Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)
At Families USA's Health Action conference last week, FUSA executive director Frederick Isasi, in a presentation for attending media, identified three healthcare trends for 2020. It struck me that at the heart of each enumerated "trend" is a looming political battle, each of them central to the U.S.'s current existential struggle between oligarchy and renewed democracy. Let's look at each in turn.
1. Value. Describing Americans' demand for "value" in healthcare, Isasi was not speaking primarily about "value-based care," i.e. outcomes-based alternatives to fee-for-service payment. He focused rather on out-of-control prices paid to providers that are rendering care unaffordable to tens of millions. He pointed out that healthcare costs have climbed 600% in the last 40 years and nearly tripled as a percentage of GDP, rendering care unaffordable for tens of millions. "Almost half of Americans say they have trouble affording healthcare," he said. "People are more scared of paying for getting sick than they are of getting sick."
As to the cause of runaway costs, Isasi blamed the market power of the various healthcare industries: "it's a highly subsidized sector with almost no government oversight." The struggle to hold down costs is less technocratic than political: forcing powerful industries to accept curbs on their pricing power. Potentially enabling that struggle is a sea change in public attitudes: While coverage has eroded in recent years, Isasi noted, the ACA has wrought a sea change in Americans' expectations: "acceptance of the right to access is a new societal norm."
Since more Americans are underinsured than uninsured, however, the salient political battles are likely to focus on affordability of care for the insured. The immediate battlefronts are over prescription drug costs and curbing surprise billing. Industry lobbyists won battles on both fronts in late 2019, blocking bipartisan legislation. With respect to ending surprise billing, Isasi said, "it's unforgivable that was not done in the fall. Congress is allowing providers to walk away from negotiating table" -- after a lobbying and advertising campaign against the balance billing legislation that would have limited out-of-network providers' pricing power, funded largely by private equity firms that own physician practices that have amped up surprise billing. Isasi added that there's a real chance of legislation passing in May, when several major national healthcare programs must be funded.
The broader point: Industry power is bloated. "As healthcare becomes less and less efficient, it becomes a larger and larger part of the economy. Some of the largest employers are hospitals. There's a lot of political power there." At the same time, though, "Political demand [for affordability] is growing as the sector becomes more powerful and consolidated." As with the highly consolidated American economy as a whole, the question is whether popular pressure for relief can build to a point where elected officials can face down powerful monied interests to impose a measure of cost control.
Battle 1: Corporate power to maximize revenue vs. popular demand for affordability
2. Equity. Under Isasi's leadership, which began in 2017, Families USA has intensified its focus on disparities in treatment and health outcomes experienced by ethnic minorities and other groups subject to discrimination. In the last two years in particular, plenary sessions at the annual Health Action conference have focused on such disparities, e.g., that women of color are more likely to die in childbirth; that African Americans are 50% more likely to die prematurely from cardiovascular disease; that people of color widely report lack of respect in their interactions with providers and express lack of trust in those providers.
By way of example, in this year's first plenary session Ola Ojewumi of Project ASCEND, a cancer survivor who had a heart and kidney transplant at age 11, recounted that after the operation she was given only a Tylenol for pain relief. Years later, mandatory drug testing hampered her ability to fill necessary opioid prescriptions.
While these disparities persist -- and, under the Trump administration's revamped "public charge" rule, worsen for immigrants -- Isasi pointed to a demographic reality that should point toward equity: a majority of the nation's kids are people of color. The population will be majority-minority in twenty years. If we don't address the persistent inequities, "our future as a country hangs in balance."
That struggle for democracy was brought into sharp focus by Marielena Hincapié of the National Immigration Law Center, who shared the podium with Ojewumi in the first plenary. Ticking off the core elements of Trump's assault on immigrants -- the Muslim ban, the threat to end DACA, the shutoff of asylum -- Hincapié identified the public charge rule, which endangers the path to citizenship for immigrants who access benefits like food stamps or Medicaid, as the greatest threat: the rule is a "racial wealth test" determining "who gets to remain, who gets to leave." Its aim: "future citizens, future voters disenfranchised. That's what this administration is about." As the country's demographics change, "the administration is trying to change what we look like as a nation -- with black and brown not being considered American."
Battle 2: the emerging democratic majority vs. rearguard white supremacy
3. Medicaid efforts on the state level -- that is, really, Medicaid bifurcation on the state level. Having failed in the ACA repeal battle to radically reduce federal spending on Medicaid, the Trump administration, under the leadership of Seema Verma at CMS, has encouraged states to reduce enrollment and services -- first by inviting states to implement work requirements, so far largely blocked by the courts, and just this week, by finalizing guidance encouraging states to apply for block grants that would limit federal funding while allowing states to cut back on services to the population rendered eligible for Medicaid by the ACA expansion.
Isasi -- a former director of the nonpartisan National Governor's Association -- expressed incredulity "that any governor would line up to get a cap on Medicaid -- that's the worst deal you could ever strike. It's unimaginable to me that a governor would look at the federal government and say please give us less support." But Tennessee has already submitted a block grant proposal to CMS (not prompted by the new guidance, as Tennessee has not expanded Medicaid), and other red states may follow follow suit. On the other side of the political spectrum, blue states are looking to use Medicaid to address social determinants of health and improve behavioral health treatment. The red state-blue state divide on healthcare access is likely to widen as states pursue opposite paths.
Battle 3: red states vs. blue states, or red vs. blue control of state government
All of these battles are of a piece. They are pivot points in a struggle to assert democratic will, and the common good, in an only partially representative democracy in which oligarchic power has been feeding on itself to control the courts, the Congress, the executive branch and a majority of state governments. To impose some price discipline on behemoth industries; to demand equity for groups that get the short end of every stick; and to commit state government to expanding access and improving care rather than exercising bureaucratic sadism -- all are integral to the struggle to renew American democracy.
At Families USA's Health Action conference last week, FUSA executive director Frederick Isasi, in a presentation for attending media, identified three healthcare trends for 2020. It struck me that at the heart of each enumerated "trend" is a looming political battle, each of them central to the U.S.'s current existential struggle between oligarchy and renewed democracy. Let's look at each in turn.
1. Value. Describing Americans' demand for "value" in healthcare, Isasi was not speaking primarily about "value-based care," i.e. outcomes-based alternatives to fee-for-service payment. He focused rather on out-of-control prices paid to providers that are rendering care unaffordable to tens of millions. He pointed out that healthcare costs have climbed 600% in the last 40 years and nearly tripled as a percentage of GDP, rendering care unaffordable for tens of millions. "Almost half of Americans say they have trouble affording healthcare," he said. "People are more scared of paying for getting sick than they are of getting sick."
As to the cause of runaway costs, Isasi blamed the market power of the various healthcare industries: "it's a highly subsidized sector with almost no government oversight." The struggle to hold down costs is less technocratic than political: forcing powerful industries to accept curbs on their pricing power. Potentially enabling that struggle is a sea change in public attitudes: While coverage has eroded in recent years, Isasi noted, the ACA has wrought a sea change in Americans' expectations: "acceptance of the right to access is a new societal norm."
Since more Americans are underinsured than uninsured, however, the salient political battles are likely to focus on affordability of care for the insured. The immediate battlefronts are over prescription drug costs and curbing surprise billing. Industry lobbyists won battles on both fronts in late 2019, blocking bipartisan legislation. With respect to ending surprise billing, Isasi said, "it's unforgivable that was not done in the fall. Congress is allowing providers to walk away from negotiating table" -- after a lobbying and advertising campaign against the balance billing legislation that would have limited out-of-network providers' pricing power, funded largely by private equity firms that own physician practices that have amped up surprise billing. Isasi added that there's a real chance of legislation passing in May, when several major national healthcare programs must be funded.
The broader point: Industry power is bloated. "As healthcare becomes less and less efficient, it becomes a larger and larger part of the economy. Some of the largest employers are hospitals. There's a lot of political power there." At the same time, though, "Political demand [for affordability] is growing as the sector becomes more powerful and consolidated." As with the highly consolidated American economy as a whole, the question is whether popular pressure for relief can build to a point where elected officials can face down powerful monied interests to impose a measure of cost control.
Battle 1: Corporate power to maximize revenue vs. popular demand for affordability
2. Equity. Under Isasi's leadership, which began in 2017, Families USA has intensified its focus on disparities in treatment and health outcomes experienced by ethnic minorities and other groups subject to discrimination. In the last two years in particular, plenary sessions at the annual Health Action conference have focused on such disparities, e.g., that women of color are more likely to die in childbirth; that African Americans are 50% more likely to die prematurely from cardiovascular disease; that people of color widely report lack of respect in their interactions with providers and express lack of trust in those providers.
By way of example, in this year's first plenary session Ola Ojewumi of Project ASCEND, a cancer survivor who had a heart and kidney transplant at age 11, recounted that after the operation she was given only a Tylenol for pain relief. Years later, mandatory drug testing hampered her ability to fill necessary opioid prescriptions.
While these disparities persist -- and, under the Trump administration's revamped "public charge" rule, worsen for immigrants -- Isasi pointed to a demographic reality that should point toward equity: a majority of the nation's kids are people of color. The population will be majority-minority in twenty years. If we don't address the persistent inequities, "our future as a country hangs in balance."
That struggle for democracy was brought into sharp focus by Marielena Hincapié of the National Immigration Law Center, who shared the podium with Ojewumi in the first plenary. Ticking off the core elements of Trump's assault on immigrants -- the Muslim ban, the threat to end DACA, the shutoff of asylum -- Hincapié identified the public charge rule, which endangers the path to citizenship for immigrants who access benefits like food stamps or Medicaid, as the greatest threat: the rule is a "racial wealth test" determining "who gets to remain, who gets to leave." Its aim: "future citizens, future voters disenfranchised. That's what this administration is about." As the country's demographics change, "the administration is trying to change what we look like as a nation -- with black and brown not being considered American."
Battle 2: the emerging democratic majority vs. rearguard white supremacy
3. Medicaid efforts on the state level -- that is, really, Medicaid bifurcation on the state level. Having failed in the ACA repeal battle to radically reduce federal spending on Medicaid, the Trump administration, under the leadership of Seema Verma at CMS, has encouraged states to reduce enrollment and services -- first by inviting states to implement work requirements, so far largely blocked by the courts, and just this week, by finalizing guidance encouraging states to apply for block grants that would limit federal funding while allowing states to cut back on services to the population rendered eligible for Medicaid by the ACA expansion.
Isasi -- a former director of the nonpartisan National Governor's Association -- expressed incredulity "that any governor would line up to get a cap on Medicaid -- that's the worst deal you could ever strike. It's unimaginable to me that a governor would look at the federal government and say please give us less support." But Tennessee has already submitted a block grant proposal to CMS (not prompted by the new guidance, as Tennessee has not expanded Medicaid), and other red states may follow follow suit. On the other side of the political spectrum, blue states are looking to use Medicaid to address social determinants of health and improve behavioral health treatment. The red state-blue state divide on healthcare access is likely to widen as states pursue opposite paths.
Battle 3: red states vs. blue states, or red vs. blue control of state government
All of these battles are of a piece. They are pivot points in a struggle to assert democratic will, and the common good, in an only partially representative democracy in which oligarchic power has been feeding on itself to control the courts, the Congress, the executive branch and a majority of state governments. To impose some price discipline on behemoth industries; to demand equity for groups that get the short end of every stick; and to commit state government to expanding access and improving care rather than exercising bureaucratic sadism -- all are integral to the struggle to renew American democracy.
No comments:
Post a Comment