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Kevin ClarkeJuly 28, 2017
Sen. John McCain, R-Ariz., speaks with reporters ahead of a health care vote on July 27 on Capitol Hill in Washington. The Senate rejected legislation to repeal parts of the Affordable Care Act, with McCain casting a decisive "no." (CNS photo/Aaron P. Bernstein, Reuters)Sen. John McCain, R-Ariz., speaks with reporters ahead of a health care vote on July 27 on Capitol Hill in Washington. The Senate rejected legislation to repeal parts of the Affordable Care Act, with McCain casting a decisive "no." (CNS photo/Aaron P. Bernstein, Reuters)

Relief was likely the overriding emotion this morning experienced by a lot of Americans who have found their way, often for the first time in their lives, to health insurance under the Affordable Care Act. It was one shared by Carol Keehan, D.C., C.E.O. and president of the Catholic Health Association.

“We are relieved and delighted that the [Affordable Care Act] remains intact,” Sister Keehan said. “We believe that there were lots of heroes on both sides of the aisle as this was sorted through, and we think that this is really an important moment now to hear the people on both sides of the aisle that have said we need to come together and work on making this better.”

In the culmination of seven years of efforts to end the A.C.A., Senate Republicans were unable to pass their “skinny repeal” of Obamacare. Senator John McCain of Arizona, in a dramatic turnabout, joined two other Republican senators, Susan Collins of Maine and Lisa Murkowski of Alaska, united with Senate Democrats and Independents in voting down a measure that had been introduced just hours before.

Sister Keehan described that last-ditch effort to repeal major components of Obamacare as “poorly thought-out” and “harmful,” hastily pulled together without input “from the people who take care of patients or even from the American public.”

“The American genius can make the A.C.A. so much better. We need to marshall that genius.”

Bishop Frank J. Dewane of Venice, Fl., chair of the bishops' Committee on Domestic Justice and Human Development, in a statement released on behalf of the U.S. Conference of Catholic Bishops this morning, suggested it may be time now for members of Congress to put the repeal effort behind them and pull up their sleeves. “Despite the Senate’s decision not to pass legislation to repeal and replace the Affordable Care Act last night,” he said, “the task of reforming the healthcare system still remains.

“The current healthcare system is not financially sustainable, lacks full Hyde protections and conscience rights and is inaccessible to many immigrants. Inaction will result in harm for too many people.”

An opportunity has come for Congress, Bishop Dewane said, “to set aside party and personal political interest and pursue the common good of our nation and its people, especially the most vulnerable.”

Sister Keehan agrees the G.O.P. failure could be a pivot point on further progress toward the universal coverage in the United States that most other industrialized nations have taken for granted for decades. “No matter how enthusiastic a supporter you may have been for the A.C.A., no one thought it was a perfect law or as good as it could be if we could work on it together,” she said. “But it is very hard to improve a law that half of Congress was trying to get rid of.”

Now, she said, “we have people on both sides who believe we need to work together. We heard that loud and clear from Senator McCain’s speech.”

“The American genius,” she said, “can make [the A.C.A.] so much better. We need to marshall that genius, to use everybody’s input and gifts to make this bill so much more of service to the American people and the American economy.”

According to Bishop Dewane’s statement, any future health care legislation should protect the Medicaid program from changes “that would harm millions of struggling Americans” and protect the U.S. social safety net “from any other changes that harm the poor, immigrants, or any others at the margins.” He said health care reform should “address the real probability of collapsing insurance markets and the corresponding loss of genuine affordability for those with limited means” and “provide full Hyde Amendment provisions and much-needed conscience protections.”

As the legislative drama concluded last night, a frustrated President Trump turned to Twitter to complain: “3 Republicans and 48 Democrats let the American people down. As I said from the beginning, let ObamaCare implode, then deal. Watch!” It was not the first time that he has suggested that his administration would remain on the sidelines as insurance markets remained vulnerable around the country. Analysts point out that the Trump administration, particularly through the Department of Health and Human Services, has many options at its disposal if undermining the A.C.A. were a deliberate aim.

Sister Keehan was hopeful that would not be the case. “Man does not live by tweet alone,” she said with a chuckle. “I don’t pay attention to tweets; I do pay attention to policy and legislation.”

She added, “It is important that we all accept our responsibility for being at the service of the people of this country when we have a job to do as a politician or as a provider of health care. We do need to work together.

“Many of the people who are the most ardent supporters of President Trump depend on Medicaid,” she pointed out. “I’m sure that he does not want to see anybody in this country hurt because we undermined service to people or undermined American health care.”

She said the C.H.A. is ready to be a constructive part of dialogue aimed at improving health care in the nation: “We offer our service to Congress, to the H.H.S. and the president to do that.”

Bishop Dewane offered a qualified commitment of support for future health care reform legislation should the 115th Congress produce it. “Any final agreement that respects human life and dignity, honors conscience rights, and ensures that everyone can access health care that is comprehensive, high quality, and truly affordable deserves the support of all of us,” he said. “The greatness of our country is not measured by the well-being of the powerful but how we have cared for the ‘least of these.’ Congress can and should pass health care legislation that lives up to that greatness.”

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Stuart Meisenzahl
6 years 9 months ago

Sister Keehan
Your Universal Care = Single Payer?
Where were you when President Obama knowing it to be untrue deliberately stated:" If you like your Doctor, you can keep your Doctor. If you like your Plan you can keep your Plan" ??
Surely you must have been aware since President Obama has praised you for essentially working hand in glove with him in getting the ACA passed.

Kevin Murphy
6 years 9 months ago

Sister Keehan has been carrying the Democrats' water for a long long time. Wouldn't believe a word she says.

JR Cosgrove
6 years 9 months ago

Any discussion on America without a frank discussion of what is possible, what is driving cost, what is wrong with the current system and what can be done is just posturing.

Let's not have all the self righteous declare what must be done without discussin feasibility and costs like these don't matter and anyone trying to get to a sensible healthcare system is some heartless non caring cynic.

Maybe someone will discuss Medicaid honestly. Certainly none of the authors here have ever done so.

Joseph J Dunn
6 years 9 months ago

A study published in the New England Journal of Medicine in 2013, "The Oregon Experiment—Effects of Medicaid on Clinical Outcomes," points to troubling clinical findings.

Two years after enrollment, “We found that insurance led to increased access to and utilization of health care, substantial improvements in mental health, and reductions in financial strain, but we did not observe reductions in measured blood-pressure, cholesterol, or glycated hemoglobin levels.”... “We found no significant effect of Medicaid coverage on the probability that a person was a smoker or obese…Medicaid coverage had no significant effect on the prevalence or diagnosis of hypertension or high cholesterol levels or on the use of medication for these conditions. It increased the probability of a diagnosis of diabetes and the use of medication for diabetes, but it had no significant effect on the prevalence of measured glycated hemoglobin levels of 6.5% or higher. Medicaid coverage led to a substantial reduction in the risk of a positive screening result for depression. This pattern of findings with respect to clinically measured health — an improvement in mental health but not in physical health— was mirrored in the self-reported health measures, with improvements concentrated in mental rather than physical health. The improvements appear to be specific to depression and mental health measures; Medicaid coverage did not appear to lead to an increase in self-reported happiness, which is arguably a more general measure of overall subjective well-being.”

Taxpayers paid $574 billion to support Medicaid in 2016. Persistent elevated glycated hemoglobin levels leave the patient prone to the worst complications of diabetes. The hazards of smoking are well known. Studies (Kaiser Family Foundation, etc.) show that high obesity rates in America (second highest in the OECD) are correlated to Americans’ shorter life expectancy and other higher morbidity statistics compared to other developed countries, while we spend more money per capita for health care than other developed nations. Empathy compels us to confront the obvious: without lifestyle changes, no amount of professional health care or subsidized insurance will reduce the prevalence of chronic disease or extend life spans.

Chuck Kotlarz
6 years 9 months ago

Oregon’s obesity rate runs lower than the average of twenty-eight right-to-work states. No r-t-w state has a lower obesity rate than California. One r-t-w state has a lower obesity rate than New York.

Joseph J Dunn
6 years 9 months ago

Interesting statistics, and I suspect this is the kind of thing that Mario Paredes and others are looking into, as discussed nearby. https://www.americamagazine.org/politics-society/2017/07/31/comprehensive-holistic-care-will-keep-medicaid-patients-healthier.
I'm encouraged that knowledgeable professionals are researching new approaches as we now realize that simply providing low-cost or no-cost (to the beneficiary) insurance is not the key to better health. For brevity I did not mention earlier a similar study (Rand Insurance Experiment) published in New England Journal of Medicine in 1983 that found minimal health improvements among recipients of low- or no-cost insurance. Let's hope one or more of the research trials lead to more effective approaches.

Stuart Meisenzahl
6 years 9 months ago

Sister Keehan represents an organization of Catholic Hospitals which need the Medicaid expansion and funding set up by the ACA. Those hospitals are required by law to provide Emergency Services to everyone who appears at their doors whether they are insured or uninsured. The ACA Medicaid expansion permitted those Hospitals to have uninsured patients sign up for Medicaid even as late as at the time of admittance .
.Thus the ACA offsets some of the uninsured costs imposed on hospitals by law. I understand why the Catholic Hospital Association wants to hang onto the ACA
But Sister Keehan's expressed pleasure"that the ACA remains intact" is more than a bit premature. That 2700 page behemoth is full of time bombs , not the least of which is a mandatory reduction in reimbursement to hospitals for uninsured care hiding under the moniker "Disproportionate Share Hospital Benefits". The ACA met its cost scoring requirements by front ending benefits and back ending costs. The new amounts allocated by the ACA to reimburse hospitals for uninsured care was suppose to start reducing in 2014 but it was noted that the Hospitals would notice this in an election year 2016 .........so the start of the reduction date was changed to 2018.. CONVENIENT.

But now that time has come and The Centers For Medicaid Services has announced on Thursday that with the failure to repeal the ACA there will be by law a $43 billion dollar reduction in such reimbursement over the next 7 years. There is no choice while the ACA is still the law.
Already a number of hospitals have indicated that they will begin to layoff or cut staff and services to make up for this lost reimbursement.This entire scheme was set up to tide the hospitals over until the expected expansion of insured admittances generated enough income to allow this scheduled reduction. But since the basic premise of the ACA that more (non Medicaid) insureds would develop failed to occur, a very big financial hole was created without permanent funds to fix it.

The defect was hidden to avoid the election issue. You can bet there will be dozens of other surprises as the front end benefits of the ACA finally reveal the deferred cost structure necessary to support them in this 2700 page disaster. See "Modern HealthCare, July 28 2017". Sister Keehan ....one of the prime movers in getting the ACA passed ....is about to "eat her own cooking" and I suspect she is not going to get a lot of help in revising the ingredients.

Stuart Meisenzahl
6 years 9 months ago

On August 4th Aetna announced it was withdrawing from ObamaCare participation in all remaining states. The President of Aetna in making this announcement stated that Obamacare "cannot be repealed" but must be fixed to have insurers rejoin. Aetna cites continued losses, but the real cause is built right into that 2700 page behemoth: .....the expiration in 2017 of the provisions requiring annually Federal Subsidy payments to the insurance companies to offset losses. This expiration date was set because the ObamaCare projection was that sufficient people would join the exchanges by 2017 to allow the insurance companies to operate without this Federal bribe/crutch. Yet another missed projection with disastrous consequences: insurance company "blackmail".
So into the mix we can now add the Insurance industry threatening to further undermine an already failing ObamaCare system unless it is "paid off". Add this to the scheduled $43 Billion loss to hospitals of reimbursement for uninsured care noted in my Comment above.
So who is responsible for this escalating disaster ? Look to ACA Architects Zeke Emanuel and Jonathan Gruber and their cast of supporters including Sister Keehan. Together they have wrecked an already troubled health care system by suborning the insurance companies with bribes/subsidies and phony projections. The Democratic Congress was fully complicit by creating a 2700 page bill no one read or understood but with full knowledge and intent that worst case a "single payer government controlled system" would emerge from the wreckage. Harry Reid has candidly admitted this was their intent (Wall Street Journal October 21, 2013). Under single payer Sister Keehan and the Catholic Hospital Association members would obtain a continued flow of Federal Medicaid and other Federal $$$ at the cost of being required to provide Federally mandated medical services including abortion. Sister Keehan will have only herself to blame.

Joseph J Dunn
6 years 9 months ago

From the Wall Street Journal today:
"Aetna previously announced plans to next year exit the ACA exchange business, which has generated losses and is expected to do so again this year, despite the results of the risk programs." If the reinsurance program you describe is intended as a bribe to insurers, it is poorly contrived, and the insurers hardly see its renewal as sufficient to induce their continuation. The WSJ article goes on to provide more details on the reinsurance program you describe as "suborning the insurance companies with bribes/subsidies."
As Sections 1341-1343 of the ACA prescribe, the reinsurance program takes premiums from insurers who operate in the ACA, and uses those funds to PARTIALLY offset underwriting losses they sustain in the ACA individual and small risk markets. So, no taxpayer money or federal money (except to the extent that the Treasury does hold the reinsurance premiums until results are tallied) are involved.
There are defects with the ACA, which the insurance industry foretold, and which remain in force. One problem is the requirement of actuarially irrational premium calculations. See Section 2701 for details. The other failure (not entirely separate) is trying to accomplish the end of 'pre-existing conditions' exclusions, without effectively pulling all or virtually all the 'young and healthier' into the insured pool. So premiums and co-pays, etc., keep going up sharply. Add these problems to the Medicaid issues already cited, and you have a good list of the major problems that need to be addressed in the ACA. I just thought it important to clear up any confusion about the reinsurance issue.

Stuart Meisenzahl
6 years 9 months ago

Would that the reinsurance program were as simple as you described. As written up in Forbes in an Article entitled
" How the Obama Administration Raided the US Treasury to Payoff Insurers" the ACA reinsurance program was designed to be a state program that was escheated to and seized by the Federal Government when States refused to set up such programs. This was all done without any legislation that would permit it as just one of any number of "work arounds". Invented to fix the deeply flawed and unworkable ACA legislation. The Federal Government then imposed the reinsurance tax on ALL insurers when it was originally only permitted to be imposed on Insurers who were part of the Exchanges. This even included Employer Plans and resulted in higher "employee shared costs" under those plans. In short a state specific reinsurance plan was nationalized to permit Exchange Insurers to write lower cost policies without as much risk exposure. To compound this blatantly unconstitutional program, HHS abandoned distribution of reinsurance benefits based both on 1) State population enrollment on an Exchange AND 2) some 50 to 100 specific medical conditions that would trigger reinsurance payments. Instead the HHS reinsurance program just decided to provide reinsurance reimbursement whenever the Insurance Company had high out of pocket risk losses. This encouraged and permitted the large insurance companies to write policies with low premiums because they were reinsured by this Federal Program against losses. The Forbes Article details how the failure to attain projected enrollment numbers inthe ACA led to a series of "HHS Fixes" for the reinsurance program that totally failed to project necessary funds for the program and proceeded to pay the deficit out of allocated Treasury funds. These other fixes included raising the reinsurance reimbursement from 80% of the unexpected insured loss to 100%.
All of this was done to entice and keep Insurers in the Exchanges and keep them writing lower premium costs. Net net the Federal Government had taken over the reinsurance program and has continued to use it to effectively "bribe" the Insurers to participate/stay in the Exchanges. But as noted, there is now the unfortunate convergence of two facts: Reinsurance reimbursement by HHS is still insufficient to offset risk losses and the expiration of the statutory authorization for the reinsurance program.
The ACA is a victim of its own flawed design and projections: a gross overestimate of the number of people who would sign up on the Exchanges; The cost of the Medicaid expansion being woefully underestimated; ridiculousunderestimate of administrative costs ; usual federal government incompetence and inefficiency.
You are certainly correct: reinsurance revival is not enough. The insurance companies are not just looking for the reinsurance program to be reinitiated, they are now demanding a whole new bailout. The Insurers currently hold all the cards and have been dealt this leveraged hand by the total failure of the ACA. The alternative to this "insurance bailout" is a complete collapse of the insurance market. I believe it was Harry Reid who said: ..."The ACA is just the first step to single payer"

Joseph J Dunn
6 years 9 months ago

Thanks for your note. I think we are in agreement about the flawed design and projections.
I did not see the Forbes article, but the Act from the beginning required "contributions" to the reinsurance entity "based on the percentage of revenue of each issuer and the total costs of providing benefits to enrollees in self-insured plans or on a specified amount per enrollee" and more specifically, "proportionally reflects each issuer's fully insured commercial book of business for all major medical products and the total value of all fees charged by the issuer and the costs of coverage administered by the issuer as a third party administrator." (Section 1341). So, no administrative change there.
Assuming Forbes's other points are accurate, then the design became even more flawed as a result of the changes made administratively, against the specific provisions of the Act. I do note that whatever reinsurance plan was set up proved inadequate to save 24 separate non-profit co-ops that were established to write individual and small group policies. They are gone. Looks like the major companies decided to continue the noble experiment through the three-year length of the reinsurance, if on a reduced basis--probably a politically wise decision, but one that cost their shareholders(real people, often working people, even the teacher with a mutual fund in her 401-3-b) hundreds of millions of dollars. Looks like a good thing there were commercial, for-profit insurers to absorb the unreinsured losses. Under single-payer, taxpayers would have been paying up for the underwriting losses.
A few random thoughts:
Years ago the decision was enacted whereby persons suffering with end-stage renal disease (acute kidney failure), who need frequent dialysis until they can receive a kidney transplant, are eligible for Medicare, regardless of age. Would such be appropriate for those affected by some or all of the "at least 50 but not more than 100 medical conditions that are identified as high-risk conditions" that the Secretary of HHS was to identify under the ACA? This would remove the most financially catastrophic illnesses out of the ACA risk pool, which would reduce the need for reinsurance AND lower insurance costs for others, including the 'young and healthies,' perhaps enough to boost enrollment and better balance the risk pool. Medicare would continue to be funded through payroll taxes into the Medicare trust. There are other precedents for this, e.g., flood insurance is a government-run program, as is insurance against acts of war. The parallels are worth considering.
Revisit the penalty (sorry, tax) imposed for failure to procure ACA-mandated coverage, so that it makes economic sense for 'young and healthies' to enroll.
Change, or entirely delete, Section 2701, which forces actuarially sound rating into a government-dictated pattern. We know from long, painful national experience that government-imposed price controls cause far more harm than good, the harm usually inflicted on those already living at the margins.
Fix Medicaid, so that we no longer spend more than a half-trillion dollars, without any meaningful improvement to the lives of the tens of millions of beneficiaries.
Just my thoughts. Peace.

Stuart Meisenzahl
6 years 9 months ago

The idea of having HHS exclude 50 to 100 conditions seems to spring from the ideas of Zeke Emanuel, one of the principal Architects of the ACA . Zeke posits as his guiding star what he describes as "The Complete Lives Curve"
....."a priority curve on which individuals between 15 and 40 get the most substantial chance whereas the youngest and the oldest get chances that are attenuated" Lancet January 31, 2009.
Mr. Emanuel was also the guiding hand behind the ACA's Independent Payment Advisory Board which was to recommend cost savings for Medicare , presumptively in part by picking and choosing procedures and drugs for reimbursement/nonreimbursement.
These approaches may or may not achieve your purposes of avoiding "massive Medicaid payments without any meaningful improvement in the lives of the tens of millions of beneficiaries". Butin any event I believe that Zeke had in mind fulfillment of Margaret Sanger's goal of not wasting limited resources on those whose contributions to society are too limited or too exhausted to be of further value (or preservation) .....so if you are under 15 or over 40 you will be entitled only to "attenuated health care". The problem is that historically doctors and patients have made these decisions but Zeke has obviated this this history by positing that physicians now owe a competing and perhaps greater duty to society. It would appear that if/when the federal government controls the purse strings of health care as the single payer that a patient is going to have to accept the government's decision on Zeke's proposition. Under those circumstances "attenuated" health care seems probable for a significant number of people. In addition Catholic Hospitals will undoubtedly have to provide mandated services such as abortion .

Joseph J Dunn
6 years 9 months ago

I read the easily-accessed Lancet article, which is definitely worth reading. Emanuel clearly proposes a "rationing" system after carefully reviewing the various existing approaches to rationing in various circumstances. Some are so subtle, or so complex, that we are unaware of them. Others are obvious, and we accept them, such as the triage that necessarily exists in some mass-casualty situations. Norway's health insurance plan has an English-language website, also worth reading, as it clearly states that in their system not everyone is entitled to all available treatments. Also worth reading. It will be interesting to see what happens next.

Leonard Villa
6 years 9 months ago

Sister Keehan is on board with the original intention of Obama and the Democrats: Obamacare was meant to fail and be a disaster so that there will be a demand for government control of all health care! So of course she wants Obamacare to continue. Government health care will involve more government and less care as bureaucrats decide who gets health care and when you get it! Does anyone want to wait months and months for operations or other medical services?This contradicts Catholic social teaching which looks for solutions closest to the problem on a more personalized level. Is Sister ready to confront the government's intrusions demanding contraceptives, abortions, euthanasia demanding the Catholic hospital conform to a reigning political correctness? Has Sister considered the fate of Veterans in government administered health care by the VA? Time to rethink this Sister.

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