February 23rd, 2017

PUBLIC HEALTH OUTCOME GOALS 101-----DON'T HAVE POLICIES WITH GOALS TO DELIBERATELY KEEP CITIZENS IN CONSTANT INSTABILITY AND IMPOVERISHMENT----DON'T KEEP OUR IMMIGRANTS CONSTANTLY DISENFRANCHISED-----

The Affordable Care Act privatized Medicare and enfolded it into bundled payments to global state health systems to do as they wanted to provide health care to seniors. Obama and Clinton neo-liberals gutted Medicare of almost $1 trillion in doing that making the amount of money reaching these state health systems even SMALLER. Now, Federal Medicare has operated for 50 years serving seniors with their health care EQUALLY-----EVERY CITIZEN IN AMERICA RECEIVED THE SAME LEVEL OF CARE SAME QUALITY OF CARE----except for Maryland which was exempted from Medicare regulations and denied equal access selectively. That's what ACA did to ALL AMERICAN SENIORS. These several years have seen state private health systems deciding what you and I will receive as our senior health care. Remember, many seniors paid LOTS OF PAYROLL TAXES just so they could get all the care they needed----with inflation each citizen working several decades has plenty of PRE-PAID MEDICAL CARE SAVINGS. That is what MEDICARE IS----PRE-PAID MEDICAL SAVINGS ACCOUNT.
The ACO managed care systems built during Obama were built knowing they could do whatever they wanted with that Medicare bundled payment----being cost effective means----if you cannot pay for health care then you will not get health care even if you did PRE-PAY THESE MEDICAL SAVING ACCOUNTS CALLED MEDICARE. Before Trump was elected across the nation seniors were already being denied access to ordinary health care and PHARMA because these global MEDICAL PAYMENT CORPORATIONS deciding how this bolus of Medicare funding is spent decides what the cheapest avenue to take in care to take.
The cheapest avenue of course is to kick 80% of Americans onto GUTTED OF FUNDING MEDICAID FOR ALL. Medicaid is far different than MEDICARE and Medicaid is a Federal program funded separately from that pre-paid Medicare account so they are again----stealing our personal savings accounts. Medicaid for All is that preventative care only so seniors will not access ordinary relatively cheap MEDICAL CARE.

Donald Trump Is Coming for Your Medicare

The selection of Tom Price to head HHS brings the president-elect into alignment with Speaker Paul Ryan.
By David Dayen

November 29, 2016

House Budget Committee Chairman Tom Price speaks at the US Capitol in Washington, January 7, 2016. (AP Photo / Al Drago)
 

For those who thought Donald Trump, someone who spent two years on the campaign trail promising to protect programs like Medicare, might consider keeping that promise, let today’s news disabuse you of that notion. The selection of Georgia Congressman Tom Price as Health and Human Services Secretary offers the clearest signal yet that Trump and House Speaker Paul Ryan are perfectly aligned, and ready to make Medicare phase-out the signature proposal of his presidency.


There’s not much daylight between Ryan’s and Price’s plans for the nation’s health system. Both want to repeal Obamacare; in fact, Price has issued a detailed replacement plan every year since 2009, before the ACA even passed. Price’s Empowering Patients First Act contains the usual features of conservative health-care plans—poorly funded high-risk pools for anyone rejected for a preexisting condition, letting insurers sell across state lines, health savings accounts, tort reform, and capping the tax exclusion for employer health coverage. Practically all of these ideas have been implemented either at the state level or during George W. Bush’s administration, and none succeeded in closing the uninsured gap or making health care cheaper. But Price’s major provision replaces the ACA with a meager tax credit to purchase private insurance on the individual market. It also allows people to opt out of Medicare or Medicaid and take the tax credit.


If that sounds familiar, it’s substantially the framework of Ryan’s premium-support plan to convert Medicare into a coupon for people to put toward insurance. Price has endorsed the Ryan plan: Earlier this month he said Congress would phase out Medicare in the first six to eight months of 2017. He even laid out how to get it done while avoiding the filibuster. Using budget reconciliation, fiscal items that don’t increase the deficit outside the 10-year budget window can get an up-or-down vote with limited debate.


Price succeeded Ryan as House Budget Committee chair, so he understands the mechanics of the process. And he would have to do something fast, because a full Obamacare repeal, including the Medicare provisions, would immediately reverse the ACA’s extension of the Medicare trust fund, triggering an inability to pay all benefits within the first year or two. So Price and Ryan would create an unnecessary crisis in Medicare to get to their favored solution of voucherizing it.


For good measure, Price’s last budget not only repealed Obamacare but turned Medicaid into a block-grant program for the states.


This is about much more than the Rube Goldberg–system of the ACA. Price’s ambitious blueprint would roll back two of America’s biggest social-insurance programs. Prior to Congress, he was an orthopedic surgeon, the kind of high-priced service provider that stands to lose from a universal system that wrings costs out of specialist fees. He has no interest in social insurance, and his top priority at HHS will be to cripple anything resembling it. And to sell Trump on the whole shebang.


The president-elect mostly stayed out of this debate during the campaign. “Abolishing Medicare, I don’t think you’ll get away with that one,” he told MSNBC last October. “It’s actually a program that’s worked. It’s a program that some people love, actually.”


The stakes are higher now than ever. Get The Nation in your inbox.

But the Price pick should leave no doubt: Donald Trump is coming for your Medicare. This is not a drill. His allies in the cabinet and on Capitol Hill mean to roll back the Great Society. They have been meticulously laying out the plan for close to a decade. None of Trump’s statements over the past year mean as much as installing Tom Price at HHS.


Liberals need to dispense with the idea that there’s one Trump, that he’ll either be singularly captured by the conservative policy establishment or singularly committed to an idiosyncratic nationalist populism. There’s ample room for him to pick and choose. Trump may adhere to his promises on immigration and trade—though calling for the repeal of fast track would prove it—and also destroy universal health-care programs. Consistency is not really his strong suit. Besides, he can simply convince himself that he’s giving people something classier and better than what they already have. Trump contains multitudes.


Anyway, Trump may actually need to gut Medicare and Medicaid if he wants conservatives to move forward on his other priorities. Trump’s advocacy for budget-busting tax cuts and Keynesian spending (though his infrastructure plan isn’t as pricey as advertised) has angered fiscal conservatives. There simply aren’t many ways to make up the difference, especially since Trump wants to increase defense spending. The federal government has been described as an insurance company with an army. The army’s staying, so to satisfy the bean-counters, Trump will have to toss out the insurance company.


So what can liberals do in response? Using reconciliation means that Republicans can accomplish this entirely on their own. The only question is whether Democrats will make the idea so toxic that they threaten the job security of anyone in Washington who goes along with it. Republicans have a 24-seat cushion in the House, but could only afford to lose two senators to phase out Medicare (I’ve questioned in the past whether Senate Republicans actually want to make these kinds of big changes). Every senior in every district in America should be aware of the GOP plan to destroy a health-care guarantee that has lasted for generations. And if Republicans pull the cowardly move of protecting those already on Medicare or close to eligibility, that should be ridiculed for the bait and switch that it is.


Democrats can take up the fight immediately, in the special elections that will arise as Trump fills out his cabinet. CIA director nominee Mike Pompeo’s seat in Kansas and Price’s in Georgia are pretty red, but seniors typically represent the largest voting bloc in these low-turnout races. In 2011, the last time Ryan made a serious push to privatize Medicare, Kathy Hochul won a right-leaning seat in upstate New York by making the race entirely about social insurance. This can be replicated, proving the concept that trying to dismantle programs Americans have paid in to their entire working lives is political suicide.


So far Democrats have mostly said the right things. Chuck Schumer defiantly asked Republicans to “make my day” by trying to take away Medicare from seniors. Even red-state Democratic senators up for re-election in 2018 aren’t budging. But being united is one thing; making this issue synonymous with Republicans and Trump for the next several years is quite another. Distractions must be pushed to the side. This is a very real assault on one of the signature pillars of the 20th-century liberal project. It’s time to organize.

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Here is how Congress and Obama laundered our Medicare funds to cover trillions of dollars lost to Medicare in Medicare fraud over these few decades-----Clinton/Bush do the same----because they work to protect global corporate profits no matter how they are made. Look at that figure for expanded MEDICAID----$1.9 trillion----where did that money go? It went to build the infrastructure for global health corporations overseas while throwing a few million at mobile health units most low-income citizens were shouting DID NOTHING----these small health businesses were full of fraud---they often harmed patients with poor care---that is where a few million of $1.9 trillion in expanded Medicaid went----LOT'S OF PRIMARY CARE PREVENTATIVE CHECKUPS.
We shout that our national labor and justice organizations are captured by global Wall Street Clinton neo-liberal leadership---this goes for AARP. AARP was created by a wealthy citizen tied to PRIVATE HEALTH INSURANCE----wanting to privatize Medicare. This is why AARP leads in MEDICARE ADVANTAGE----MEDIGAP insurance---these are the privatizing vehicles installed through Clinton/Bush. So, it get MILLIONS OF DOLLARS to come out in support of Affordable Care Act and these cuts to MEDICARE.



All of this occurred these several years of Obama----so Ryan and Trump are simply going to MOVE FORWARD with state health systems receiving gutted of funding Medicare payments which these state systems will then selectively distribute or pocket.


Below you see why Obama and Clinton neo-liberals needed to cut the Medicare budget------back in 1998---Clinton era----the frauds against Medicare and Medicaid were already at $250 each year----government watchdog groups placed that at $400 billion each year through Bush then Obama. This is what expanded health corporations like Hopkins and UNITED HEALTHCARE INSURANCE overseas.

'It is clear to see why Americans consider this the biggest cause, when health care fraud was estimated to cost approximately $100 billion to $250 billion per year in 1998, or 10 percent to 25 percent of total health care spending'

'An Undergraduate Honors Thesis by
Emily Fisher
V449
Professor Nicole C. Quon
April 2008

ABSTRACT
Health care fraud is an important and visible factor associated with increasing health care costs in the United States. Medicare and Medicaid contribute to a vast majority of those cost sand therefore must be heavily scrutinized. This thesis will investigate the types of fraud, who commits them, and why the health care system is more susceptible to fraud. More specifically, the problems and complications of current fraud investigation for Medicare and Medicaid are examined. This thesis will then evaluate how successful these initiatives were in reducing health care fraud and explore new suggestions for preventing health care fraud in the future'.

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Sep 22, 2012 @ 12:13 AM 93,023 views The Little Black Book of Billionaire Secrets


How the AARP Made $2.8 Billion By Supporting Obamacare's Cuts to Medicare
The Apothecary
Insights into health care and entitlement reform.

Avik Roy, Forbes Staff


United States Senator Jim DeMint at a rally for United States Senate candidate Rand Paul in Erlanger, Kentucky. (Photo credit: Wikipedia)


As you know if you’ve been reading this blog, Obamacare cuts $716 billion from Medicare in order to pay for its $1.9 trillion expansion of coverage to low-income Americans. It’s one of the reasons why seniors are more opposed to the new health law than any other age group. So why is it that the group that purports to speak for seniors, the American Association of Retired Persons, so strongly supports a law that most seniors oppose? According to an explosive new report from Sen. Jim DeMint (R., S.C.), it’s because those very same Medicare cuts will give the AARP a windfall of $1 billion in insurance profits, and preserve another $1.8 billion that AARP already generates from its business interests.


(DISCLOSURE: I am an outside adviser to the Romney campaign on health-care issues. The opinions contained herein are mine alone, and do not necessarily correspond to those of the campaign.)


Here’s how it works. AARP isn’t your every-day citizens’ advocacy group. The AARP is also one of the largest private health insurers in America. In 2011, the AARP generated $458 million in royalty fees from so-called “Medigap” plans, nearly twice the $266 million the lobby receives in membership dues.


Medigap plans are private insurance plans that seniors buy to cover the things that traditional, government-run Medicare doesn’t, like catastrophic coverage. Medigap plans also help seniors eliminate the co-pays and deductibles that are designed to restrain wasteful Medicare spending.


AARP blocked Medigap reforms, saving the group $1.8 billion
Adding catastrophic coverage to Medicare, while restraining the ability of Medigap plans to waste money, is a key to Medicare reform, one that has been a big part of bipartisan plans in the past. According to the Kaiser Family Foundation, the Medigap reforms that AARP blocked would have saved the average senior as much as $415 in premiums per year.


But the AARP aggressively, and successfully, lobbied to keep Medigap reforms out of Obamacare, because AARP receives a 4.95 percent royalty on every dollar that seniors spend on its Medigap plans. Reform, DeMint estimates, would have cost AARP $1.8 billion over ten years.


Cuts to Medicare Advantage could earn AARP over $1 billion


Not only did AARP succeed in getting Democrats to balk at Medigap reform. Obamacare’s cuts to Medicare Advantage will drive many seniors out of that program, and into traditional government-run Medicare, which will increase the number of people who need Medigap insurance.
That means more royalty profits for the AARP. Reps. Wally Herger (R., Calif.) and Dave Reichert (R., Wash.) estimated that the change “could result in a windfall for AARP that exceeds over $1 billion during the next ten years.”


AARP Medigap plans exempted from Obamacare’s insurance mandates


It gets worse. AARP Medigap plans are exempted from most of Obamacare’s best-known insurance mandates. AARP Medigap plans are exempted from the ban that requires insurers to take all comers, regardless of pre-existing conditions. The plans are exempted from the $500,000 cap on insurance industry executive compensation; top AARP executives currently make more than $1 million. AARP plans are exempt from the premium tax levied on other private insurers. IPAB, Medicare’s rationing board, is explicitly barred from altering Medicare’s cost-sharing provisions, provisions that govern the existence of Medigap plans.


And AARP Medigap plans are allowed to have twice the administrative costs that other private insurers are allowed under Obamacare’s medical loss ratio regulations. This last point is key, because AARP’s 4.95 percent royalty is a significant administrative cost.
Democrats routinely excoriate private insurers for supposedly putting profits above people. "No American should ever spend their golden years at the mercy of insurance companies," President Obama told the AARP yesterday. But the typical private insurer gets by on a profit margin of about 5 to 6 percent. AARP’s 4.95 percent royalty, on the other hand, doesn't do anything to make a health plan operate more smoothly: it's just pure profit for AARP.


Publicly, the AARP poses as an independent, non-partisan organization. But privately, the organization strongly favored Obamacare. “We will try to keep a little space between us,” one senior AARP executive told the White House in November 2009, according to records unearthed by DeMint. “[Our] polling shows we are more influential when we are seen as independent, so we want to reinforce that positioning…The larger issue is how best to serve the cause” of Obamacare.


Kim Strassel at the Wall Street Journal goes through 71 pages of emails uncovered by the House Energy and Commerce Committee, which "show an AARP leadership...that from the start worked to pass Obamacare, before crucial details pertaining to seniors had been addressed." AARP had "long lambasted cuts in fees to Medicare doctors," she notes, but the lobby reversed itself for Obamacare, claiming that Obamacare's provider cuts were just fine.



AARP has a multibillion-dollar 'conflict of interest'


This week, the AARP hosted a convention in New Orleans, at which President Obama and Paul Ryan spoke about Obamacare and Medicare. When Rep. Ryan spoke to the AARP about the importance of repealing Obamacare, he was booed. Small wonder, given the AARP’s extreme financial interest in the law. According to DeMint, during the Obamacare debate in Congress, the AARP’s phone logs from seniors registered more than 50 to 1 against the law.


Remember these issues the next time someone points out that the AARP supports Obamacare’s Medicare cuts, and opposes the Romney-Ryan plan. The Romney-Ryan plan would dramatically reduce the need for Medigap plans, because it would encourage the formation of comprehensive insurance plans within the Medicare program itself.


Obamacare, on the other hand, saved the AARP from $1.8 billion in Medigap reforms, while potentially earning the group an additional $1 billion in royalties from seniors who are forced out of Medicare Advantage. That’s a swing of $2.8 billion over ten years, all thanks to Obamacare.


"There's an inherent conflict of interest," says Marylin Moon, who served as director of AARP's Public Policy Institute from 1986 to 1989. "A lot of people there are trying to do good, but they're ending up becoming very dependent on [Medigap royalty] sources of income."


It’s a testament to AARP's political power—and our broken health-care system—that the lobby is allowed to carry on a half-billion-a-year business that’s based on increasing the premiums that seniors pay, and draining money from the taxpayers who get billed for wasteful Medicare spending. Sen. DeMint has done a public service by bringing these problems out into the open.


UPDATE 1: In its 2014 annual financial statement, AARP reported receiving $297 million in dues, and approximately $528 million in Medigap royalties from UnitedHealth.


UPDATE 2: In the Fall 2012 issue of National Affairs, Daniel Kessler of Stanford does a nice job of explaining AARP's strong financial incentives to oppose premium support-style Medicare reform:


To be sure, health-care providers are not the only parties with an interest in preserving Medicare as we know it. Special-interest groups, too, are deeply invested, and thus highly engaged in the politics of entitlement reform. One powerful advocacy group in particular — the AARP — merits special attention. The motives behind its fierce opposition to the Wyden-Ryan premium-support proposal illustrate further advantages to moving from administrative to competitive pricing in Medicare.


It is not immediately obvious why the AARP — formerly known as the American Association of Retired Persons — should so strenuously oppose a reform that would not affect current seniors or anyone now over 55. Nor is it clear why the group would agitate against a proposal that could save the Medicare program from future collapse while retaining a guaranteed and comprehensive insurance benefit for seniors — both today and in the future. The group may well judge the IPAB's administrative-pricing model to be superior, but such a policy preference seems unlikely to account for the intensity of the AARP's opposition to premium support.


A look at what the AARP actually is and does helps to solve the mystery. As the country's largest non-profit advocacy group, the AARP has always been an important player in Washington. In recent years, however, its size and funding sources have changed. In 1990, the AARP had gross receipts of $300 million (which would be about $525 million in 2009 dollars); by 2009, gross receipts had grown to $2.2 billion.
This makes the organization eight times as large as the second-largest non-profit advocacy group, the National Rifle Association. In 1990, AARP membership dues were one-third of gross receipts, but by 2009, they had fallen to one-ninth.


Where is the rest of the money coming from? The key to answering this question lies in understanding Medicare supplemental insurance: private policies that pay for services not covered by Medicare, or that cover the program's co-payments and deductibles. These policies have an adverse effect on Medicare's finances, because they effectively eliminate cost-sharing as a motivator to keep health-care consumption in check. After all, if seniors have supplemental insurance, they basically have free health care — which means they pay no price for seeking more and more care. Several studies have shown that this leads to significantly greater spending, and only marginal medical benefit. Indeed, one recent study conducted for MedPAC showed that, all else being equal, supplemental coverage led to 33% more spending, largely in the form of elective outpatient procedures (as opposed to emergency or other urgent, non-discretionary inpatient services).


Supplemental insurance is thus harmful to Medicare's finances. But it's great for the AARP. Why? Choosing among the different supplemental plans — sorting through their various benefits and coverage differences, and weighing those against prices — can be a daunting task for seniors. The AARP steps in by lending its name to commercial insurers for the sale of AARP-approved and -branded Medicare supplemental, Medicare Advantage, and Medicare prescription-drug policies. AARP earns enormous royalties from these sources; indeed, they now account for about half of the group's income.


It is therefore not surprising that the AARP is deeply committed to — and in fact dependent upon — preserving this state of affairs. Hence the ferocity of the group's opposition to premium support. In a system like the one proposed by Wyden-Ryan, seniors would select coverage from among plans that all have the same required minimum benefits; as a result, there would be much less uncertainty about what one plan or another would or would not cover. This, in turn, would reduce seniors' reliance upon AARP endorsements or branding to select plans. And from the insurers' perspective, being forced to compete for seniors' business — by offering a good product at the lowest possible price — would give them every incentive to eliminate unnecessary costs. Immense royalty payments to the AARP in order to borrow the group's name would surely be among the first expenses to go. Moreover, any serious premium-support insurance plan would probably eliminate traditional Medicare's unlimited cost-sharing — thereby undermining the political and economic rationales for Medicare supplemental policies in the first place.


This would be a disaster for the AARP, but a boon to the cause of making Medicare more efficient (and thus more sustainable). Given that countless other powerful advocacy groups have similar stakes in keeping Medicare as it is, the story of the AARP is yet another example of how premium support would keep politics out of the system, and thereby help keep spending under control.
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This article has very good graphs showing the attack on hospital access for seniors especially through 1990s.  The funding was sent out----it simply didn't end with patient care----

Remember the COMMONWEALTH FUND is that global hedge fund no doubt holding trillions of dollars off shored from our Federal agencies and people's pockets in these few decades of fraud by Robber Baron global Wall Street pols.  It does not GIVE PUBLIC INTEREST ANALYSIS-----it tells the 99% what it thinks is COST EFFECTIVE.  This is what Obama and Clinton neo-liberals installed in changing how our Medicare funding is dispensed.  This is when what was simply a direct line from Medicare Trust to hospitals billing Medicare becomes that network of private corporations each called THE DECIDERS ---the middle-men now taking several percent of Medicare here----several percent of Medicare there---all ADMINISTRATIVE---ALL PRIVATE then reaching our state health systems where so little is actually left to be spent on SENIOR HEALTH CARE.

THE CHEAPEST ROUTE TO SENIOR HEALTH CARE IS GIVING 99% OF AMERICANS HOSPICE.


'Payment Approaches That Reinforce Quality

Medicare provides bonuses to hospitals and other providers that achieve top-level scores on patient outcomes and care experiences. As of 2015, 1.5 percent of base payments for more than 3,500 hospitals is withheld and used to reward top-performing hospitals for the quality of their care and their patients’ experiences of care; this amount increases to 2.0 percent by 2017.13 A similar program was initiated in 2015 for physicians in larger practices, and will expand to include all physicians by 2018'.

Medicare Payment Reform: Aligning Incentives for Better Care

This brief is the first of four in The Commonwealth Fund’s Medicare at 50 Years series that explore the key issues confronting the Medicare program and discuss potential policy options. Two earlier reports in the series traced the evolution of Medicare and its major accomplishments over the past 50 years and examined the Affordable Care Act’s reforms to the program and the challenges facing policymakers going forward.

The Commonwealth Fund’s Medicare at 50 Years series is now available in its entirety for viewing and download as an e-book.



Abstract

The Affordable Care Act (ACA) has provided the Medicare program with an array of tools to improve the quality of care that beneficiaries receive and to increase the efficiency with which that care is provided. Notably, the ACA has created the Center for Medicare and Medicaid Innovation, which is developing and testing promising new models to improve the quality of care provided to Medicare beneficiaries while reducing spending. These new models are part of an effort by the U.S. Department of Health and Human Services to increase the proportion of traditional Medicare payments tied to quality or value to 85 percent by 2016 and 90 percent by 2018. This issue brief, one in a series on Medicare’s past, present, and future, explores the evolution of Medicare payment policy, the potential of value-based payment to improve care for beneficiaries and achieve savings, and strategies for accelerating its adoption.


BACKGROUND

Medicare payment policy has evolved from the cost- and charge-reimbursement approach that was the predominant model when the program was enacted to the establishment of prospective payment systems in the 1980s and 1990s and, more recently, to movement toward value-based payment. The enactment of the Affordable Care Act of 2010 (ACA) and the recent announcement of value-based payment goals for Medicare, along with the enactment of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), have accelerated that movement and provided Medicare with the means to accomplish the goals of better health care, smarter spending, and a healthier population. The first two papers in this series focused on Medicare’s accomplishments over its first 50 years, the impact of the ACA on the program, and the challenges that remain; this paper focuses on the evolution of Medicare payment policy and the potential of payment reform to help address those challenges.


EVOLUTION OF MEDICARE PAYMENT POLICY

When Medicare was first established, it adopted the payment methods used by Blue Cross and Blue Shield plans at the time. Hospitals were paid on the basis of their own costs, and physicians were paid on the basis of the fees they charged. These payment systems provided no incentive to control costs—in effect rewarding higher hospital costs and physician fees—and did not take into account the quality or appropriateness of care or its contribution to patient outcomes. Between 1975 and 1985, annual Medicare spending per beneficiary rose from $472 to $1,579—a growth rate of 12.8 percent per year, or 5.3 percent when adjusted for economywide inflation.


To counter this trend, Medicare in 1983 adopted a prospective payment system for hospital inpatient services, under which hospitals receive a fixed rate of payment per patient based on the average hospital cost nationwide for patients in the same diagnosis-related group (DRG). If the hospital’s cost is less than the DRG payment rate, it retains the surplus payment, and if its cost exceeds the DRG payment rate, it bears the loss on that case. Hospitals responded by sharply reducing average length of stay. Spending per beneficiary by Medicare Hospital Insurance (Part A, which covers hospital inpatient and other facility-based care) subsequently declined sharply (Exhibit 1). Similar payment approaches subsequently were adopted by many private insurers and state Medicaid programs, as well as in more than 40 other countries. Medicare also has adopted prospective payment methods for postacute care, including home health and skilled nursing facility services.


At the same time, Supplementary Medical Insurance (Part B, which covers physician and other ambulatory care) continued to rise rapidly, as physicians continued to receive payments based on usual, customary, and reasonable charges, which rewarded increased spending. In 1989, legislation was enacted to replace the old system. The Medicare fee schedule, implemented in January 1992, was based on an estimate of the resources required to provide each service, rather than having each provider set his or her own charges. Part B spending subsequently slowed dramatically (Exhibit 2). This resource-based relative value scale (RBRVS) has become the standard in the health insurance industry, with most private insurers using a form of RBRVS to set or negotiate rates.


Outpatient prescription drugs were not part of the initial Medicare benefit package. When Congress enacted Medicare prescription drug coverage in 2003, it was made available only through newly created private prescription drug plans. Those plans negotiate payment rates with pharmaceutical companies or contract with private pharmaceutical benefit managers. Unlike other countries, the U.S. does not negotiate pharmaceutical prices for the entire population—and it pays much higher prices for brand-name drugs.


In 1982, Congress established the Medicare risk contracting program, which provided an alternative option for enrollees who chose to obtain their Medicare benefits from private managed care plans. In 1997 and again in 2003, Congress expanded the number and scope of private plans available through this program, now called Medicare Advantage. Medicare Advantage plans receive a monthly payment for each Medicare beneficiary enrolled in the plan, based on the location, age, and health status of the beneficiary. The fixed per-member per-month payment should give the plan a financial incentive to provide more coordinated, effective, and efficient care—but payments to Medicare Advantage plans historically have exceeded what their enrollees were expected to cost in traditional Medicare, diluting the incentive for efficiency; moreover, although Medicare Advantage plans receive a fixed payment per enrollee, it is not clear how those incentives influence the way the plans actually pay their providers.


MOVING THE FOCUS OF PAYMENT POLICY FROM VOLUME TO VALUE

Medicare has made significant improvements in the original payment methods modeled on the private insurance payment practices of the 1960s, and recent actions by Congress and the Department of Health and Human Services (HHS) have focused on accelerating that change. The ACA includes an array of provisions that are laying the foundation for fundamental Medicare payment reform, linking payment to patient outcomes and experiences of care, and giving providers an incentive to limit spending by rewarding reductions in the projected spending for their Medicare patients.


The HHS secretary has set a goal of linking 85 percent of traditional Medicare provider payment to quality or value by the end of 2016, and 90 percent by the end of 2018. A recent study indicates that, as of the end of 2013, 42 percent of provider payments in traditional Medicare are tied to the value of care. This represents significant progress, but much still remains to be done (Exhibit 3).11 Many initiatives that were not included in that study are in place now or will soon be implemented, supporting expectations that the percentage will increase considerably over the next few years.


In addition, Medicare Advantage plans, which cover 30 percent of Medicare beneficiaries as of 2014, are now financially rewarded under the ACA for receiving a high rating based on their performance on measures of quality and patient experience. Although little is known about how Medicare Advantage plans actually pay their providers, the addition of rewards for plan performance to the existing incentive for efficiency in a per-enrollee per-month payment system can be expected to support the move from volume to value in Medicare.


Payment Approaches That Reinforce Quality

Medicare provides bonuses to hospitals and other providers that achieve top-level scores on patient outcomes and care experiences. As of 2015, 1.5 percent of base payments for more than 3,500 hospitals is withheld and used to reward top-performing hospitals for the quality of their care and their patients’ experiences of care; this amount increases to 2.0 percent by 2017.13 A similar program was initiated in 2015 for physicians in larger practices, and will expand to include all physicians by 2018.


Several ongoing initiatives involve penalties for specific indicators of poor performance. One such program focuses on hospital readmissions; for several decades, almost 20 percent of Medicare beneficiaries who were hospitalized were readmitted within 30 days.15,16 The Medicare program began to target specific surgical procedures and medical conditions, with the expectation that the list would expand over the years; in just a few years, the overall rate of readmissions has dropped below 18 percent. Another initiative penalizes hospitals with higher-than-expected rates of hospital-acquired conditions; those conditions decreased across all hospitals by 17 percent between 2010 and 2013.


In the MACRA legislation, a merit-based incentive payment system (MIPS) will be established, beginning in 2019, that will combine several current value-based purchasing initiatives and will tie payment more closely to measures of performance. The success of these efforts will depend greatly on the ability to develop metrics that are viewed by a broad spectrum of stakeholders as accurate measures of performance—an endeavor that has made great progress but still faces substantial challenges.


Alternative Payment Models That Reward Value



The ACA created the Medicare Shared Savings Program (MSSP) for accountable care organizations (ACOs), which are groups of providers who accept joint responsibility for the quality and cost of the Medicare patients they treat and can share in the savings they generate as compared with a cost target.21 The ACA also created the Center for Medicare and Medicaid Innovation (CMMI) to develop and test value-based alternative payment methods.22,23 Many of those initiatives represent more far-reaching reforms, and put providers at financial risk for a portion or all of the cost of providing Medicare services. Among the most prominent activities being conducted by the CMMI are several aimed at transforming primary care, and several of its models involve a bundled payment for specified sets of hospital and/or postacute care related to specific procedures or conditions.


Accountable Care.

The MSSP began in 2012; as of April 2015, there were more than 400 ACOs participating in the program, serving more than 7 million Medicare beneficiaries in 49 states, the District of Columbia, and Puerto Rico.25 Early results from the MSSP participants indicate that, as a whole, they have achieved modest savings and generally improved the quality of care.26 In the first year, 54 percent of the organizations for which results were available spent less than their targets, and 24 percent saved enough to earn shared-savings bonuses (Exhibit 4).


The CMMI designed the Pioneer ACO

Model for early adopters of coordinated care. It offers both upside shared savings and downside risk for losses in return for a larger share of achieved savings.28 When it began in 2012 there were 32 participating organizations in 18 states; the number of Pioneer ACOs has fallen to 19 as of 2015, but most of the organizations that left the initiative switched to the MSSP. Over the first two years of the program, total Medicare expenditures increased more slowly for beneficiaries aligned with Pioneer ACOs than for beneficiaries in traditional Medicare, with little difference in patient experience. These findings established the Pioneer ACO Model as the first CMMI initiative to meet the ACA criteria (proven potential to reduce Medicare spending while maintaining the quality of care) for expansion to other areas and organizations.


Primary Care Transformation.

Since 2012, the Centers for Medicare and Medicaid Services (CMS) has been collaborating with commercial and state health insurance plans to offer population-based care management fees and shared-savings opportunities to participating primary care practices in order to support prevention, access to care, care coordination, chronic care management, and shared decision-making among patients and their providers. As of February 2015, the Comprehensive Primary Care (CPC) initiative includes 480 sites in seven regions, including more than 2,700 providers who serve 2.7 million patients, of which 400,000 are Medicare and Medicaid beneficiaries. Altogether, there are 38 public and private payers participating in this initiative.30 Results from the first year are mixed: there was a statistically significant reduction in total Medicare expenditures per beneficiary, but not quite enough to offset the care management fees paid to the practices; several quality measures improved among participants, but none of the changes was statistically significant.


Through the Multi-Payer Advanced Primary Care Practice demonstration, begun in 2011, CMS is participating in multi-payer reform initiatives currently under way in eight states to make advanced primary care practices more available. The demonstration, which was originally planned for three years, has been extended through 2018; it is anticipated that approximately 1,200 medical homes, serving more than 900,000 Medicare beneficiaries, will participate. In the first year, only two of the seven states for which data were available generated savings; no evidence is yet available on access to or quality of care.


Although the initial results have been mixed, these models do show some promise for providing vehicles for increasing the emphasis on primary care and facilitating more coordinated care. More time may be needed to overcome the adverse incentives and fragmented delivery and payment systems that still predominate in the U.S. health system.


Bundled Payment.

Bundled payment is designed to provide financial incentives to improve the continuity and effectiveness of care, reduce the use of unnecessary services, and slow spending growth by creating financial incentives for providers to coordinate care across settings.

The CMMI has developed the Bundled Payments for Care Improvement (BPCI) initiative, which provides a single payment amount for a specified course of inpatient and/or post-hospital care. Four payment models cover different combinations of those services, with almost all of the approximately 7,000 participating providers opting for Model 2 (acute and postacute care episodes) or Model 3 (postacute care only).35 Evaluation of first-year performance indicates that Model 2 may decrease variation in the use of postacute care, which has been a major factor in health spending differences across regions.


Progress, But a Long Way to Go


The testing of alternative payment models is still in an early stage. General evaluations have found gains in quality and modest savings, but the results so far have been mixed. There is some evidence that, as experience with alternative payment models accumulates, savings can increase.38 Key requirements for success include setting incentive payments so that they align with potential savings; targeting interventions that help high-cost, high-need individuals avoid unnecessary hospitalization or emergency room use39; and aligning policies among public and private insurers.


STRATEGIES FOR EXPANDING VALUE-BASED PAYMENT


One powerful tool that the HHS secretary possesses is the authority, granted by the ACA, to adopt innovations found to save money and improve quality for use throughout the Medicare program. In addition to continuing to test how well different incentives improve value, HHS is focused on improving the way care is delivered through learning networks such as the recently announced Health Care Payment Learning and Action Network.40 It also aims to increase the availability of information to guide decision-making, by increasing the use of health information technology, enhancing transparency, and generating information through the Patient-Centered Outcomes Research Institute that can guide care decisions.


As described above, the MACRA legislation provides strong impetus to support Medicare’s movement toward value-based payment: it provides 5 percent fee increases to physicians who receive a significant portion of their revenue from an alternative payment model, such as a blended, bundled, or global payment model, or from care provided through patient-centered medical homes or ACOs.


In addition, MACRA provides funding to increase the rewards for providers who achieve exceptionally high performance on measures of health care quality, patient experience, and efficiency. Further legislation may be necessary to fix the flawed fee-for-service physician payment system, since it is likely to remain a component of payment methods for some time.


To accelerate movement away from fee-for-service payment with no link to value, it may be necessary to continue to widen the differential in payment rates for providers that participate in value-based payment models. Rewarding beneficiaries for seeking care from high-value providers would align provider and beneficiary incentives, and could go a long way toward supporting the success of those incentives.42 It would require that beneficiaries be given access to useful information on the prices and quality of participating providers.


Finally, the move to value-based payment will be much more effective if Medicare continues to actively seek partnerships with private insurers, state Medicaid, and other federal programs that adopt value-based payment methods. The ultimate goal is to transform the delivery of care for everyone, improving patient outcomes and care experiences, preventing avoidable hospitalization, and lowering costs. Reducing or eliminating avoidable, unnecessary, and ineffective care, and redeploying those savings to provide better financial protection and lower federal outlays, would be a major step toward improving the financial sustainability of the Medicare program in particular, and the U.S. health system in general.

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Will we were shouting WRAP-AROUND SERVICES including HEALTH CARE to low-income through community schools was never a real substitution for closing public health clinics, public hospitals, or ending access to private for-profit hospitals our pols in Baltimore spent these several years touting WRAP-AROUND SERVICES to our low-income communities. These global Wall Street players do ANYTHING GLOBAL HEDGE FUNDS TELL THEM---knowing these children as 99% of Americans will not access ordinary health care.
THE CHEAPEST ROUTE SAYS GLOBAL WALL STREET----YOU BETTER STAY AS HEALTHY BECAUSE YOU AIN'T GETTING INTO OUR PROFIT-DRIVEN GLOBAL HEALTH TOURISM FOR THE 1% AND THEIR 2% HOSPITALS.

GLOBAL WALL STREET REALLY, REALLY, REALLY DOES NOT WANT TO TAKE CARE OF HUMAN CAPITAL FOLKS!

Health & Human Services

A ‘Wraparound’ System of Care for Schools


Several school systems are implementing so-called wraparound programs in an effort to help troubled kids, families and communities.


by Jonathan Walters | March 11, 2014


Elementary school students get lunch at a school in Osceola County, Fla., where 71 percent of students are eligible for free or reduced price meals. MCT/George Skene

 If you've spent any time following education policy these days, you probably know that Common Core Standards are the topic du jour. Depending on political leanings, people either love them or hate them. But even the most brilliant, focused and politically embraceable education reform initiative will fail if kids flat out aren't ready to learn when they show up at school each day because they're not getting what they need at home.


The importance of supporting potentially troubled kids in school was a key part of an interesting panel conversation on education reform held last month during Governing's annual Outlook in the States & Localities conference in Washington, D.C. The panel featured Roy Romer, former governor of Colorado; Randy Weingarten, president of the American Federation of Teachers; and Elaine Weiss, head of the Economic Policy Institute's Broader Bolder Approach to Education initiative, which is aimed at moving the educational debate beyond didactics and to the ground-level realities of the well-being of kids and families.

As everyone on the panel pointed out, kids who show up at school hungry, tired, scared or in poor health -- and whose home lives might be in shambles -- aren't going to learn very well, regardless of the core course work or the quality of the teachers. Making matters worse, there's a good chance that these kids will be flat out disruptive in school, compounding the problem.


Fortunately, there are some school districts that are tackling this problem: In Cincinnati, the district has fully embraced the concept of "wraparound schools," or schools that house a variety of support services aimed at getting kids everything from food to health care to counseling in order to ensure that all students are ready to pay attention and perform in the classroom.
But true wraparound schools are much more than that, says Weiss of the Economic Policy Institute. As a first step, she says, wraparound schools certainly do look at the "opportunity gaps" that exist for some students, whether it's as basic as getting them a backpacks to carry around school work and supplies, or as complicated as ensuring they get decent dental care. But the best wraparound programs are those that involve families and whole communities in looking out for the complete health and well-being of students and their families.


"A lot of educators complain that they can't engage parents," says Weiss. "So you have schools that are open from 8 a.m. to 5 p.m., and teachers say they can't get parents involved? Well, maybe that's because the parents are working." As a solution, Weiss points to wraparound schools that have a coffee and meeting room for parents who walk their kids to school, along with schools that have evening hours so that working parents have a chance to engage.


Good wraparound programs go even further. A lot of parents in many school districts never graduated from high school or don't speak English, so some wraparound programs offer English and high school equivalency classes. "Some are even offering things like tax preparation clinics in the evening," says Weiss.
Ultimately, it's all about engagement and coordination. Schools that are serious about the wraparound movement actually have dedicated staff who do nothing but coordinate parent and community involvement, social and health services, and the day-to-day learning environment. So while the educational world may at presently consumed by the debate over Common Core Standards, several schools are addressing the real building block to learning: Ensuring kids are healthy and secure.

____________________________________

Now the right wing is hawking HEALTH SAVINGS ACCOUNTS----which are of course what MEDICARE was-----MEDICAID was our Federal tax dollars coming back to our communities for low-income health care----that's the point----the right wing does not see ANY TAXES PAID BY WE THE PEOPLE as coming back to WE THE PEOPLE and our community as services---they see it all going to boost global corporate profits.

CLINTON/BUSH/OBAMA have been working to make the poor pay taxes these few decades.  The NEW DEAL policies placed tax burden on corporations and the rich while allowing the poor tax freedom to give opportunity to grow wealth.  Obama and Clinton neo-liberals started this movement to POOR PAYING TAXES by calling these SAVINGS ACCOUNTS taken from paychecks of poor as bootstrap paying for health care.  Obama called it myRA------he created created structures where low-income had to provide community services to access health care.  As Obama Republicans now want to send to global Wall Street to use as FODDER these 21st Century 401K/IRA accounts that no one will ever see again. Where PAYROLL TAXES pre-paid our health insurance----now they are going to tell the poor who already get almost nothing in wages that SAVINGS ACCOUNTS will be there when they need them.

This policy was already MOVING FORWARD under Obama and for Trump lovers-----these policies are United Nations written and installed in all Foreign Economic Zones bringing America in line with all other developing third world nations.


Trumponomics

Health savings accounts may flourish under Trump

Tom Anderson | @bytomanderson
Wednesday, 16 Nov 2016 | 8:30 AM ETCNBC.com


President-elect Donald Trump and Republican lawmakers want to expand access to health savings accounts. If that happens, people who use these tax-advantaged plans to pay for health costs as well as investors who treat HSAs as another retirement option could benefit.


Trump has proposed making it easier to pass on HSAs to heirs while House Republicans want a nearly-twofold increase in contribution limits.

"We feel the election outcome certainly seems to lean more favorably toward HSAs, however, it may take time for that to play out," said Jon Robb, senior vice president of research and technology at HSA consulting firm Devenir.
Americans had opened 18.2 million HSAs as of June 30, up 25 percent from a year earlier, according to Devenir. Assets had grown to an estimated $34.7 billion by June, up 22 percent year over year. (See chart below.)
HSAs, introduced in 2003, offer you triple tax advantages.

First, contributions to the account are tax-deductible. Second, those contributions can be invested and grow tax-free. Third, withdrawals aren't taxed as long as you use them for qualified medical expenses.
If you use an HSA to pay for unqualified medical expenses, the tax penalty is 20 percent, unless you are 65 or older, when you can take money out for whatever you want, but the withdrawals will still be subject to regular income taxes.
A drawback of HSAs is that they are paired with a high-deductible health plan.


Such a plan means you'll have to pay a deductible of at least $1,300 for individual coverage and $2,600 for families. The maximum annual out-of-pocket costs for these plans are $6,550 for individuals and $13,100 for families.
In 2017, you (and your employer) can contribute up to $3,400 to an HSA for individuals and $6,750 for families. Account holders age 55 and older can contribute an extra $1,000.

HSA proposals on the table

The Trump administration and Congress would have to hammer out details next year before any changes to HSAs could be made.


The president-elect has proposed HSAs "would become part of the estate of the individual and could be passed on to heirs without fear of any death penalty." Currently, there is no tax penalty for HSAs inherited from a spouse, but those inherited from someone other than a spouse are included in an heir's income.
House Speaker Paul Ryan and fellow Republicans want to increase the HSA contribution limits to the maximum out-of-pocket limits for high-deductible health plans. So if those rules were in effect next year, the individual HSA limit would rise to $6,550 from $3,400 and the family contribution limit would grow to $13,100 from $6,750.



House Republicans also want to allow spouses to make catch-up contributions to the same HSA account and permit qualified medical expenses incurred before HSA-qualified coverage begins to be reimbursed from an HSA as long as the account is established within 60 days.

"HSAs can be a bipartisan force that drives better outcomes for all." -Michael Trilli, senior consultant at Aite GroupAnother way the Trump administration and Congress could juice the adoption of HSAs would be by repealing the so-called Cadillac tax.


The tax is a key part of the Affordable Care Act, levying a 40 percent excise tax on high-cost health plans. The tax is scheduled to go into effect 2020. Last year, a divided Congress pushed back the start of the tax by two years.


"The employer Cadillac tax could be abolished immediately and will propel HSAs," said Michael Trilli, senior consultant at financial services consulting firm Aite Group. "HSAs can be a bipartisan force that drives better outcomes for all."


However, Trilli worries that while HSAs have been popular as employee benefits, the accounts have struggled to gain traction among people who are not offered them in the workplace. He sees government subsidies, similar to those provided by employers, as a way get more consumers to start contributing their own funds to HSAs and an area of potential bipartisan compromise.

"Nearly half of employers may offer a high-deductible health plan within two years." -William Ziebell, executive vice president at insurance brokerage Arthur J. Gallagher & Co.Regardless of what a Trump administration or Congress does with HSAs, you will probably hear more about them at your workplace.


"Nearly half of employers may offer a high-deductible health plan within two years," said William Ziebell, executive vice president at insurance brokerage Arthur J. Gallagher & Co.


His prediction is based on a survey Gallagher did of 3,107 U.S. employers in March. The survey found that about 31 percent of employers offer an HSA-compatible health plan now and 15 percent said they are likely to adopt those health plans by 2018.

How to pick an HSA

Unlike the flexible spending accounts, you don't have to "use it or lose it" with an HSA.


In fact, more than three-quarters of HSA account holders withdrew less than they contributed last year, and 24 percent didn't touch any money from their accounts, according to a Fidelity Investments analysis of the more than 500,000 accounts it administers.
Your employer may direct you to sign up with their preferred HSA provider, but if you are enrolled in a qualified high-deductible health plan, you can choose whatever provider you want. However, if employers only offer matching HSA contributions to their preferred provider, it makes sense to stick with them.
HSAs can travel with you if you change jobs or insurers. Just like with any retirement account, fees and investment options matter.


Use this HSASearch to comparison-shop for more than 320 providers.
"Whenever feasible, we recommend that clients leave their HSAs alone to grow and to not use the funds," said Wade Chessman, a certified financial planner and president of Chessman Wealth Strategies in Dallas. "It's really the perfect investment ... pretax in and tax-free out."

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Trump will MOVE FORWARD a United Nations ONE WORLD ONE GOVERNANCE universal health care----single-payer-----preventative health care for all just as Clinton/Obama were---global labor pool workers already have what is called INTERNATIONAL HEALTH INSURANCE that will be brought here to US and indeed it will cover our immigrant citizens but not with health care looking like America---with health care looking third world. Obama and Affordable Care Act restructured our health system to do just this----with global 1% and their 2% getting our first world quality health care all Americans received ----and 99% of Americans joining the global labor pool in ONE WORLD ONE UNIVERSAL PREVENTATIVE HEALTH CARE. Trump is not using the term UNIVERSAL CARE because he moved left------universal care IS THE RIGHT WING HEALTH CARE POLICY written to end our US quality care access to all care needed.
'The apparent gap between what Trump appears to be proposing (universal coverage) and what Republicans have supported (universal access) isn’t nearly as wide as many analysts think. This gap is both narrow and bridgeable: There are policies that can ensure universal access to health insurance while also putting our nation on the path toward universal coverage.
Any market-based replacement for the ACA should include four key elements to move us toward universal coverage'.
We want to shout to our immigrant citizens that they pay SOCIAL SECURITY AND MEDICARE PAYROLL TAXES and they should receive same level of care as US citizens with Medicare---sadly that will move to the gutted of funding MEDICAID FOR ALL---RIGHT WING UNIVERSAL CARE.


Trump wants health ‘insurance for everybody.’ Here’s how the GOP can make it happen.

President Donald Trump smiles. (Win Mcnamee/Bloomberg)


By Lanhee J. Chen and Tevi D. Troy February 2Lanhee J. Chen is a research fellow at the Hoover Institution and director of domestic policy studies in the public policy program at Stanford University. Tevi D. Troy is chief executive of the American Health Policy Institute and was deputy secretary of health and human services from 2007 to 2009.


Donald Trump’s statement that his preferred replacement for the Affordable Care Act (ACA) would provide health “insurance for everybody” surprised those who have followed the contentious debate over the health-care law since its passage in 2010. Rep. Tom Price (R-Ga.), Trump’s nominee for health and human services secretary, signaled agreement with the president when he said during his confirmation hearing that a Republican replacement for the ACA should cover more people.
In recent years, though, Republicans have emphasized that gains in insurance coverage should not be the sole barometer by which health-care reform is measured. Rather, they have said, the affordability of that coverage is the key to a better health-care system with fewer uninsured Americans. The ACA’s cardinal sin is its focus on access first, while doing little to address cost.


As a general matter, the conservative focus on lowering health-care costs first is exactly right. Yet Trump was also right to argue that the ACA’s replacement ought to have universal coverage as a goal. Democrats should not be allowed to claim this health-care moral high ground uncontested.

For too long, Republicans have shied away from calling for “universal coverage” because they’ve equated it with the Democratic push for a government-run, single-payer health-care system. But that simply isn’t the case. Market-based reforms can both lower costs and lead to health insurance coverage for more Americans. Indeed, any health-care reform that can’t compete with the ACA on coverage is sure to face significant political headwinds. It also would make it far less likely that Democrats can be persuaded to support replacement legislation. Perhaps most important, this is a fight that conservatives can — and should — win.


The starting point for this seemingly audacious claim is the fact that the ACA has been a significant failure even for those who value universal coverage above all else. While the law has unquestionably decreased the number of uninsured people in the United States, the Census Bureau reported last year that 29 million remained without health coverage in 2015. (About a quarter of these were undocumented immigrants or residents of states that opted against the Medicaid expansion.) In 2015, the Internal Revenue Service found that 19.2 million taxpayers either paid the individual-mandate penalty or received hardship exemptions from that mandate — meaning that tens of millions of people went without health insurance, primarily because it’s too expensive.

Kellyanne Conway, a senior aide to President Trump, told CBS on Jan. 22 that Trump wants to replace “Obamacare with a more patient-centric, free-market solution.” (Reuters)Republicans have traditionally been more comfortable talking about the importance of ensuring that every American has access to quality, affordable health insurance. Indeed, “universal access” has been a relatively noncontroversial way for conservatives to avoid making promises about how market-based health-care reform would affect the number of Americans who remain uninsured after the passage.


The apparent gap between what Trump appears to be proposing (universal coverage) and what Republicans have supported (universal access) isn’t nearly as wide as many analysts think. This gap is both narrow and bridgeable: There are policies that can ensure universal access to health insurance while also putting our nation on the path toward universal coverage.


Any market-based replacement for the ACA should include four key elements to move us toward universal coverage.


First, it should expand access to consumer-directed coverage arrangements such as health savings accounts coupled with high-deductible insurance plans. These products not only help reduce costs but also give consumers greater control over their own care. Such increased control incentivizes individuals to do what consumers do best: make value-based decisions that collectively drive down costs and improve quality.



Second, assistance should go to those who need it but be tailored to their individual situations. Low-income Americans should have access to a more innovative and modern Medicaid program, while the working poor should have access to a tax subsidy to help them afford private plans.

Third, those with preexisting conditions should have access to mechanisms, such as properly funded high-risk pools, to help them both acquire and afford coverage.

Finally, the federal government should allow for alternative pathways to private, tax-preferred coverage, by allowing health plans to be sold across state lines, as well as by giving unions, churches and other civic organizations the opportunity to offer coverage to members.

Taken together, these policies provide a powerful set of tools to both drive down health-care costs and expand coverage to every American. Trump and the Republican Congress have a remarkable opportunity not only to do away with the ACA and all of its shortcomings but also to put in place reforms that will truly improve our health-care system. Republicans in Congress should not hesitate to embrace Trump’s call for universal coverage. Indeed, they should work with the new administration to pass legislation to make this goal a reality.

_____________________________________________

PLEASE REMEMBER UNIVERSAL HEALTH CARE WAS WRITTEN BY RIGHT WING HERITAGE FOUNDATION TO END PUBLIC HEALTH CARE ---MEDICARE AND MEDICAID----BY CREATING A PRIVATE HEALTH SYSTEM BASED ON REDUCING HEALTH COSTS BY MAKING INSURANCE AND DEDUCTIBLES TOO HIGH SO THE AMERICAN PEOPLE COULDN'T AFFORD IT.
That is from where the term AFFORDABLE came---see as well the INSURANCE MANDATE came from right wing Heritage because it sends a steady stream of profit. Having our ability to pay increasing insurance costs from global health systems tied to how much access we receive
'Heritage has shaped American public policy in major ways, from Reagan’s missile-defense initiative to Clinton’s welfare reform: Both originated as Heritage proposals. So, too, did the idea of a universal health-care system based on a mandate that individuals buy insurance'.

The Fall of the Heritage Foundation and the Death of Republican IdeasHow the Heritage Foundation went from the intellectual backbone of the conservative movement to the GOP's bane—and how it's hurting the party's hopes for a turnaround

• Molly Ball
• Sep 25, 2013

The story of the conservative movement that has come to dominate the Republican Party over the last four decades is inextricably intertwined with the story of the Heritage Foundation. In that time, it became more than just another think tank. It came to occupy a place of special privilege—a quasi-official arm of GOP administrations and Congresses; a sponsor of scholarship and supplier of legislation; a policy base for the party when out of power. Heritage has shaped American public policy in major ways, from Reagan’s missile-defense initiative to Clinton’s welfare reform: Both originated as Heritage proposals. So, too, did the idea of a universal health-care system based on a mandate that individuals buy insurance. Though Heritage subsequently abandoned it, the individual mandate famously became the basis of health-care reforms proposed by Massachusetts Governor Mitt Romney and President Barack Obama.


"They're destroying the reputation and credibility of the Heritage Foundation. The respect for their policy work has been greatly diminished."These days, Heritage has a different crusade. The foundation’s president, the confrontational former Senator Jim DeMint, spent the last month touring the country, drawing cheering crowds as he demanded that Republican politicians insist that Obamacare be defunded—and denouncing those who wouldn’t go along. “Republicans are afraid,” DeMint told NPR. “And if they are, they need to be replaced.” The foundation’s three-year-old activism arm, Heritage Action, spent half a million dollars on online ads targeting 100 Republican House members who didn’t sign on to the defund crusade (“Tell Representative Tom Cole to Stop Funding Obamacare”).


Outsourcing PolicymakingWith imposing buildings flanking the Capitol on both sides and a budget of more than $80 million, Heritage looms large in the Washington professional right. More than just another nonprofit peddling legislative ideas, it has become the de facto policy arm of the congressional conservative caucus. “The Heritage Foundation is where policy agendas are set and tactics are developed hand-in-hand with Hill staff,” a rival researcher wrote last year, describing Republicans in Congress as essentially “outsourcing” their policy work to the foundation.
Unique among nongovernmental organizations, Heritage’s Center for Data Analysis has the number-crunching capacity to compete with the White House’s Office of Management and Budget and the Congressional Budget Office in using sophisticated modeling to assess legislation’s impact on the economy. When Representative Paul Ryan drafted his conservative budget proposal in 2011, he submitted it to Heritage as well as to the CBO to be “scored.” (Heritage scored it more favorably.)
Nothing better symbolizes Heritage’s integration with Republican policymaking than its longtime partnership with the Republican Study Committee, a conservative caucus in the House that, at 172 members, now claims the majority of the House GOP. Heritage and the committee were both founded in 1973 with the involvement of Ed Feulner, then a Republican congressional staffer. After leaving the Hill, Feulner served as Heritage’s president until DeMint took the reins this year.