The first, of what’s sure to be many, health care reform battles

It’s been a whirlwind couple of months filled with political intrigue and maneuvering. And still, Obamacare stands–for now.

Last Friday the GOP leadership in the House did the unthinkable. They pulled their health care reform bill, the American Health Care Act (AHCA), just before it went up for a vote.

As a patient advocate, I had naively believed I could track the health care reform efforts in Washington, contact my legislators to urge them to vote to preserve health care coverage, and write blog posts about it along the way. I was wrong.

Political intrigue and maneuvering

It’s been a whirlwind couple of months filled with political intrigue and maneuvering leading up to the introduction of the AHCA. It started with Trump’s inauguration day signing of an executive order calling for Obamacare to be dismantled by the federal government. This was followed by a lot of speculation about which plan the Republicans would propose to replace Obamacare. Once the bill was ready the draft was locked-down in a meeting room and made available to select Republican House members. Then the bill was rushed through two committee hearings before the Congressional Budget Office (CBO) could issue it report on its impact. Once the bill was leaked to the press, the mad scramble to read and analyze the bill began.

As soon as it became available, I started reading the analysis and reporting on the bill. I read analysis from the Washington Post, the Kaiser Family Foundation, the CBO, and many others.

Nothing good to say

No one had anything good to say about the bill. Not the American Medical Association. Not health insurers. Not even the White House’s own analysis, which said the results would be even more devastating than what the nonpartisan CBO reported.

The contents were disastrous for anyone who needed health care and didn’t have deep pockets to pay for it. The CBO reported that 24 million people would lose health insurance. So much for the promise to keep everyone covered.

A call to action

Then something very amazing happened.

People took action.

Constituents showed up at town hall meetings and district offices. And they were vocal. A video of Representative Chaffetz (R-Utah) being shouted down with chants of “do your job!” went viral. So many vocal constituents showed up that it was reported that some legislators feared for their safety. It was Tea Party tactics, only this time people who wanted governmental protections were using them.

Constituents called their legislators’ offices in DC and in their district. And, again, they were vocal. So many calls were placed that the Capital switchboard busied-out. So many calls were placed that every staffer ended up on phone duty. Various legislators said that the calls tallied were by-and-large against AHCA. Rep. Daniel Donovan (R-N.Y.) was quoted as saying the calls to his office were 1000-to-1 against.

Facing reality

Last Friday, when it became clear that they didn’t have the votes to pass even after Trump issued an ultimatum to House Republicans, the Republicans bill was pulled before the vote. Speaker Paul Ryan appeared before the press and said that the Affordable Care Act (ACA), aka Obamacare, remains “the law of the land” for the foreseeable future. There were reports that Trump was ready to move on from health care reform.

Patient and health care advocates breathed a collective sigh of relief. A bill that would be disastrous for millions of Americans went down to defeat.

But here we are four days later and Speaker Ryan is quoted as saying, “We are going to keep getting at this thing.” This “thing” being overhauling health care.

The battle might have been won, but the fight is not over.

Last chance to sign up for Obamacare

Today is the last chance to sign up for Obamacare. What happens next?

Today, January 31, 2017, is the last day of open enrollment for health insurance on the Obamacare exchanges.

For those of us living with a chronic health condition, like diabetes, this is a sad day. Are we hearing the death knell of access to affordable health insurance? We don’t know.

While the new administration has begun the process of repeal with Congress passing a budget resolution and the President signing the Executive Order Minimizing the Economic Burden of the Patient Protection and Affordable Care Act Pending Repeal, it hasn’t presented a clear plan for replacement.

Since Obamacare touches nearly everyone, patients aren’t the only ones concerned about the effects of repeal without a replacement, or as some are framing it “repeal and delay.”

Health insurance companies are saying that repeal and delay will “destabilize the individual insurance market.” Without a replacement in place, they warn that premiums could go up as much as 20% in 2018.

Economists estimate repeal will result in the loss of 3 million jobs. One report goes so far as to say repealing Obamacare will cost the federal government $350 billion over the next decade.

The Republicans have floated a couple of replacement test balloons.

There’s the Cassidy-Collins plan which is most simply described as giving the states three options: keep Obamacare, make their own replacement with some federal subsidy, or opt-out completely not taking any federal funding. This proposal also eliminates “essential health benefits” including hospitalization, pregnancy and maternity care. And while insurers still have to offer coverage to people with pre-existing conditions, they can charge higher premiums if that person had any interruption in health insurance coverage.

The American Healthcare Reform Act of 2017 was introduced to the House and referred to committee on January 4th. Based on work by the Republican Study Committee, this bill would make the cost of health insurance a standard tax deduction for employers and individuals, expand funding for high-risk pools for the states, guarantee coverage for pre-existing conditions as long as there hasn’t been a break in coverage, allow buying health insurance across state lines, reforms medical liability law, and prohibits federal funding of abortion.

Neither of these seems as comprehensive or balanced as Obamacare.

Finally, there’s the A Better Way blueprint for healthcare reform. Looking at the summary of this proposal it seems the most comprehensive. It talks about using a tax credit to make health insurance portable, allowing people to buy health insurance across state lines, enacting medical liability reform, protecting people with pre-existing conditions, allowing dependents to stay on their parent’s insurance up to age 26, and prohibiting sudden cancellations. It also proposes a one-time open enrollment for individuals to get insurance “regardless of how healthy they are.” It proposes to “bring Medicaid into the 21st century” by empowering states “to design Medicaid programs that best meet their needs.” And it would enact the Weldon Amendment giving healthcare professionals “the freedom to exercise their conscience” and enforce the Hyde Amendment keeping “federal tax dollars from being used for abortion or abortion services.” Also in this proposal, there’s a declaration to strengthen funding to the NIH, accelerate development of new drugs, spur the use of electronic health records, and secure the financial future of Medicare.

Last week the Republican retreat took place in Philidelphia. Healthcare was clearly at the top of the agenda for this annual gathering of congressional Republicans. But when all was said and done no clear consensus or direction on repeal and replace/delay emerged. Both the Washington Post and the New York Times reported that rather than unifying on the issue, Republicans agonized over the effects of quickly repealing Obamacare and potential political fallout.

PBS Newshour reported hat the legislative timeline is very loose; the effort “could take them through the summer.” And don’t expect a single, comprehensive bill. Rep. Greg Walden, R-OR, and chair of the House Energy and Commerce Committee, told reporters to not look for a single plan or a single fix.

If that holds true we’re looking at a long road ahead filled with a lot of small, piecemeal bills. I expect the Republicans will try to maintain the popular aspects of Obamacare, like no exclusions for pre-existing conditions. But without a comprehensive approach to healthcare it’s not clear that anyone living with a pre-existing condition will be able to afford health insurance under Trumpcare.

 

Patient advocacy under Trump

President Trump was quick to take action on repealing Obamacare. With no replacement in sight, here are some thoughts on how to be effective patient advocates.

It’s official. Donald J. Trump has taken the oath and become the 45th president of the United States. And, as promised, one of his first official acts was aimed at dismantling the Affordable Care Act (ACA), also known as Obamacare. Hours after the swearing-in President Trump signed his first executive orders, including one that “eases the burdens” of Obamacare. While it’s unclear exactly how this executive order will be implemented (as of this writing the only public copy I was able to find was a photo on Twitter) there are warnings that it is will severely damage or gut Obamacare.

Looking ahead to the next four years I expect patients and their advocates will be more politically active, defending their rights to access affordable healthcare. To be effective we have to get and stay engaged for the long haul. Healthcare policy is complex and it’s not going to be resolved with a single action or piece of legislation.

Where do we start? Here are my thoughts.

Start by taking a deep breath.

Advocating for patient rights and healthcare access is going to be a lot of work and it’s going to take time to get done. Your brain can use the shot of oxygen and your nerves can use the calming effect of a deep breath.

Choose one thing to focus on.

You can’t be everywhere all the time. If you try to follow every issue or answer every call to action you will exhaust yourself.

In choosing your focus make it something that’s important to you and that you have an emotional stake in. Remember, we need you to be in this for the long haul. That takes energy and passion.

Choosing a single issue to focus on doesn’t mean that you have to ignore all the related issues. It just means that you’re committed to working on that one issue. It’s your priority.

Build a deep understanding of your chosen issue.

Go deep. Learn about the issue you’ve chosen to focus on. Learn its history so that you know how we got to where we’re at. Read what the experts are saying the problem and solutions are so that you have an idea of where we should be heading. Think about your own experience of this issue. Talk with other people about their experiences.

Chances are you are going to be asked to speak up. Whether you’re writing a letter to your legislator, giving testimony, or speaking publicly you’ll want to be able to persuade your audience. You can’t be persuasive if you don’t know what you’re talking about.

Have faith that others are working on the issues that you are not.

We will be more effective as advocates if we split up the work, so to speak. No one person can know everything about a system as big and complex as healthcare. No one person can stay on top of every issue all the time.

Also, recognizing that others are working on the issues that aren’t your priority relieves that feeling of overwhelm that often comes with big projects.

Connect with others and support each others’ efforts.

Advocacy is the kind of work that requires a group effort. There is power in numbers that persuades policymakers to enact laws and regulations that support patient access and affordable healthcare.

Connect with a local branch of a national healthcare advocacy organization. Be active in social media groups like the #DOC (diabetes online community). Donate time, energy, and money, if/when you can afford it.

Knowing that you’re not alone can be energizing and keep burnout away.

Take another deep breath.

We’ve got a long road ahead of us.

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Obamacare: Looking ahead and not liking what I see

We are barely into the first week of 2017 and The New Unified Republican Government™ has Obamacare in its crosshairs.

We are barely through the first week of 2017 and The New Unified Republican Government™ has Obamacare in its crosshairs.

I’m not going to pretend that the Affordable Care Act (also known as Obamacare) is without its problems. The very first problem is the “affordable” part. For some, that hasn’t turn out to be the case. Higher premiums were announced last fall, just before the presidential election. Some health insurance companies have opted out of the exchanges, reducing options for coverage.

But Obmacare has yielded some good results, particularly when it comes to access to healthcare. According to the White House:

  • An estimated 20 million people gained health insurance.
  • 105 million Americans benefit from the elimination of lifetime and annual limits on insurance coverage and the establishment of annual limits on out-of-pocket spending on essential health benefits.
  • As many as 129 million Americans who have some type of pre-existing health condition, including up to 19 million children, can no longer be denied coverage or have their coverage reduced.

This last point is hugely important to people living with chronic illnesses like diabetes.

You see, it used to be difficult to get health insurance with a pre-existing condition. Obamacare changed that. It made it possible (even if it might be expensive) to get health insurance on your own. And this made it possible for people living with diabetes to have some peace of mind.

No longer do people living with chronic illnesses have to worry that if they lose a job or leave a job or move they will be left without health insurance.

No longer do people living with chronic illnesses have to worry that if they end up in the emergency room they, or their families, will end up in financial ruin.

No longer do the lives of people with chronic illnesses have to be determined by their access to health insurance.

This is about to change.

◊ ◊ ◊

“Repeal and replace” is the rallying call among Republicans. But I see a couple of problems with this.

The health care system is vast and complex.

It’s foolhardy to think that you can simply repeal a law that’s taken the better part of six years to implement and everything will be okay. Obamacare touches pretty much everyone in the US in some way.

Repealing it completely will cost the US government $350 billion over the next decade. Hospitals and physicians face uncertainty. Hospitals, especially those providing safety net healthcare services, expect their revenues to drop dramatically. Some healthcare stocks have taken a hit.

No one knows what “replace” means. 

The Republicans have destabilized healthcare in the US by making every aspect of Obamacare uncertain.

There’s a debate about which aspects of Obamacare might be kept. Being able to keep your child on your insurance until they reach 26, removing the prohibitions for pre-existing conditions, and automatic coverage for preventative care have all proved popular.

But can we have these popular benefits without some of the unpopular ones? Like the mandate to have healthcare insurance, for one?

You see, Obamacare was structured so that one part balances out the other. If you chip away at that balance will the financial and structural underpinnings of healthcare in the US be undermined? That remains to be seen, but conventional wisdom says yes.

In the meantime, we’re already starting to hear promises from Republicans and their spokespeople assuring us that no one will lose their healthcare coverage after Obamacare is repealed.

Forgive me for being skeptical.

 

Prediabetes? Ain’t nobody got time for that!

Prediabetes? Ain’t nobody got time for that! The Ad Council’s type 2 prevention campaign misses the mark.

In the first of its kind campaign the ADA, AMA, and CDC released a series of Ad Council public service announcements aimed at preventing type 2 diabetes. The campaign is called So…Do I Have Prediabetes?

Boy did they miss the mark.

The campaign takes on a snarky tone. Now, I’ve been known to enjoy a snarky joke as much as the next person. But this snark is aimed at the patient, that just adds to the blame and shame people living with diabetes, especially type 2 diabetes, already face.

You eat bacon? Well, don’t. It’s a variation on the “Eat 100 candy bars and what do you get?” joke. We’ve all heard the punch line: Diabetes!

Only, it’s not true and it’s hateful. And when people feel blamed for their health or shamed for their behavior that disempowers them to change. Don’t believe that? Listen to what the research of Jane K. Dickinson, CDE has to say.

And what if you’re a busy mom?

Well, this busy mom doesn’t appreciate the sentiment. Yeah, busy-ness is a common excuse. I’ll cop to using it myself once or twice. Okay! I used it for about a million years while I was in pre-diabetes.

The doctor’s response to the patient saying she’s a busy mom made me think of this:

CharlieBrownLucyFootball

Lucy van Pelt pulling the football away at the last moment yet again and the ever trusting Charlie Brown taking a tumble mid-kick.

I don’t want my doctor to be paying a cruel joke on me. And I don’t want to end up the looser in this scenario.

But more damning is the image that comes to my mind when I reflect on what the busy mom says. Her distress is real. And yet her words come off more like this:

Ain't nobody got time for that!

And this is just plain wrong.