d filled out two years earlier.

The discrepancies? A one-inch difference in her height and the fact that she’d gained 12 pounds!

It took us 14 years to pay those medical bills with no help from the insurer. After years of us sending them monthly premium payments, they’d left us holding the bag.

Then came the ACA. Kristi and I finally got quality, affordable health care, like many other small-business owners. The law isn’t perfect, but it provided a measure of stability we needed to keep our business going strong.

Now the Trump administration and some Republicans in Congress are attacking the ACA again. They want to let insurance corporations discriminate against people with pre-existing conditions, like my wife and me.

This comes after Republicans in Congress voted to pass the new tax bill — a huge giveaway to giant corporations that did nothing for farmers like us.

This tax bill doesn’t just funnel billions in preferential tax treatment to mega-corporations. It also eliminates the ACA’s penalty for not having health insurance. Trump is using that as an excuse to ask a judge to throw out the ACA’s pre-existing condition protections, too. A new Trump-appointed Supreme Court justice like Brett Kavanaugh just might help him do it.

Meanwhile, Republicans in Congress are advancing a budget that cuts health care and raises prices for all of us enrolled in Medicare, Medicaid, and the ACA.

Let’s not go backwards.

Any politician who believes in thriving family farms and small businesses should protect people with pre-existing conditions and support universal health care.

Any politician who believes in us should reverse the Republican corporate tax giveaways and adopt fair taxes that fund public investments and help fuel small business development.

And any politician who supports us should reject the finger-pointing. No more blaming our hard times on immigrants, people of color, or on those who seem “different.” Our strength comes from working together — on health care and all the other things that matter in our lives.

Last year, the GOP Congress tried to repeal our health care. People of all walks of life stopped them. Believe me, like my friends and neighbors, this family farmer is persistent. We’re not done fighting for everyone to get the health care they need.

Chris Petersen is an independent family farmer near Clear Lake, Iowa. He’s a leader of the Main Street Alliance, a national small business network. 



LeeAnne Hall: Many have jobs BECAUSE they're on Medicaid


On Jan. 11, the Trump administration issued a cruel announcement: If you can’t find a job, don’t count on being able to get health care.

Under an unprecedented new policy, the administration will let states kick people off Medicaid for the crime of being unemployed. Instead of providing good jobs to struggling people, the administration is offering threats and tougher times.

Those hurt could include the Carrier plant workers from Indiana, whose jobs Trump promised to save when he was campaigning for the presidency. Last year, the company announced 600 layoffs.

Now the last of these employees are being pushed out the door. One worker says she’s “a lost paycheck away from homeless.”

Imagine telling her Medicaid won’t be there for her on top of everything else she’ll lose. The heartlessness is incomprehensible.

Still, her state’s governor is one of ten that’s jumping on the administration’s new proposal to require work or work-related activities. Kentucky’s plan has already been approved.

This is no way to treat people you claim to care about — especially when lawmakers can improve our lives with policies providing child care, paid family and medical leave, and living-wage jobs in a clean-energy economy, to say nothing of affordable health care for all.

Simple facts show that this work requirement isn’t about jobs. Most working-age adults who use Medicaid already work, and many of them have jobs thanks to Medicaid — not despite it.

That’s because Medicaid helps them get and stay healthy enough to work. After Ohio expanded Medicaid, three quarters of those who signed up said getting coverage helped them get work. In Michigan, more than two-thirds also said it helped better at a job they already had.

This policy is another blow for those facing racial or other discrimination on the job. It punishes people in job-scarce communities. It hurts people struggling to find work when they have a past criminal conviction.

And, while the administration says people with disabilities won’t be affected, that could be by only by the strictest definition of disability. Those who’ve been hurt on the job won’t necessarily be protected. Neither may many people struggling with addiction, mental health concerns, or physical conditions that make working difficult or impossible.

We can see from Kentucky’s plan what this could look like. New premiums for struggling families. Paperwork lockouts. A financial or health “literacy test” reminiscent of tests that barred African American people from voting. State officials say 90,000-95,000 people will lose their coverage.

Last year, Americans demanded we not go backwards on health care. Thousands of us showed up at town halls to block the GOP effort to repeal the Affordable Care Act and the gutting of Medicaid.

Everyone should get the care they need.

The expansion of Medicaid under the Affordable Care Act was a step in that direction. It gave many of us hope for the country we can be: one where a family’s fortunes don’t depend on the good graces of a giant corporation, and our lives don’t depend on the size of our wallet.

We still have a long way to go. Many are shut out of health care because of citizenship status, because coverage is still too expensive, or because our states refuse to expand Medicaid.

But the Trump administration and GOP Congress are moving us backward. This new Medicaid scheme is just part of it. There’s also the recent tax bill that will raise insurance premiums while giving huge cuts to corporations like Carrier — which, according to one employee facing layoffs, is “getting money hand over fist.”

Americans want health care expanded, not taken away. They can’t trick us with yet another scheme. Let’s raise our voices again and protect Medicaid.

LeeAnn Hall is the co-director of People’s Action and a member of the executive committee of Health Care for America Now. Distributed by


Patty Wright: Maine governor puts brakes on Medicaid expansion

Maine State House, in Augusta.

Maine State House, in Augusta.

Via Kaiser Health News

Just hours after Maine voters became the first in the nation to use the ballot box to expand Medicaid under the Affordable Care Act, Republican Gov. Paul LePage said he wouldn’t implement it unless the Legislature funds the state’s share of an expansion.

“Give me the money and I will enforce the referendum,” LePage said. Unless the Legislature fully funds the expansion — without raising taxes or using the state’s rainy day fund — he said he wouldn’t implement it.

LePage has long been a staunch opponent of Medicaid expansion. The Maine Legislature has passed bills to expand the insurance program five times since 2013, but the governor vetoed each one.

That track record prompted Robyn Merrill, co-chair of the coalition Mainers for Health Care, to take the matter directly to voters Tuesday.

The strategy worked. Medicaid expansion, or Question 2, passed handily, with 59 percent of voters in favor and 41 percent against.

“Maine is sending a strong and weighty message to politicians in Augusta, and across the country,” Merrill said. “We need more affordable health care, not less.”

Medicaid expansion would bring health coverage to about 70,000 people in Maine.

As a battle now brews over implementation in Maine, other states will likely be watching: groups in Idaho and Utah are trying to put Medicaid expansion on their state ballots next year.

With passage of the ballot measure, Maine is poised to join the 31 states and the District of Columbia that have already expanded Medicaid to cover adults with incomes up to 138 percent of the federal poverty level. That’s about $16,000 dollars for an individual, and about $34,000 for a family of four.

Currently, people in Maine who make too much for traditional Medicaid and who aren’t eligible for subsidized health insurance on the federal marketplace fall into a coverage gap. It was created when the Supreme Court made Medicaid expansion under the Affordable Care Act optional.

That’s the situation Kathleen Phelps finds herself in. She’s a hairdresser from Waterville who has emphysema and chronic obstructive pulmonary disease. She said she has had to forgo her medications and oxygen because she can’t afford them. “Finally, finally, maybe people now people like myself can get the health care we need,” she said.

Medicaid expansion would also be a win for hospitals. More than half of those in Maine are operating in the red. Across the state, hospitals provide more than $100 million a year in charity care, according to the Maine Hospital Association. Expanding Medicaid coverage will bolster their fiscal health and give doctors and nurses more options to treat their formerly uninsured patients, said Jeff Austin, a spokesman with the association.

“There are just avenues of care that open up when you see a patient from recommending a prescription drug or seeing a counselor,” he said. “Doors that were closed previously will now be open.”

But voter approval may not be enough. Though a legislative budget analysis office estimates Medicaid expansion would bring about $500 million in federal funding to Maine each year, it would also cost the state about $50 million a year.

The fate of the Medicaid expansion will now be in the hands of the Legislature, where lawmakers can change it like any other bill. Four ballot initiatives passed by Maine voters last year have been delayed, altered or overturned.

But state Democratic leaders pledge to implement the measure. “Any attempts to illegally delay or subvert the law … will be fought with every recourse at our disposal,” Speaker of the House Sara Gideon said. “Mainers demanded affordable access to health care yesterday, and that is exactly what we intend to deliver.”

Patty Wright is a journalist for Maine Public.

This story is part of a partnership that includes Maine Public, NPR and Kaiser Health News.

Martha Burk: Employees have 'religious' freedom, too


When Obamacare — aka, the Affordable Care Act — became law in 2010, it mandated coverage of birth control without co-payments.

Some employers didn’t like the rule, and Hobby Lobby hated it so much that the company filed a lawsuit to stop it. Company owners said they didn’t believe in contraception and claimed that covering it for female employees violated their religious freedom.

Understand, the Obama administration went to great lengths to exempt churches and church-related institutions from the rule, while still guaranteeing their female employees the right to birth control if they wanted it.

Then the Supreme Court stepped in, siding with Hobby Lobby and ruling that “closely held” corporations with religious objections could join religious employers in excluding birth control from their insurance plans.

Now the Trump administration has gone a giant step further. They’re now allowing any and all businesses, including publicly traded ones, to also cite “religious or moral objections” in denying their employees contraception coverage.

Wait a minute.

Corporations not only have religious freedom but now moral principles, too? I didn’t even know they went to church, and I’m pretty sure I’ve never seen one get down on its knees and pray.

On the other hand, I know women — who are actual people — have religious freedom under the Constitution, too. What about their right not to be forced to bow to their employers’ religious beliefs or highly suspect “moral” principles?

Massachusetts, California, and the ACLU have filed lawsuits to stop the rollback. Good luck. Besides Hobby Lobby, the conservative majority in the Supreme Court ruled years ago in the Citizens United case that corporations have constitutional rights, and they’ve consistently ruled in favor of their corporate buddies over women in employment discrimination cases.

On top of that, six of the nine justices are male, and most of them of rather conservative religious persuasions. The odds look to be stacked against women.

Expanding so-called corporate citizen rights deeper into health care could ultimately affect everybody, not just women.

Christian Scientists are opposed to all kinds of medical treatment, including for diabetes, cancer, and meningitis. Jehovah’s Witnesses don’t believe in blood transfusions. There are undoubtedly other religious taboos on medical procedures.

Enterprising businesses that want to save money could cite “religious freedom” to exclude virtually any medical treatment from their insurance plans. Surgery, antibiotics, immunizations — you name it.

Where will it end? We don’t know. Even if the lawsuits are ultimately successful, a decision could take years.

All I know is that I don’t want my neighborhood corporate citizen making my health care decisions.

Martha Burk is the director of the Corporate Accountability Project for the National Council of Women’s Organizations (NCWO) and the author of the book Your Voice, Your Vote. 


Martha Burk: 'Religious' companies and your health care



When Obamacare — aka, the Affordable Care Act — became law in 2010, it mandated coverage of birth control without co-payments.

Some employers didn’t like the rule, and Hobby Lobby hated it so much that the company filed a lawsuit to stop it. Company owners said they didn’t believe in contraception and claimed that covering it for female employees violated their religious freedom.

Understand, the Obama administration went to great lengths to exempt churches and church-related institutions from the rule, while still guaranteeing their female employees the right to birth control if they wanted it.

Then the Supreme Court stepped in, siding with Hobby Lobby and ruling that “closely held” corporations with religious objections could join religious employers in excluding birth control from their insurance plans.

Now the Trump administration has gone a giant step further. They’re now allowing any and all businesses, including publicly traded ones, to also cite “religious or moral objections” in denying their employees contraception coverage.

Wait a minute.

Corporations not only have religious freedom but now moral principles, too? I didn’t even know they went to church, and I’m pretty sure I’ve never seen one get down on its knees and pray.

On the other hand, I know women — who are actual people — have religious freedom under the Constitution, too. What about their right not to be forced to bow to their employers’ religious beliefs or highly suspect “moral” principles?

Massachusetts, California and the ACLU have filed lawsuits to stop the rollback. Good luck. Besides Hobby Lobby, the conservative majority in the U.S. Supreme Court ruled years ago in the Citizens United case that corporations have constitutional rights, and they’ve consistently ruled in favor of their corporate buddies over women in employment discrimination cases.

On top of that, six of the nine justices are male, and most of them of rather conservative religious persuasions. The odds look to be stacked against women.

Expanding so-called corporate citizen rights deeper into health care could ultimately affect everybody, not just women.

Christian Scientists are opposed to all kinds of medical treatment, including for diabetes, cancer, and meningitis. Jehovah’s Witnesses don’t believe in blood transfusions. There are undoubtedly other religious taboos on medical procedures.

Enterprising businesses that want to save money could cite “religious freedom” to exclude virtually any medical treatment from their insurance plans. Surgery, antibiotics, immunizations — you name it.

Where will it end? We don’t know. Even if the lawsuits are ultimately successful, a decision could take years.

All I know is that I don’t want my neighborhood corporate citizen making my health care decisions.

Martha Burk is the director of the Corporate Accountability Project for the National Council of Women’s Organizations (NCWO) and the author of the book Your Voice, Your Vote


David Warsh; McCain and looking for the road back to 'regular order'


I wasn’t surprised in the least when Sen. John McCain (R-Ariz.) flew back to Washington last week to put a stake through the heart of the Republican Party’s effort to kill  the Affordable Care Act. That’s because I remember the last time that McCain interrupted himself to fly back to town.

He was running for president then, against Illinois Sen. Barack Obama, in 2008. The financial crisis had come to a head after a year of growing apprehension. Lehman Brothers had failed on Monday, Sept. 15.  Panic was taking hold in global credit markets for the first time since 1933.

Acute problems had spread beyond the banks.  By Tuesday, Sept. 16, 2008, insurance giant American International Group was on the verge of failure, thanks to the effect of plummeting share prices on its derivative and stock-lending businesses. Treasury Secretary Henry Paulson Jr., had begun calling both candidates daily to brief them, hoping to keep them from saying something that might upset the markets.

On the stump Sept. 16, McCain said, “We cannot have the taxpayers bail out AIG or anybody else.”  Paulson phoned immediately to talk him back from that position. The next day McCain reversed himself, foreshadowing the days ahead.

Two days later, Paulson and Federal Reserve Chairman Ben Bernanke persuaded President George W. Bush and leaders of both parties, meeting in the office of Speaker of the House Nancy Pelosi, to accept the hastily drafted Troubled Assets Relief Program  (TSRP) bill.  And on Friday, Sept.  19, Friday, Bush stood in the White House Rose Garden, along with Bernanke, Paulson and SEC chairman Christopher Cox, to ask Congress to approve a hazy $700 billion bailout plan.  By the following Tuesday, it was clear that the measure lacked the necessary Republican votes to pass in the House.

With the first presidential debate scheduled for the following Friday, McCain announced  that he was suspending his campaign in order to fly back to Washington.  He asked for a meeting with President Bush and Obama. Paulson later wrote that he was “dumbfounded” that the president had agreed to such a conclave. (I am relying here on Paulson’s memoir, On the Brink: Inside the Race to Stop the Collapse of the Global Financial System.) Bush explained that he felt he had little choice.

The meeting was held; Obama and his chief economic adviser Lawrence Summers danced rings around the Republicans:  McCain spoke only when called upon at the end, and the meeting dissolved in chaos at its end. In their televised debate that Friday, Obama and McCain condemned Wall Street, but neither mentioned the bailout. Mostly they argued about Afghanistan and Iraq.  Obama decisively won the debate.

The following Monday the TARP bill was defeated in the House.  When it finally passed three days later, as the banking system continued to threaten to collapse, McCain got little credit for his dramatic gesture. Paulson wrote:

"His return to Washington was impulsive and risky, and I don’t think he had a plan in mind. If anything, his gambit only came back to hurt him, as he was pilloried in the press afterward, and in the end I don’t believe his maneuver significantly influenced the TARP legislative process.

"A number of people I respect on the Hill have a different view. They believe McCain ended up being helpful by focusing public attention on TARP and galvanizing Congress to action. And John did later try to find ways for House Republicans to support legislation.   But Democrats absolutely did not want him to get any credit. They wanted the economic issue as their own.''

Looking back, McCain was a central player in one of the great dramas of the 21st Century. The leaders of both parties in Congress, a reluctant administration, central bankers around the world, and both U.S. presidential candidates in an election year – they all agreed on measures that, after many adjustments behind the scenes, prevented a second Great Depression.

Granted, it had been ugly. Every actor displayed a wart or two. “There was no hiding McCain’s rudderlessness over the [first few] days, as he lurched from blunder to blunder,” was how John Heilemann and Mark Halperin described his introduction to the crisis in Game Change.  Sen. Lindsey Graham (R.-S.C.) repeatedly helped his good friend McCain maintain his bearings.  But strip away all the self-interested accounts of the matter by technocrats, and what’s left is a distinct harbinger of McCain’s dramatic action last week.

In a speech two days before his fateful vote last week, McCain took stock of the battles of the last eight years.

"Our deliberations today are more partisan, more tribal more of the time than any other time I remember…. Both sides have let this happen. Let’s leave the history of who shot first to the historians. I suspect they’ll find we all conspired in our decline – either by deliberate actions or neglect…

"The Obama administration and congressional Democrats shouldn’t have forced through Congress without any opposition support a social and economic change as massive as Obamacare. And we shouldn’t do the same with ours.''

Since I clearly remembered the White House event, in March 2009, with which Obama opened his campaign to reorganize healthcare-insurance markets, I couldn’t resist a taking a little peek back at the history of what happened next. Obama’s proposal’s was patterned on Massachusetts’'s 2006 adoption of “Romney Care,” itself based on a Republican proposal for an individual mandate advanced ten years before, in opposition to Hillary Clinton’s more ambitious plans. Obama invited 150 participants to a conference, drawn from all corners of the debate, including Congressional Republican leaders.

 In “The Party of No,” a chapter in The New New Deal:The Hidden Story of Change in the Obama Era, author Michael Grunwald describes the evolution of the Republican leadership’s thinking the wake of Democratic victories – not just the White House, but control of both houses of Congress. Eric Cantor (R.-Va.) was the minority whip then, transparently coveting minority leader John Boehner’s job.  Cantor’s deputy, Kevin McCarthy (R.-Calif.), and Paul Ryan (R.-Wis.) were said to be the GOP’s “young guns.” Rep. Mike Pence (R.-Ind. chaired an initial conference of the party’s leadership in Annapolis. Grunwald wrote:

"The new leaders who gathered in Annapolis had a new mantra.  Our mistake was abandoning our principles, not following our principles. They saw John McCain as a typical Republican In Name Only (RINO) who had sought electoral salvation in ideological equivocation – and look what happened to him.  They even revised their opinions of George W. Bush, who in retrospect seemed less a conservative hero, more a big-spending apostate.''

“Most important, Republicans need to stick together as a team,” exhorted Senate Minority Leader Mitch McConnell.  And so they did.  The Tea Party election came next, in 2010. Republicans took back the House.  Obama was re-elected in 2012. In 2014, Republicans took back the Senate. And by 2016, the strategy of full-throated opposition seemed to have worked. Republicans won the White House.

At least in the matter of healthcare legislation, the Republicans clearly fired the first shot, opposing a program of their own invention just because the opposition party had embraced it.  Let McCain’s exaggeration on this count pass. In the offer of olive branches, no more than in lapidary inscriptions, is a man upon his oath. The path back to the state of mind Senate rules describe as “normal order” is much as McCain described it:

Incremental progress, compromises that each side criticize but also accept, just plain muddling through to chip away at problems and keep our enemies from doing their worst isn’t glamorous or exciting. It doesn’t feel like a political triumph. But it’s usually the most we can expect from our system of government, operating in a country as diverse and quarrelsome and free as ours.

In “The Sanctimony and Sin of G.O.P, ‘Moderates',''  New York Times columnist Paul Krugman, writing last week before McCain’s vote last Thursday against his party,  invited readers “to consider the awfulness of Senator John McCain.” Indeed, Krugman condemned all politicians “who pretend to be open-minded, decry partisanship, tut-tut about incivility and act as enablers for the extremists again and again.” Krugman wrote:

"I started with McCain because so many journalists still fall for his pose as an independent-minded maverick, ignoring the reality that he’s a reliable yes-man whenever it matters.''

Krugman has got it exactly backwards.  On the two occasions of the last 10 years when it has mattered most, McCain stood in the center, with the majority consensus, against his party’s leaders (and, often enough, in matters of lesser issues as well, especially immigration and campaign finance). Krugman, himself an unbridled partisan, should stop insisting that there are no Republican moderates.  The road back to “regular order” begins with giving credit where credit is due.

David Warsh, a longtime business and political columnist and an economic historian, is proprietor of


Llewellyn King: Start all over again with healthcare reform

The process now underway in Congress to repeal and replace the Affordable Care Act (Obamacare) reminds me of what would happen if you tried to thread a small darning needle with a strand of bulky yarn: It won’t go through the eye. The more you try to pull the strand through the eye, the less useful the yarn coming through it will be.

Therefore, isn’t it time to reconsider the whole proposition as though there were no Obamacare, no House version of its replacement, and no preconceived objective beyond affordable care for all?

Also, there should be no pre-established conditions, such as single-payer and multiple-payer; no pre-established goals, such as preserving particular insurance practices and expectations that employers will always be part of the deal; and no expectation that the health-care bill should also be a tax bill or a welfare bill.

Its simple goal should be to free people from fear of medical catastrophe and enable physicians and hospitals to care for the sick without commercial pressure.

I’ve come to the belief that big, new ideas are needed from my own experience as an employer-provider. For more than 30 years, as a small Washington publisher, I provided health insurance for my staff of 25. It was a nightmare that got worse as medicine got more expensive.

Of many strange situations, none was worse than the employee who developed nasopharyngeal cancer, a rare type of head and neck cancer. The insurance paid for chemotherapy and radiation, but refused to pay for expensive painkillers. These had to be brought in from France by a family member.

Maybe the most discouraging was a printing-press operator who wanted the premiums given to him, as he refused to see the point of insurance, although he was married with three small children. “We don’t use insurance,” he declared. “When the kids are sick we go to the emergency room and tell them we have no money.” When pressed, he said they did this because they didn’t want the bother of filling out forms.

If you think, as I do, that the system we have is less than perfect, one is immediately thought to be a believer in British-type national health insurance. Not necessarily so.

As a former citizen, I know something about Britain’s National Health Service and I think it is better than what is happening in the United States. I’ve received treatment in Britain under the system and members of my family in England are devoted to it. There is good treatment for major procedures. However for lesser ailments, there are long waiting lists. Bureaucracy is everywhere.

Worse, can you imagine a health-care system dependent on the budget cycle in Congress?

In Switzerland there is a totally private system, which looks like improved Obamacare. Everyone is obliged to buy insurance, just as everyone has to pay taxes. There are no limits on troublesome things like preexisting conditions. The government regulates the insurers. In a referendum, the Swiss rejected a switch to a single-payer system by 60-40 percent.

There also are mixed systems in Germany and Holland. The commonality is that everyone is covered and the governments regulate. That way, insurance pools are large and have the correct mix of old and young — otherwise the old will overwhelm any system.

Unless we devise a structure that caters to all, we will continue with overburdened emergency rooms, preposterous hospital charges and doctors who will pick and choose their patients.

No one on a gurney being wheeled down a hospital corridor should be thinking, “How will I pay for this?”

The chances are that when Congress has finished trying to thread the unthreadable needle, there will be a groundswell on the left for single-payer — better, possibly, but not a fit in the United States.

Meanwhile, there are too many pre-existing conditions in congressional thinking. We need a new prescription, a bigger needle and a finer thread.

Llewellyn King (llewellynking1@gmail,com) is host and executive producer of White House Chronicle, on PBS, and a veteran publisher, editor, columnist and international business consultant. He is based in Rhode Island and Washington. This piece first ran in Inside Sources.

Chuck Collins: Healthcare costs, not taxes, are the big hit on businesses

Members of the House GOP were in a hurry on May 4 to pass their bill to gut Obamacare. They rushed it through before anyone even had a chance to check its cost or calculate its impact on people’s access to insurance.

Their urgency, however, had little to do with health care. The real reason for the rush? To set the table for massive tax cuts.

Indeed, the House health plan would give a $1 trillion boon to wealthy households and pave the way for still bigger corporate tax cuts to come, as part of the so-called “tax reform” they’re pushing.

Meanwhile, dismantling the Affordable Care Act will cause up to 24 million people to lose their health coverage, according to the non-partisan Congressional Budget Office. (Though even that estimate is based on the less extreme version of the bill that failed to pass in April. The new plan may be even worse.)

Why would a GOP politician support an unpopular bill that fewer than 20 percent of voters think is a good idea? Why risk angry constituents showing up at town hall meetings?

Put simply, to please their wealthy donors and Wall Street corporations. For complex legislative reasons, repealing Obamacare’s taxes on the rich first will make it easier for them to slash corporate taxes next.

As the “tax reform” debate begins, prepare for sermons about how cutting taxes for rich and global corporations will be great for the economy. Slashing the corporate tax rate, we’ll be told, will boost U.S. competitiveness.

But if Congress were really concerned about the economy, policy wouldn’t be driven by tax cuts. The real parasite eating the insides of the U.S. economy isn’t taxes, billionaire investor Warren Buffett explained recently, but health care.

In fact, taxes have been steadily going down, especially for the very wealthy and global corporations. “As a percent of GDP,” Buffett told shareholders of his investment firm, the corporate tax haul “has gone down.” But “medical costs, which are borne to a great extent by business,” have increased.

In 1960, corporate taxes in the U.S. were about 4 percent of the economy. Today, they’re less than half that. As taxes have fallen, meanwhile, the share of GDP spent on health care has gone from 5 percent of the economy in the 1960s to 17 percent today.

These costs are the real “tax” on businesses. As any small business owner can tell you, health care costs are one of the biggest expenses in maintaining a healthy and productive work force.

Yet the GOP bill will weaken healthcare coverage and regulation, which will increase costs and hurt U.S. companies.

U.S. employers, remember, must compete with countries that have superior universal health insurance for their citizens and significantly lower costs. While health care eats up 17 percent of the U.S. economy, it’s around just 11 percent in Germany, 10 percent in Japan, 9 percent in Britain and 5.5 percent in China.

No wonder Buffett concluded that “medical costs are the tapeworm of American economic competitiveness.”

Buffett observed that the House healthcare bill would give him an immediate $680,000 annual tax cut, a break he doesn’t really need, while only allowing that tapeworm to bore deeper.

For all its limitations, the Affordable Care Act has expanded coverage and the quality of life for millions of Americans. It’s also put in place important provisions to contain exploding health care expenses, slowing the rise of costs.

The GOP plan to reduce coverage and deregulate health care will take us in the wrong direction. That’s a pretty poor bargain for yet another tax cut for the richest Americans.

Chuck Collins is a senior scholar at the Institute for Policy Studies and a co-editor of He’s the author of the recent book Born on Third Base. 


GOP would cost-shift massive obligatory medical costs to states

Adapted from  an item in Robert Whitcomb's "Digital Diary'' in GoLocal 24

The Congressional Budget Office figures that the Republican healthcare bill would reduce the federal budget deficit by $337 billion through fiscal 2026. I doubt that, but even assuming that it’s true, it doesn’t project how much the bill could cost the states.

A problem is that every state mandates that all sick and/or injured people who show up in inefficient and expensive hospital emergency rooms (which is most of them), and indeed at many other providers, must be treated regardless of ability to pay. There will be a heightened flood of such people at ERs over the next few years if the GOP bill is enacted because many of these folks would no longer have coverage that has let them get preventive treatment as part of a regular clinical relationship with a physician, especially with a primary-care doctor.

Hospitals and other providers and state governments would have to eat much of the cost of caring for the low-income people cast off with the demise of the Affordable Care Act. Unless state governments decide that they’ll just let a lot of poor people die on the street. Now that’s libertarian!

As former Massachusetts Gov. Mitt Romney said in 2006 in explaining his health-insurance plan for the Bay State: “Some of my libertarian friends balk at what looks like an individual mandate {as in the future Affordable Care Act}. But remember, someone must pay for the healthcare that must, by law, be provided: Either the individual pays or the taxpayers pay.’’

As for the alleged evil of “individual mandates,’’ states have long had them for auto insurance, and generally those who want to own a home are compelled to buy property insurance to get mortgages.

In any event, the Republican healthcare plan, among other things, is a great big inefficient cost-shifting to the states.

There are elements of the GOP approach that, in principle, have merit. For instance, the Trump administration wants the states to charge Medicaid patients at least some premiums, require them to pay part of their emergency-room charges (Medicaid patients tend to overuse ER’s) and push recipients to get jobs. These changes might reduce some of the vast amount of waste pervasive in American healthcare. And everyone should be reminded that healthcare is never “free’’; it’s just a question of who’s paying for it. But what percentage of Medicaid folks can meet these demands is unknown.  Many of them are already under a lot of economic and other stress.

Josh Hoxie: Repealing the ACA another windfall for the rich


Great magicians are masters of diversion. They attract our attention with one hand while using the other to trick us into thinking a supernatural act is taking place.

But even the best street performers could learn a lesson from the folks in Congress who are trying to repeal the Affordable Care Act, also known as Obamacare.

When we talk about repealing Obamacare, we almost never talk about the windfall payday it would bring to multi-millionaires and billionaires. In fact, this massive tax cut is the proverbial card hiding in the sleeve of lawmakers pushing repeal.

A new study from the Center on Budget and Policy Priorities shows the 400 richest Americans, a group whose average annual income tops $300 million each, would get a combined annual tax cut of $2.8 billion if the Affordable Care Act is repealed.

In other words, people who already have more money than they could spend in a dozen lifetimes would get a massive pile of cash.

Meanwhile, those who make less than $200,000 per year — also known as “the rest of us” — would see no benefit. That’s because the two taxes that funded the expansion in healthcare coverage included as part of Obamacare don’t extend to these moderate-income households.

And many of us would do worse.

In fact, about 7 million low-income people would actually see their taxes go up if the law’s repealed, since they’d lose insurance premium tax credits that were enacted as part of the bill.

So, to be perfectly clear on this point, repealing Obamacare equals payday for the wealthiest households and higher taxes for the poorest households — millions of whom would also lose their health coverage.

Remember the story of Robin Hood? It’s just like that, but backwards.

Poll after poll shows Americans have no idea how concentrated wealth inequality is today — it’s far worse than most suspect.

A report I co-authored last year looked at the 400 wealthiest individuals in the country. This group together owns more wealth than the entire GDP of India, a country with over a billion people.

The report also showed this great concentration of wealth splits largely, although not exclusively, along racial lines. The 100 wealthiest Americans, none of whom are black, today own more wealth than the entire African-American population combined.

Unsurprisingly, most of us would like to live in a much more egalitarian society. If we can’t swing it, economist and author Thomas Piketty warns, we’re heading towards a hereditary aristocracy of wealth and power, where the children of today’s billionaires will dominate our economy and our government.

As we look back at the Obama legacy, we see a number of efforts aimed at beginning to bridge that massive wealth divide. From expanding opportunities for low-income children and families to asking the ultra-wealthy to pay their fair share, progress has been made on this front in the past eight years.

The Affordable Care Act was one of these efforts, and it touched directly on issues of life and death.

Don’t be fooled by the smoke and mirrors of today’s illusionists: Repealing it will directly counteract this progress. It will further concentrate wealth into fewer hands and strip low-income families of what little resources they have.

Josh Hoxie directs the Project on Taxation and Opportunity at the Institute for Policy Studies.

David C. Pate, M.D.: America's healthcare-payment system must be transformed

At this stressed moment in Washington, this is as good a description of American healthcare "system'' challenges as I've read in a while. 

-- Robert Whitcomb

David C. Pate, M.D., a physician and lawyer who has been president and CEO of St. Luke’s Health System, based in Boise, Idaho, since 2009, spoke Dec. 14 as part of the Boise Metro Chamber of Commerce’s CEO Speaker Series. These remarks are edited for length and clarity from a transcript prepared by the chamber’s public-relations director, Caroline Merritt.

There’s a lot of discussion about healthcare, a lot of fear about what’s going to be happening with healthcare from a national level. I think there are answers — answers that healthcare providers are best prepared to implement, not Washington.

For the seven years that I’ve been here, we have been working at St. Luke’s, building the capabilities and competencies necessary to manage healthcare in a very different world than has existed.

Six months after I got here, the Affordable Care Act was enacted. We at St. Luke’s did not support the Affordable Care Act. Not because it doesn’t have a lot of really good features. It does. The discussion at the time was that if we add tens of millions of people to the newly insured in what was at the time, and still is, a broken healthcare delivery system, we’re going to end up saving money. We did not believe that. We have seen with the Affordable Care Act the continued growth and cost in healthcare. Something different has to happen.

Now the discussion is, “Let’s repeal and replace the Affordable Care Act.” I think it’s going to miss the mark as well. In both cases, Republicans and Democrats are coming up with the right answers to the wrong question.

Get a service, pay a bill

Most experts in healthcare would agree that the single biggest problem is our reimbursement model. It’s what’s called fee-for-service. You go to the doctor, you get a bill. You get a lab test, you get a bill. You go to the hospital, you get a bill.

It leads to a fragmented healthcare-delivery system. Everything is being paid by this unit-of-service or episode-of-care. Regardless of whether it helped you or not. Regardless of whether it provided value. Regardless of whether there was a less costly alternative.

An ideal reimbursement system ought to align the incentives of the payment with what we say are the important objectives that we want. You go places and you’re always having to repeat the same things because nobody seems to have all the information. You get bills from all the different ones.

It’s estimated that, at minimum, 30 percent of all healthcare spending in the United States goes to low-value or no-value services. So we are spending money on things that don’t help people. With fee-for-service, we pay for a lot of duplication.

One of the consequences is that we have these consistently rising premiums, and they have outpaced the growth in incomes. In Idaho this is particularly serious, because premiums as a percentage of average income [are] about 17 percent, and even the federal government with the Affordable Care Act said affordable is less than 9.5 percent.

High-deductible health plans don’t help

What has been a response is, “Let’s create really high-deductible health plans that make the patients have skin in the game and make them a little bit resistant to buy these services unless they really need them.”

Most of us can remember the day when we thought a high deductible was a thousand dollars for an individual. These high-deductible plans now are in the neighborhood of up to $6,000 for an individual, $12,000 for a family. Nearly half of Idahoans don’t have enough liquid assets to be able to pay the deductible.

So insurance is increasingly become more like a catastrophic health plan, not something that you can really use. People do avoid getting care, but they avoid getting the care they need as well as the care that you’d like to discourage. This isn’t working.

Now imagine a new world that I’ll call pay-for-value. Imagine that I’m getting paid $500 a month for people to provide all of their healthcare, and that’s all I’m getting,

The majority of the population [accounts for] a very small amount of the healthcare spending – 4 percent. In fee-for-service, Saint Al’s {Boise-based St. Alphonsus Health System} and St. Luke’s would go broke. They just don’t use many services.

Today, in fee-for-service, what I want to know when I come to work is: Are all our hospital beds full? Are our emergency departments full? Are women lined up down the hallway to give birth? Because this is how we get paid.

When [a patient is] ready to be discharged, we’re going to wheel [her] out in a wheelchair to the front sidewalk, and her family members are going to pull up, and we’re going to put her in the car and close the door. We’re done. Now, if anything else happens to her, that’s fine, come on back. We’d be glad to have you, and we’ll do it again. Re-admissions aren’t really a problem for us under fee-for-service. It’s just an opportunity to make more money.

New financial incentives for better care

Think about pay-for-value. I’m getting $500 per month. Is there any hospitalization that you can have for under $500 that you can think of? No.

Now don’t misunderstand me. We’re still going to have hospitalizations, even under pay-for-value. But we’re looking at them differently: Could we have prevented this?

Under pay-for-value, complications are very expensive, and now they’re our expense, because we’re just getting that $500. And we’re looking at two things. How can we give the right care 100 percent of the time? And how can we get to zero complications?

If you have a knee or a hip replacement, one of the dangers is that the prosthesis, the artificial part of it, can get infected. We figured that if someone got an infection from their knee or hip surgery, it added about $120,000 to the cost. That’s a lot of $500 premiums to pay for that complication. So what we’ve been doing is trying to figuring out how do we get to zero complications.

With hip and knee infections — I’m going to oversimplify — there are two ways you can get infected. One is: There can be bacteria on the skin that we don’t get off, so in the operation we put the bacteria in it. But today, the bigger problem is there’s particulate material in the air. We’ve got your wound open. That particulate matter can settle in your wound.

So we partnered with Micron and Boise State University to come into our operating rooms and to study about these particulate counts. Who knew there were such things as air engineers, but there are, and Boise State has one. And what we found is that every time the OR door opened, it stirred up the particulate count in the room. Just by us making sure everything is needed is in the room, and putting in new procedures about minimizing traffic through the OR, we have cut what was already a very good infection rate in half. These are the kind of things that you have got to do in this new world.

A very small percentage of the population accounts for a lot of the healthcare spending. [A man] has diabetes and heart failure and chronic kidney disease, and he’s a couch potato and he’s not very active. He is just a mess. People in [his] category, on average, are going to have six to eight doctors. In fee-for-service, they’re not talking to each other.

‘We’re driving this forward

In pay-for-value, that’s where we can reduce costs and make healthcare more affordable. Instead of concentrating all of my health systems’ resources on all of them, I’m going to focus my resources on this group, because there is so much we can do just by paying those doctors differently. They’re not just getting paid for the office visit. They are now paid to actually coordinate his care. You use other resources like care managers to help coordinate that care.

Starting Jan. 1,  25 percent of our revenue will be in this new model. We expect that sometime in 2018, it actually may be 50 percent. So we’re driving this transformation forward.

Now, the Boise/Meridian hospitals are five-star hospitals designated by CMS [the federal Centers for Medicare and Medicaid Services], the only one like that in the state of Idaho — in fact, in the surrounding six states. And our health system has been named, and that’s all of the hospitals, a top 15 health system for three years in a row. We’re showing that this can be done. We’re doing it.

The other piece is: Drive it at the lowest possible cost. That’s what we’ve got to deliver on.

We’re not counting on Washington to figure out how to fix healthcare.

Q: You’re talking about the transformation, but I’m wondering how that’s going to happen. You partner with SelectHealth, right? To deliver this model? Are you going to be able to work with the other insurance companies to make this happen? Or maybe it’s something bigger, like CMS changing from fee-for-service to pay-for-value. How are you going to get from 50 to 100 percent?

A: This is a great question, because the only way we can do it is if the payment system is transformed as well. It’s not going to work for us to transform the clinical model if the business model doesn’t change with it.

We have a great partnership with SelectHealth. That is certainly accelerating our efforts. One reason we went to SelectHealth was there wasn’t a lot of appetite for this in the market with the insurers at the time many years ago. Now other payers are getting aligned with this same concept.

In defense of my insurance-company colleagues, let me tell you, it’s really hard to change your business model. What we’ve gone through with our board to convince them that we should do this, and for them to understand you’re going to take 25 percent of our revenue and put it at financial risk? It’s a big step. And it’s hard for any business to transform their business when they’re doing well.

I think there’s going to be a competitive advantage to who can figure this out first. What I can do is: With the insurance companies that want to partner with us, we can now get by on a lower premium. So you can actually lower your premium, and we know that is what will shift market share.

As far as the federal government:

The Obama administration has been all in favor of this, and they would applaud what we are doing.

I am concerned with the new pick for secretary of HHS [President-elect Trump has chosen Rep. Tom Price,  M.D., a Georgia Republican congressman] because I’m not convinced based on what I’ve read about him that he believes in this. He’s a physician that came from the fee-for-service world and did well in that world.

I think the question is: How difficult is the new administration going to make it for us to do this? But I hope not.

This story appears in the December 21, 2016-January 17, 2017, edition of the Idaho Statesman’s Business Insider magazine.  To get to the magazine, hit this link.




Isaiah J. Poole: Give 'tax and spend' a chance


This time of year, a whole lot of Americans are feeling taxed enough already.

But the astonishing momentum of Bernie Sanders’s presidential candidacy reveals something else: Millions of taxpayers are willing to entertain the idea that some of us aren’t taxed enough, and that it’s hurting the rest of us.

Sanders has propelled his race against Hillary Clinton on a platform that would ramp up government investment — in infrastructure, education, health care, research and social services — while boosting taxes on the wealthiest Americans and big business to cover the cost.

Clinton’s own vision is less ambitious, but it’s also a far cry from “the era of big government is over” days of her husband’s administration.

The old conservative epithet against “tax-and-spend liberals” hasn’t completely lost its sting, says Jacob Hacker, a political-science professor at Yale University who pushed the idea of a public option for health insurance during the Affordable Care Act debate. But “we are moving toward the point where we can have an active discussion” about why “you need an activist government to secure prosperity.”

Hacker’s latest book, with Paul Pierson of the University of California at Berkeley, is American Amnesia: How the War on Government Led Us to Forget What Made America Prosper.

Hacker and Pierson argue that it was “the strong thumb” of a largely progressive-oriented government, in tandem with “the nimble fingers of the market,” that created the broad prosperity of the post-World War II era. Conservative ideologues and corporate leaders then severed that partnership.

Anti-government activism replaced the virtuous cycle of shared prosperity that existed into the 1970s with a new cycle that’s reached its depths in today’s radical Republican-run Congress: Make government unworkable. Attack government as unworkable. Win over angry voters. Repeat.

But in today’s mad politics, growing numbers of voters seem to have gotten wise to the routine and how it’s been rigged against them. Some are gravitating toward Donald Trump, as Hacker puts it, out of “the need to put a strong man who you know is not with the program in Washington in charge.”

Sanders has the opposite vision. He’s looking to spark a people-powered reordering of what government can do, with the biggest wealth-holders paying the share of taxes that they did when America’s thriving middle class and thriving corporate sector were, together, the envy of the world.

That vision is embodied in "The People's Budget.'' a document produced by the Congressional Progressive Caucus as an alternative to the House Republican budget.

It’s based on the premise that America can break out of its slow-growth economic malaise through a $1 trillion infrastructure spending plan that would create more than 3 million jobs, increased spending on green-energy research and development, and universal access to quality education from preschool through college.

“There are two messages that come out of the progressive budget,” Hacker said. One is that “we can actually increase investment if we don’t cut taxes further on the wealthy.” The other is that “if we got tougher with the modern robber barons in the healthcare and finance and energy industries, we could actually achieve substantial savings without cutting necessary spending.”

Unfortunately, The People’s Budget won’t get close to a majority vote in Congress — and that’s if it gets a vote at all in the dysfunctional Republican House.

Yet together with the debate provoked by the Sanders campaign, Hacker says, it shows that now “we have a little bit more of an opening for the kind of conversation we should’ve had 20 or 30 years ago, when we were trashing government and abandoning all of these long-term investments that are essential to our prosperity.”

Isaiah J. Poole is the online communications director at Campaign for America’s Future ( 

Philip K. Howard: Congress needs to clean out the stables of long-outdated laws

Government is broken. So what do we do about it? Angry voters are placing their hopes in outsider presidential candidates who promise to “make America great again” or lead a “political revolution.”

But new blood in the White House, by itself, is unlikely to fix things. Every president since Jimmy Carter has promised to rein in bureaucratic excess and bring government under control, to no effect: The federal government just steamed ahead. Red tape got thicker, the special-interest spigot stayed open, and new laws got piled onto old ones.

What’s broken is American law—a man-made mountain of outdated statutes and regulations. Bad laws trap daily decisions in legal concrete and are largely responsible for the U.S. government’s clunky ineptitude.

The villain here is Congress—a lazy institution that postures instead of performing its constitutional job to make sure that our laws actually work. All laws have unintended negative consequences, but Congress accepts old programs as if they were immortal. The buildup of federal law since World War II has been massive—about 15-fold. The failure of Congress to adapt old laws to new realities predictably causes public programs to fail in significant ways.

The excessive cost of American healthcare, for example, is baked into legal mandates that encourage unnecessary care and divert 30 percent of a healthcare dollar to administration. The 1965 law creating Medicare and Medicaid, which mandates fee-for-service reimbursement, has 140,000 reimbursement categories today and requires massive staffing to manage payment for each medical intervention, including giving an aspirin.

In education, compliance requirements keep piling up, diverting school resources to filling out forms and away from teaching students. Almost half the states now have more administrators and support personnel than teachers. One congressional mandate from 1975, to provide special-education services, has mutated into a bureaucratic monster that sops up more than 25 percent of the total K-12 budget, with little left over for early education or gifted programs.

Why is it so difficult for the U.S. to rebuild its decrepit infrastructure? Because getting permits for a project of any size requires hacking through a jungle of a dozen or more agencies with conflicting legal requirements. Environmental review should take a year, not a decade.

Most laws with budgetary impact eventually become obsolete, but Congress hardly ever reconsiders them. New Deal Farm subsidies had outlived their usefulness by 1940 but are still in place, costing taxpayers about $15 billion a year. For any construction project with federal funding, the 1931 Davis-Bacon law sets wages, as matter of law, for every category of worker.

Bringing U.S. law up-to-date would transform our society. Shedding unnecessary subsidies and ineffective regulations would enhance America’s competitiveness. Eliminating unnecessary paperwork and compliance activity would unleash individual initiative for making our schools, hospitals and businesses work better. Getting infrastructure projects going would add more than a million new jobs.

But Congress accepts these old laws as a state of nature. Once Democrats pass a new social program, they take offense at any suggestion to look back, conflating its virtuous purpose with the way it actually works. Republicans don’t talk much about fixing old laws either, except for symbolic votes to repeal  the Affordable Care Act. Mainly they just try to block new laws and regulations. Statutory overhauls occur so rarely as to be front-page news.

No one alive is making critical choices about managing the public sector. American democracy is largely directed by dead people—past members of Congress and former regulators who wrote all the laws and rules that dictate choices today, whether or not they still make sense.

Why is Congress so incapable of fixing old laws? Blame the Founding Fathers. To deter legislative overreach, the Constitution makes it hard to enact new laws, but it doesn’t provide a convenient way to fix existing ones. The same onerous process for passing a new law is required to amend or repeal old laws, with one additional hurdle: Existing programs are defended by armies of special interests.

Today it is too much of a political struggle, with too little likelihood of success, for members of Congress to revisit any major policy choice of the past. That’s why Congress can’t get rid of New Deal agricultural subsidies, 75 years after the crisis ended.

This isn’t the first time in history that law has gotten out of hand. Legal complexity tends to breed greater complexity, with paralytic effects. That is what happened with ancient Roman law, with European civil codes of the 18th Century, with inconsistent contract laws in American states in the first half of the 20th Century, and now with U.S. regulatory law.

The problem has always been solved, even in ancient times, by appointing a small group to propose simplified codes. Especially with our dysfunctional Congress, special commissions have the enormous political advantage of proposing complete new codes—with shared pain and common benefits—while providing legislators the plausible deniability of not themselves getting rid of some special-interest freebie.

History shows that these recodifications can have a transformative effect on society. That is what happened under the simplifying reforms of the Justinian code in Byzantium and the Napoleonic code after the French Revolution. In the U.S., the establishment of the Uniform Commercial Code in the 1950s was an important pillar of the postwar economic boom.

But Congress also needs new structures and new incentives to fix old law.

The best prod would be an amendment to the Constitution imposing a sunset—say, every 10 to 15 years—on all laws and regulations that have a budgetary impact. To prevent Congress from simply extending the law by blanket reauthorization, the amendment should also prohibit reauthorization until there has been a public review and recommendation by an independent commission of citizens.

Programs that are widely considered politically untouchable, such as Medicare and Social Security, are often the ones most in need of modernization—to adjust the age of eligibility for Social Security to account for longer life expectancy, for example, or to migrate public healthcare away from inefficient fee-for service reimbursement. The political sensitivity of these programs is why a mandatory sunset is essential; it would prevent Congress from continuing to kick the can down the road.

The internal rules of Congress must also be overhauled. Streamlined deliberation should be encouraged by making committee structures more coherent, and rules should be changed to let committees become mini-legislatures, with fewer procedural roadblocks, so that legislators can focus on keeping existing programs up-to-date.

Fixing broken government is already a central theme of this presidential campaign. It is what voters want and what our nation needs. A president who ran on a platform of clearing out obsolete law would have a mandate hard for Congress to ignore.

Philip K. Howard, a New York-based lawyer, civic leader and writer, is the founder of the advocacy group Common Good and the author, most recently, of The Rule of Nobody.



Robert Whitcomb: Health-care beacons, Snowden, our big river



The Connecticut River at Orford, N.H. (See item at bottom.)

Much of American health care’s future can be seen in two synergistic kinds of institutions in Rhode Island.

One is Federally Qualified Health Centers (FQHCs). These facilities, set up around America, provide a wide range of free and insurance-subsidized clinical help for millions of patients, most of them low-income. The other is Johnson & Wales University’s spanking new Center for Physician Assistant Studies.

Consider the state’s biggest FQHC organization -- Providence Community Health Centers (PCHC). Its teams of physicians and other clinicians, such as nurses and nurse practitioners, work for what is the biggest single provider of primary-care services in Providence, with more than 35,000 patients. (I toured PCHC’s immaculate Prairie Avenue campus the other week, led by Merrill Thomas, its CEO, and Jane Hayward, the Rhode Island Health Center Association’s president.)

PCHC ‘s mission, it says, is to “provide neighborhood-based high quality and accessible primary medical care to improve the health status of the residents of Providence and surrounding communities regardless of their ability to pay.’’ FQHCs play especially important roles in inner cities and impoverished rural areas, such as Appalachia, where many physicians don’t want to practice, especially because of low reimbursement and so many difficult cases involving seemingly intractable behavioral-health issues.

Expanding primary care -- especially preventive care -- is essential if America is to improve overall health outcomes that are near the bottom of the Developed World while better controlling medical costs, which are the highest.

Whatever happens with the Affordable Care Act, the U.S. population’s aging (older means sicker); the daunting complexity of our health-insurance system; the permanent exit of many well-paying jobs; emigration to the United States of low-income people, and the decline of the stable, two-resident-parent family suggest that Federally Qualified Health Centers ought to play even bigger roles.

Of course, increasing the numbers of primary-care clinicians is essential for the long-term success of these clinics. Doing just that is the Johnson & Wales Center for Physician Assistant Studies, which has a beautiful building in Providence’s Jewelry District.  George Bottomley, its director, gave  me a tour the other week.

Its 24-month master’s program addresses the need to train many more non-physician clinicians who can perform highly professionally and cost-effectively some of the tasks now performed by over-worked (if highly paid) doctors. PAs are especially useful in getting patients to make the behavioral changes needed to prevent serious illness, in part because they can generally spend more time with patients than can physicians; many of the latter are more harried than ever because of onerous electronic-health-record duties and administrative pressures to boost patient volume.

J&W notes that PAs work in integrated medical teams to “provide diagnostic, therapeutic and preventive health-care services.’’ (By the way, the differences between physician assistants and nurse practitioners mostly involve some education details. They’re very similar professions.)

With physicians as supervisors, physician assistants take patients’ histories and perform exams; order lab tests; prescribe medications; diagnose illnesses; develop treatment plans, and counsel and educate patients.

No wonder that demand for PAs is surging. has listed Physician Assistant Studies as the “No. 1 Best Master’s Degree for Jobs.’’ The American Academy of Physician Assistants ( says that “demand for physician assistants and nurse practitioners rose by more than 300 percent in the last three years.’’

We’ll need Johnson & Wales PAs in droves in coming years as, technology, demographics and new cost controls continue to transform U.S. health care for all patients, especially in primary care, in which physician assistants will be at the forefront.


Edward Snowden – as a Russian spy and/or as an arrogant but naïve narcissist-- has provided vast amounts of U.S. security information to Vladimir Putin’s police state, perhaps resulting in the death of agents working for us. And he has aided the Chinese dictatorship’s relentless cyber-warfare against America. Some hero!


Last week we cruised the gorgeous Upper Connecticut River on a pontoon boat. Because it’s by far New England’s biggest river, on it you get a sense of what Mark Twain might have felt on the Mississippi. We yakked desultorily in the soft breeze about big projects we’d do – as if we were 30 years younger than we are.

Robert Whitcomb (, overseer of New England  Diary, is a partner in  Cambridge Management Group (, a healthcare-sector consultancy, and a fellow of the Pell Center for International Relations and Public Policy.

Robert Whitcomb: Oregon points to better Medicaid

  Unsurprisingly, Rhode Island Gov. Gina Raimondo is getting pushback from interest groups against her goal of “reinventing Medicaid’’ – the federal-state program for the poor. The Ocean State’s Medicaid costs are America’s second-highest per enrollee (Alaska is first) and 60 percent higher than the national average.

Many in the nursing-home and hospital industries will fight the governor’s effort to cut costs even if it can be shown that her plan can simultaneously improve care. After all, the current version of Medicaid has been very lucrative for many in those businesses. The Affordable Care Act has brought them even more money.

As we watch her plan unfold, let’s be very skeptical when we hear lobbyists for the healthcare industry and unions asserting that reform would hurt patients. Lobbyists are adept at getting the public to conflate the economic welfare of a sector’s executives, other employees and owners with its customers’. Ambrose Bierce called politics “a strife of interests masquerading as a contest of principles.’’ Often true!

So “nonprofit’’ Lifespan, the state’s largest hospital system, has just hired eight lobbyists to work the General Assembly to defend its interests. (And beware healthcare executives’ citing their businesses’ “nonprofit’’ status. Many of these enterprises take their profit in huge executive compensation.) Some unions are also on the warpath. They worry that reform to reduce the overcharging, waste and duplication pervasive in U.S. health care might reduce the number of jobs.

But economic and demographic reality (including an aging population, widening income inequality and employers’ eliminating their workers’ group insurance) make Medicaid “reinvention’’ mandatory as more patients flood in.

Oregon provides a model of how to do it.

There, in an initiative led by former Gov. John Kitzhaber,  M.D., an emergency-room physician, the state has both improved care and controlled costs. It did so by creating 16 regional coordinated-care organizations (CCO’s). The state doesn’t pay for each service performed but gives each CCO a “global budget’’ of Medicaid funds to spend. The emphasis is on having a range of providers work with each other to create holistic treatment plans for patients that include the social determinants of health (such as access to transportation and housing quality) as well as patients’ presenting symptoms.

Oregon’s “fee for value’’ approach rewards providers for meeting performance metrics for quality and efficiency and punishes them for poor outcomes and increased costs.

Oregon CCO’s have great flexibility in spending Medicaid money. For example, they could use it to buy patients air conditioners, which may make it less likely that they’ll show up in the E.R. And Oregon CCO’s pay much attention to how behavioral and mental problems can lead to the more obviously physical manifestations of illness. After all, many in our health-care “system’’ “self-medicate’’ through smoking, drinking, drugs, eating unhealthy food and lack of exercise. You see many of these people again and again in the E.R. –wheezing from smoking and obese.

In Rhode Island, 7 percent of Medicaid beneficiaries account for two-thirds of the spending; many of these “frequent fliers’’ have mental and behavioral health problems best addressed through Oregon-style coordinated care.

Unlike the Oregon approach, the “fee for service’’ system that’s still dominant in U.S. health care encourages hospitals and clinicians to order as many expensive procedures as possible, prescribe the most expensive pills and do other things to maximize profit – and send the bills to the taxpayers, the private insurers and the patients.

But “evidence-based medicine’’ -- as opposed to “reputation-based medicine’’’ -- has helped to show that doing more procedures does not necessarily translate into better outcomes; indeed overtreatment can be lethal. I recommend Dr. H. Gilbert Welch’s book “Less Medicine/More Health’’.

Meanwhile, Oregon points the way:

Among the Oregon Medicaid reform’s achievements: a 5.7 percent drop in inpatient costs; a 21 percent drop in E.R. use (which is always very expensive), and an 11.1 percent drop in maternity costs, largely because of hospitals not performing elective early deliveries before 39 weeks of pregnancy. Thus Oregon officials assert that the state can reach its goal of saving $11 billion in Medicaid costs over 10 years.

Rhode Island can achieve similar successes.

Robert Whitcomb (, overseer of New England Diary, is a Providence-based editor and writer and a partner  in Cambridge Management Group (, a national healthcare-sector consultancy. He's also a Fellow of the Pell Center for International Relations and Public Policy.

Llewellyn King: The new world of work

One thing we think we know about the Republicans is that they take a dim view of waste, fraud and abuse. So how come the U.S. House of Representatives, in Republican hands, has voted 56 times to repeal or cripple the Affordable Care Act, better known as Obamacare?

They've put forth this extraordinary effort despite an explicit veto threat from President Obama. Their repeated effort reminds one of Onan in the Bible, which politely says he spilled his seed on the ground.

It’s a waste of the legislative calendar and the talents of the House members. It’s a fraud because it gives the impression that the House is doing the people’s business when it is holding a protracted political rally. It’s an abuse of those who need health care because it introduces uncertainty into the system for providers, from the insurers to the home-care visitors.

It’s symptomatic of the political hooliganism which has taken over our politics, where there is little to choose between the protagonists.

Republican groups think that Obama is the doer of all evil in the nation — especially to the economy — and the world. Daily their Democratic counterparts gush vitriol against all the potential Republican presidential candidates, only pausing for an aside about the wickedness of Fox News.

Their common accusation is middle-class job woes. They’re on to something about jobs, but not the way the debate on jobs is being framed.

The political view of jobs is more jobs of the kind that we once thought of as normal and inevitable. But the nature of work is changing rapidly, and it cries out for analysis.

The model of the corporation that employs a worker at reasonable wages that rise every year, toward a defined-benefit pension, is over. Today’s businesses are moving toward a model of employment at will; the job equivalent of the just-in-time supply chain.

While more of us are becoming, in fact, self-employed, the structure of law and practice hasn’t been modified to accommodate the worker who may never know reliable, full-time employment.

The middle-class job market is being commoditized, as the pay-per-hour labor market includes everything from construction to network administration. Sports Illustrated — synonymous with great photography — has just fired all six of its staff photographers. Don’t worry, the great plays will still be recorded and the Swimsuit Issue will still titillate, but the pictures will be taken by freelancers and amateurs.

Two forces are changing the nature of work. First, the reality that has devastated manufacturing: U.S. workers are in competition with the global labor pool, and business will always take low-cost option. If unemployment goes up in China, that will be felt in the U.S. workplace. Second is the march of technology; its disruptive impact is the new normal. Accelerated change is here to stay.

All is not gloom. The trick is to let the old go — particularly difficult for Democrats — and to let the new in. There will be new entrepreneurs; more small, nimble businesses; and whole new directions of endeavor, from gastro-tourism to cottage-industry manufacturing, utilizing 3D printing. Individuals will be free in a new way.

Government needs to think about this and devise a new infrastructure that recognizes that the nature of work is changing. The emerging new economy should have simplified taxes and Social Security payments for the self-employed; portable, affordable health care; and universal catastrophe insurance, so that those who are not under an employer umbrella can benefit from the equivalent of workers’ compensation. The self-employed, rightly, fear the day they can’t work.

Rugged individualism has a new face. The political class needs to look and see the new workplace.

Llewellyn King (, an occasional contributor, is executive producer and host of “White House Chronicle” on PBS.

Bob Lord: A tax cut for tax cheats

If the most frequently dialed federal agency in America can’t even answer two-thirds of the millions of phone calls it gets, should the government cut its budget?

Congress thinks so. That agency is the Internal Revenue Service (IRS). And lawmakers have hacked at its budget yet again.

Worse still, those cuts will cost more money than they’ll save. They’re basically “a tax cut to tax cheats,” said IRS Commissioner John Koskinen.

Regardless of your feelings about the IRS, Koskinen is right.

The government has slashed the enforcement portion of the IRS budget by nearly 20 percent over the last five years. That’s forcing the IRS to shrink the number of employees working on enforcement by 15 percent.

Talk about being penny-wise and pound-foolish. For every dollar the IRS spent in 2013, it collected $255, according to National Taxpayer Advocate Nina Olson.

Imagine that someone told a CEO that a given department was bringing in hundreds of dollars to his company for every dollar it spent. “It is difficult to see how the CEO would keep his job if he chose not to provide the department with the funding it needed,” Olson said.

Yet, she noted, “that is essentially what has been happening with respect to IRS funding.” Congress has slashed the IRS budget four times in five years. And those cuts are feeding the budget deficit that conservatives supposedly fret about.

It’s all about political expedience. Remember when the IRS faced accusations of singling out conservative nonprofits for tax scrutiny? Along with other experts, I predicted that it would spur further IRS budget cuts. Now Republican lawmakers are taking their revenge.

It’s a vicious cycle. Critics attack the IRS for making mistakes, darkening the public’s view of it. That gives political opportunists a chance to lobby successfully for cuts. A smaller budget virtually guarantees future mistakes by a cash-strapped agency.

Taxpayer services are underfunded too. The IRS now is unlikely to answer even half the phone calls it gets from taxpayers, Olson says. The average wait time is 30 minutes.

So another vicious cycle plays out as taxpayers who try to do the right thing get frustrated. Evasion rates rise. Pressure on the IRS enforcement team mounts.

On top of all that, taxpayers and collectors alike are coping with a tax code that’s more complex than ever. The IRS is responsible for implementing about 40 new provisions of the Affordable Care Act alone, for example.

And it could get more absurd.

The Republican Party is fundraising on the promise of abolishing the IRS altogether, as Citizens for Tax Justice reports. What happens when a country can’t collect taxes?

“Italy and Greece have been stuck in vicious cycles in which tax evasion runs rampant,”Washington Post columnist Catherine Rampell recently wrote. So politicians “raise tax rates to extract more money from the few law-abiding saps still out there, encouraging people to hide economic activity from even higher tax rates, and so on.”

That kind of dysfunction hurts honest taxpayers and bankrupts governments.

Let’s change course before it’s too late.

Bob Lord, a veteran tax lawyer, practices and blogs in Phoenix.  He is an Institute for Policy Studies associate fellow. This was distributed via

Robert Whitcomb: Why people don't work; my training

News media have recently reported on the many people who have permanently given up looking for work. Among the causes cited: federal and some states’ generous disability programs, marriage’s decline, the aging population, the rise of the Internet and the Affordable Care Act.

I would add corporate short-termism, which leads companies to lay off people faster and to be more disinclined to share profits with lower-level employees in raises. Many ex-workers decide it isn’t worth working again. (And grifters game disability payments …)

Especially since the 1980s, senior executives have been heavily rewarded for quarter-to-quarter earnings gains with gigantic pay packages. When I worked for The Wall Street Journal, in the ’70s, the annual earnings report was the big thing; now it’s the quarterly one. Pension and other investment funds (including unions’!) have also pushed for short-term-profit maximization.

A wider view of corporate duties — such as lower-level employees’ compensation and the communities where the companies do business — has slipped in the priority list, especially in public companies. That chief executives tend to stay in their jobs only a few years encourages this by eroding loyalty to fellow employees.

And private-sector union membership has plunged, weakening a power to push companies to share their wealth more widely with non-executives and people without company stock. So while senior execs’ compensation may rise by double digits in a year, average workers are lucky if their raises reach the inflation rate.

Don’t expect any major share-the-wealth action by executives or owners or a higher federal minimum wage anytime soon.

But the large voting constituencies of these seemingly permanently jobless people make it unlikely that programs that help them avoid work will be slashed. Interestingly, their percentages are highest in the Tea Party regions, where complaints about “welfare’’ and the taxes to pay for it are most strident.

Many of the sort of people who 40 years ago would have been working will henceforth continue not contributing to America’s productive energy. Based on anecdotal reportage, most of these people seem pretty depressed and/or bored by their status.


I TOOK THE TRAIN the other week to and from Philadelphia. As I gazed out the window at the beautiful Long Island Sound marshes, I thought of how much of my life I have spent on trains, and how nice it is that we still have so many on the East Coast.

I remember the excitement of being in Pullman car sleeping compartments on trips to the Midwest to see relatives, and the train down to Tennessee to see family there. At every major stop, they’d bring aboard local newspapers. The attendants were almost entirely African-American; being a sleeping-car porter was the most reliable job that blacks could get then.

Then there were the rackety Old Colony Line commuter trains, with their itchy seat upholstery, from Boston’s South Shore to South Station — with the cars and the station dingy and reeking of cigarette and cigar smoke. Still, it was exciting to be put on a train alone as a little kid. And I began the habit of using the train time to figure out assorted issues and to catch up on sleep.

In school I often took a Budd Car train from Bridgeport to Waterbury, Conn., through a heavily polluted sort of Ruhr Valley industrial landscape (most of the factories are long closed now), after getting to Bridgeport from Boston on an old New Haven Railroad train where you could order a nice meal, with linen tablecloth, in a dining car, checking off your order on a card since inane union rules prohibited speaking the order to a waiter. They were remarkably relaxed about enforcing drinking-age rules.

Then I commuted on such innovations as the Metroliners between New York and Washington, and, for a time in the sexy TurboTrains on the Shoreline Route in New England. (They had an elevated section, like trains Out West.)

The Northeast Corridor trains are too often late, especially when they come from the south, the infrastructure way behind European and many East Asian trains and the eating accommodations mediocre. Still, you have much more space than increasingly unhealthy planes (whose ever tighter seating sets you up for a pulmonary embolism), buses and cars and a moving train’s rhythm is soothing, indeed soporific. Trains get you away from it all, even if you’re going to a job.

Robert Whitcomb ( is the overseer of New England Diary.

Don Pesci: Of Gruber, abortion and crime rates



As many students of politics know, there are two kinds of truth: political truth and all other varieties. Political truth, unlike scientific truth, need not be connected verifiably with objective reality. Political truth sometimes dresses up in the robes of science, but bad science also leaves objective reality behind at the altar.
Jonathan Gruber of the Massachusetts Institute of Technology (MIT), the Cassandra of Obamabots, was one of the architects of Obamacare who, unlike many proponents of President Obama’s “Affordable Care Act,” went off script and, in venues he may have thought were off record, simply laid out the truth about Obamacare in such unvarnished terms that even those over-friendly to President  Obama in the media could not easily misunderstand Mr. Gruber’s essential message – which was: Obamacare, right from the get-go, was intentionally misleading. More importantly, he noted, it was of necessity misleading. The sales pitch of the used car salesman who wants you to buy the lemon on his lot, likewise and for much the same reasons, is misleading.
The press spotlight having been focused on Mr. Gruber and the Obamacare warts, media sleuths have now discovered that Mr. Gruber has also told the inconvenient truth about abortion. In a paper co-written during the Clinton administration and printed in the National Bureau of Economic Research (NBER), “Abortion, Legalization and Child Living Circumstances,” Mr. Gruber, along with two other co-authors, wrote:
“Legalization of abortion in five states around 1970, followed by legalization nationwide due to the 1973 Roe v. Wade decision, generates natural variation which can be used to estimate the effect of abortion access. We find that cohorts born after abortion was legalized experienced a significant reduction in a number of adverse outcomes. Our estimates imply that the marginal child who was not born due to legalization would have been 70% more likely to live in a single parent family, 40% more likely to live in poverty, 50% more likely to receive welfare, and 35% more likely to die as an infant. These selection effects imply that the legalization of abortion saved the government over $14 billion in welfare expenditures through 1994.”
Mr. Gruber also touted a positive link between abortion and a precipitous drop in crime rates among “cohorts,” by which term Mr. Gruber means to indicate single parents, the poor and welfare recipients – or, to put the matter bluntly, the underclass, mostly African American and Latino city dwellers, all of whom are fortunate enough to live in close proximity to abortion mills.
A more recent report published in the National Bureau of Economic Research in 2000, “NBER Working Paper No. 8004, probes the connection between legalized abortion and recent crime reductions:
“We offer evidence that legalized abortion has contributed significantly to recent crime reductions. Crime began to fall roughly 18 years after abortion legalization. The 5 states that allowed abortion in 1970 experienced declines earlier than the rest of the nation, which legalized in 1973 with Roe v. Wade. States with high abortion rates in the 1970s and 1980s experienced greater crime reductions in the 1990s. In high abortion states, only arrests of those born after abortion legalization fall relative to low abortion states. Legalized abortion appears to account for as much as 50 percent of the recent drop in crime.”
The  Center for Disease Control and Prevention's Abortion Surveillance report has found that between 2007 and 2010, nearly 36 percent of all abortions in the U.S. were performed on black children, even though blacks make up only 12.8 percent of the population. Another 21 percent of abortions were performed on Hispanics, and an additional  7 percent on other minority races. More than half of all babies killed by abortion between 2007 and 2010 were minorities.


Note that both  Connecticut Gov.  Dannel Malloy and his prison czar, Mike Lawlor, the architect of a bill that awards early-release credits to violent prisoners, have claimed responsibility for a reduction of crime in Connecticut that parallels a national reduction in crime attributed by Mr. Gruber and other economists to abortion. This is the kind of pseudo-science that leaves objective reality waiting impatiently at the altar for a marriage that never occurs. Neither Mr. Lawlor nor Mr. Malloy has yet been so brash to claim credit for the drop in crime rate that has occurred nationwide.


Don Pesci ( is a writer who lives in Vernon