It’s a stretch to say the firing of FBI director James Comey and Trump’s declassification of sensitive information to Russia are stratagems meant to distract you from the AHCA. But in case it’s having that effect, let’s gloss over the brutality in store for Americans if TrumpCare passes the Senate.
In simple terms, the American Health Care Act would position Mainers and Americans vulnerable to a health care system that could be so inaccessible that it infringes on a person's basic right to live — which is, lest we forget, constitutionally inalienable. Though Democratic leadership has settled on a weak-sauce position toward the adoption of a universal health care plan (like single-payer), the majority of Americans support it, and there’s no better time to push for it.
If Democrats don’t renew their support for single-payer and away from a market-based, consumer-driven health care, the consequences could be dire. But astonishingly, Democrats have seemed to all but abandon the fight for single-payer, which has been a touchstone of their platform since the Truman Administration.
It’s a long road they’ve taken toward conceding this principle. In 1994, Hillary Clinton herself was reportedly a proponent of single-payer coverage, saying in a statement to the Lehman Brothers Health Corporation that “...I believe that by the year 2000 we will have a single-payer system in this country … I think the momentum for a single-payer system will sweep this country.”
But something caused her to change her tune. It could be political expertise, or it could be that from 2013 to 2015, Clinton pocketed over $2.8 million from 13 paid speeches to the health industry.
Meanwhile, Democrats’ insistence on distancing themselves from universal health care has become commonplace. After the AHCA passed the House last week, Minority Leader Nancy Pelosi had a golden opportunity to pin support for a single-payer system to the Democratic platform after issuing the soundbite that TrumpCare was “Robin Hood in reverse.” But she demurred. Instead, Pelosi stated that the political reality is that Congress “isn’t ready” for a single-payer system.
Whether a Republican-controlled Congress is “ready” is arguably besides the point. Democrats controlled both the House and Senate in 2010, yet President Obama still failed to pass a single-payer system, or even a public option.
Writes Branko Marcetic in a treatise this spring in the lefty journal Jacobin: “The particularly bizarre thing about many of these attacks on single-payer from prominent liberals and Democrats is that they’re fundamentally conservative arguments: single-payer is too radical and farreaching a change; it’s too expensive; it’ll mean raising taxes; it’ll involve giving the federal government too much power.”
Despite these cries, a 2016 Gallup poll found that 58 percent of Americans support it. Even a recent survey by The Economist, ideologically aligned with market-driven systems, reported that a majority of Americans support “expanding Medicare to provide health insurance for every American.”
Of course, Bernie Sanders hitched his campaign to the hopes of establishing a single-payer system. In an op-ed for the Brookings Institute in January, 2016 Henry J. Aaron wrote that a single-payer system would cost the government 4.1 trillion a year, “or 1.4 trillion more than the federal government now spends on programs Sanders” would have replaced. “New money would come from taxes.” Opponents say that specifics were fuzzy and the proposal too radical.
But radical is what’s happening now. Rep. Bruce Poliquin voted for the AHCA, which passed the House by a 217-213 vote in early May, despite the fact that the majority of his constituency, elderly and low-income Mainers, would be hardest hit. Rep. Chellie Pingree, who voted no, has gone on record as saying she was “disappointed that we did not accomplish single payer health care or a public option” in the Affordable Care Act. Angus King has said the Affordable Care Act was “not ambitious enough” but has not endorsed single-payer. And Susan Collins, ever the political expedient, has made statements on both sides of the fence.
IT STARTS LOCALLY
If Democratic leadership won’t fight for single-payer, then someone has to. This month, the Portland-based Southern Maine Workers’ Center released a lengthy report titled “Enough For All: A People’s Report on Health Care” as part of the organization’s Health Care Is a Human Right campaign. In it, they surveyed 1300 Mainers in 13 Maine counties about their relationship to health care and their difficulties finding adequate, comprehensive, affordable coverage.
Consisting of plentiful data attesting to the hardship of receiving quality, affordable care and a litany of personal testimonies, the report is powerful. According to the SMWC’s findings, 90 percent of respondents believe “that it is the government’s job to protect our human right to health care," and 83 percent like the idea of a universal, publicly-funded health care system.
States the report: “Our understanding of universal human need leads us to the conclusion that health care is a human right for every person.” In one succinctly put testimony, credited to Rachel in York County, “wealth is created from our health needs.”
Elsewhere in the report, they write that “Our current system of coverage, rather than care, deepens racial health disparities and promotes worse health outcomes for people of color and immigrants. Nationally, more than half of the total 32.3 million nonelderly uninsured are people of color [a demographic representing five percent of the population in Maine]. Black people are twice as likely to fall into the coverage gap that exists in the 19 states, including Maine, that have not expanded Medicaid.” This means lower-income people go to emergency rooms, or delay care because of concerns about cost. This, of course, turns into a system of entrenched debt for people who can least afford to take it on, with the benefit of profit for those in the insurance and medical industries.
The Southern Maine Workers’ Center argues for an equity-based system, one where those participating in the health care system put in what they can and take what they need. Focusing on principles of equity, universality, transparency, accountability, and participation, some of the principles they argue for include:
All state residents are enrolled. There are no exceptions, including people who are homeless, do not have employment or income, and immigrants with or without documentation. Everyone benefits, including those enrolled in existing public programs such as Medicare and MaineCare. There is no convoluted enrollment process.
Care is comprehensive. There is a focus on our right to safe, effective, and therapeutic preventative care. Baseline services include dental, vision, hearing, mental health services, reproductive health and family planning services like abortion and contraceptives, as well as gender affirming care.
“A new system must evolve in response to people’s experiences with it,” they write. “To ensure accountability to residents, communities, and Mainers’ human right to health, local community boards, statewide commissions, and annual public hearings will be created. Representatives will reflect the diversity of Maine’s patients and providers.”
How do we get there? They offer three proposals:
“1. A progressive income tax, where higher wage earners pay more than workers who earn less. This is a sliding scale that goes down to zero for people living at a certain level of poverty. 2. A progressive payroll tax, where larger employers with significant wage disparities pay more than smaller employers who pay their workers higher wages. This incentivizes larger employers to fairly compensate workers, while accounting for the benefits small businesses make to local economies. 3. A tax on non-wage wealth. There is a small percentage of the state population who accumulate wealth from stocks, interest, dividends, etc. rather than through working hourly or salaried jobs. This tax ensures that a wealthy minority don’t leave the ordinary, working majority to cover all the costs.”
Other local initatives resisting the AHCA are cropping up too. This week, Maine Public Radio reported that state lawmakers are considering a bill (proposed by Eloise Vitelli, D-Arrowsic) that would enfore greater transparency in drug costs, requiring drug makers to disclose how they arrived at prices for prescription medication.
RIGHT VS. GOOD
Opponents of a single-payer system — and there are many — have long held that health care is a commodity, not a right. This is, essentially, an argument conservatives hold dear: People with poor health have brought their health concerns upon themselves with bad choices, and that “individual responsibility” dictates that those in healthy, “low-risk” pools shouldn’t be required to pay for anyone else.
Girding this is a belief that health care is a consumer good, and is thus governed by the innate logic of the market and its system of price determinations. Conservative economist Kevin D. Williamson argues we’re dealing with a scarce good, not a right. “Health care is physical, not metaphyiscal,” he writes in a May 7 article in the right-wing journal The National Review. “It consists of goods, such as penicillin and heart stents, and services, such as oncological attention and radiological expertise.”
“Rich people always get better stuff. That’s what it means to be rich,” Williamson adds.
A fight for universal health care is nothing less than a determination of the immorality of using statements like this to determine health. Of course goods and services cost money, but strict market fundamentalism, as the AHCA is set to prove, is a sort of violence of its own, and those directly affected are soon to be the majority of the population. In another article (titled “Why Shouldn’t Women Pay More For Health Insurance?” on May 5), Williamson argues that “women have radically higher lifetime medical expenses than men do, about one-third higher, on average.” Therefore, they should accept the logic that they should have to pay more.
This argument absolves conservatives of the responsibility of dealing with fundamental injustices in American social life, from wage and lifestyle inequity among women, LGBTQ people, and people of color, to reproductive services, to health and wellbeing affected by domestic abuse and rape.
If there’s a silver lining to TrumpCare — at least in the current proposal existing between the House and Senate — it’s that it’s primed to expose the flawed logic and basic immorality of this thinking more than any time in history.
In our current system, no insurer can make a profit off someone who is sick. But putting an insurer’s right to profit over the health and wellbeing of American citizens is fundamentally immoral. People are catching on.
GUESS WHO'S PRIORITIZED
Some of the people who will suffer the most under the AHCA are the elderly. In Maine, that’s the second highest state demographic in the country. A huge portion of this comes from the $900 billion cut to Medicaid. But don’t be fooled into thinking those who retain coverage have it any easier. Under the ACA, it was forbidden for insurance companies to charge more than three times the rate of a low-risk individual in the same region. Under TrumpCare, they can charge five times that.
Literally being a woman isn’t a pre-existing condition, but it’s close. It’s not that the GOP will admit it has anything against women; they just believe that women need to fend for themselves, with fewer resources than anyone else.
The AHCA would harm women dramatically. For all Obamacare’s entanglements, it drastically improved women’s access to health care. According to the Kaiser Family Foundation, the total rate of women who went without health care coverage fell from 17 percent in 2013 to 11 percent across the board in 2015. (For single mothers, the rate fell from 24 to 16 percent; for Black women, it fell 19 to 14 percent; for Latino women, it fell 31 to 20 percent.)
Of course, the GOP is also going hard after Planned Parenthood, proposing to cut off federal Medicaid payments to the organization entirely. In 2015, Planned Parenthood comprised only six percent of the 10,708 health centers providing family planning and reproductive health care, a group that also includes community health centers and specialized centers. Yet 32 percent of women who sought care at any of these facilities were treated at Planned Parenthood, a testament to its value.
The AHCA would starve off federal payments to Planned Parenthood, for what seem like purely ideological reasons. It’s already federal law that patients cannot use federal money for abortion services (other than cases of rape, incest, or a threat to the woman’s life). The bill would provide additional funds to community health centers (CHCs) — a point for which right-wing advocates are crowing will “give women more options.” There's nothing wrong with CHC's, but there’s also nothing that states that additional federal dollars given to CHCs under the AHCA would be used for women’s health care, as Planned Parenthood supporters are quick to point out. In a report by the Congressional Budget Office in March, cutting off access to Planned Parenthood would result in the loss of access in lower-income communities. It would also result, health experts estimate, in a significant boost in unintended pregnancies.
In short, those who aren’t wealthy, or who aren’t young, healthy white men, will be hit hard.
THE TRUE COST OF CARE
If there’s a silver lining to the AHCA, it’s that it’s such a transparent transfer of wealth to the insurance industry that it risks widespread exposure for its failed moral logic. When pundits like Williamson pedantically argue that women cost more to insure, ergo they should pay more, it takes a special kind of person to ignore that women earn 78 percent of what men make for the same work, and are systematically excluded from protections across the board. What the AHCA truly exposes is the immorality inherent in the doctrinal conservative belief in personal responsibility. Dating back to the late 19th century, conservative thought has attempted to stave off the notion that federal government has a responsibility to ensure the health and wellbeing of its people. But if the alternative is a sick and ravaged country, then it it’s clearer than ever who profits off a consumer-driven system.
Said Tim Faust, a Brooklyn writer who studies health care, in a recent lecture at SUNY, “the federal government is the only actor that recognizes the cost of care and the cost of not providing care.” Faust believes that a consumer-driven health care model compels doctors to unwittingly make choices that ultimately harm their patients.
Shades of this are echoed in the Southern Maine Workers’ Center report. Sandra from Westbrook articulates a common issue with citizens receiving appropriate care, and the concerns they have about getting priced out.
“When I went to the doctor to have some standard screenings done, I was told, ‘We don’t think you have cancer, but we want to do one more thing… just to put it to rest.’ No conversation about how much this will cost or contacting my insurance to see if it’s covered. Then I get this bill for almost $3,000! I sure didn’t get peace of mind. When I think about all the things I could do for my health with that $3,000 … Our healthcare system needs to be transparent about the cost of the services prior to receiving services.”
The ideology that health care is a consumer good follows that making patients bear a higher share of medical costs will ultimately bring those costs down. This presumes that a “rational” health care consumer exists and will shop for coverage in the same way we shop for toothpaste or avocados.
In reality, no one does this. The need for health care coverage is often pinned to anxiety, illness, worry, in-the-moment reaction, and so on. As much as the GOP wants to reduce it to an a la carte menu of goods and services, people living in a society are largely dependent on the health and wellbeing of one another. Put another way, if you’re a thirty-something white bro with the resources to eat organic and do CrossFit, you might not need insurance coverage for awhile, but you’re still living in — and beholden to — a system that ensures people who need care, from penicillin to contraceptives to cancer screenings, receive it.
Terralyn, a registered nurse who works in a small emergency room in Millinocket, says in the same report: “I care for patients who often arrive to our facility sicker than they should be. They are from working families afraid to seek care sooner due to concerns about medical bills, or elderly patients already struggling to pay. Regular physician office care treatment would have made ER services unnecessary. These people, however, are fearful of losing their savings, or their homes after a major illness. I have seen patients leave our ER against medical advice and die within a day or two. Their financial situation and lack of affordable health insurance was the deciding factor in their choice. Our healthcare system is broken, and even when you pay for health insurance there is no guarantee that your care will be covered. There needs to be a fair system for everyone.”
A HIDDEN SIDE-EFFECT
There’s also evidence that those who with a precarious relationship to coverage are made sicker by that relationship. Viewed in this light, cost of care can be seen as a “negative side-effect” of an ineffective health care system. Zack Buck, Associate Professor at the University of Tennessee College of Law, calls this an example “financial toxicity,” or the idea that “individuals experiencing financial distress as a result of the cost of their care experience higher rates of mortality than those who do not.” Essentially, this means that long-term health care-related financial debt is itself deleterious to your health.
HOW IT'S GONNA GO DOWN
Though the AHCA leaves roughly four-fifths of the ACA intact, it cannot be overstated how difficult average people will have it under the proposed changes, particularly the poor and elderly. There’s a lot of details we can’t cover here, but early reports by the Congressional Budget Office estimate that roughly 24 million people will lose coverage. Besides the roughly $900 billion decrease in Medicaid coverage, essentially a tax cut for insurance companies and the already-wealthy, the plan penalizes those who go more than 63 days without insurance, further disincentivizing them from obtaining health care when they’re able to.
In Maine, this will have a pronounced effect on the opioid crisis. Quoted in a recent article in Mother Jones, Richard Frank, Professor of Health Economics at Harvard University, estimates that roughly three million Americans with addiction disorders would lose some or all of their coverage, according to a recent report in Mother Jones as part of the shifting to states’ ability to determine “essential benefits.” Under the Affordable Care Act, insurers were prevented from denying coverage or charging people higher rates based on pre-existing conditions. The ACHA, of course, guts those provisions. Health experts believe that premiums, which were the major talking point behind the push to dismantle Obamaare, would increase dramatically.
Instead of the individual mandate in the ACA, the AHCA introduces continuous enrollment penalties. Insurance companies would now be able to charge new enrollees a 30 percent mark-up on their premiums the next year.
Under the ACA, the elderly could only be charged three times what young people were charged. Now they can be charged five times. Instead of subsidies based on income, recipients of health care under the AHCA would receive subsidies based on age: up to two thousand to four thousand, which is often insufficient.
Additionally, the Affordable Care Act had community ratings, which meant that premiums were the same for a region. Insurers could adjust cost for age but nothing else. Under the AHCA’s McArthur Amendment, states have the option to use waivers to get out of a community rating for people who don’t have continuous coverage. When you re-enroll, your state has a waiver to ask people questions to determine your premium.
In the cases where insurers can’t literally deny coverage, they would be able to theoretically offer an exorbitant, astronomical premium. This would apply for a host of possible preconditions, like if someone had a cancer scare, was assaulted or raped, and so on.
Writes Matthew Friedler, a fellow for the Center for Health Policy (Schaeffer Initiative) in a report published by the Brookings Institute, “a single state’s decision to weaken or eliminate its essential health benefit standards could weaken or effectively eliminate the ACA’s guarantee of protection against catastrophic costs for people with coverage through large employer plans in every state. The two affected protections are the ACA’s ban on annual and lifetime limits, as well as the ACA’s requirement that insurance plans cap enrollees’ annual out-of-pocket spending. Both of these provisions aim to ensure that seriously ill people can access needed health care services while continuing to meet their other financial needs.”
AND THEN THERE'S MAINECARE
At the local level, the AHCA has embolded conservatives to put up even more barriers to adequate care. The Department of Health and Human Services has proposed a series of rule changes, currently under review. Under those proposals, the new rules would require “able-bodied adults” to meet “community engagement or work requirements” to be eligible for MaineCare, as well as pay monthly premiums as an individual contribution toward health care costs. For a program designed as a social safety net, the fabric is thin. “Members who fail to make timely premium payments will be disenrolled from MaineCare.” It would also institute a number of “asset tests” to determine eligibility, cease to provide retroactive coverage, and eliminate the option for hospitals to make presumptive eligibility determinations. (This means more of those determinations would be made by Mary Mayhew and the DHHS, which has been far more concerned with saving taxpayer money than ensuring Mainers get adequate coverage.)
A public hearing opposing these rule changes will be held at the Cross Insurance Arena on Wednesday, May 17 at 9 am, and at the Augusta Civic Center on Thursday, May 18 at 9 am.
The AHCA is in limbo while the Senate considers it, and many expect its provisions to change mightily. In the meantime, Americans have an opportunity to closely examine the conflicting philosophies behind the health care debate — is it a right or is it a commodity — while the stakes have never been higher.