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PBS NewsHour

What you need to know about the GOP’s Graham-Cassidy health care bill

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JUDY WOODRUFF: A few weeks ago, Republicans’ long-fraught efforts to repeal and replace the Affordable Care Act looked all but dead on Capitol Hill. But just in the past few days, a new proposal is gaining sudden momentum in the Senate, as a critical deadline looms for the GOP.

This afternoon, President Trump told reporters that he believes the bill has a very good chance of passing the Senate.

John Yang has more.

JOHN YANG: Judy, the new health care bill is sponsored by four Republican senators, Lindsey Graham of South Carolina, Bill Cassidy of Louisiana, Dean Heller of Nevada, and Ron Johnson of Wisconsin.

It would bring sweeping changes to the current health care system, including ending the individual mandate that everyone have insurance or pay a penalty, eliminating the Medicaid expansion in states, and instead give states lump sums so they can spend as they choose, eliminating federal tax credits to help offset health care costs, and removing protections so that insurers cannot charge more for preexisting conditions.

Majority Leader Mitch McConnell said he intends to have a vote in the Senate next week, before the chamber loses its chance to pass a health care bill with just 50 votes, instead of 60 to overcome a filibuster.

One of the bill’s original sponsors, Lindsey Graham, defended the push:

SEN. LINDSEY GRAHAM, R-S.C.: You can have different opinions about the quality of this bill. At the end of the day, this is the only process left available to stop a march towards socialism.

We have between now and the end of the month to have a vote and a debate about whether this is better than the status quo. My friends on the other side are never going to agree to a bipartisan proposal that does anything other than prop up Obamacare.

JOHN YANG: Today, former President Barack Obama, at a Bill and Melinda Gates Foundation — in New York City ripped into the bill.

FORMER PRESIDENT BARACK OBAMA: When I see people trying to undo that hard-won progress for the 50th or 60th time, it is aggravating.

And all of this being done without any demonstrable economic or actuarial or plain commonsense rationale, it — it frustrates.

JOHN YANG: Here to help us understand the policy and the politics behind all of it, Sarah Kliff, who covers health policy for Vox, and our own Lisa Desjardins, who covers Capitol Hill.

Lisa, a lot of changes not only to the current system, but also to the previous bills, repeal bills. One is how the federal money is going to be distributed.

What are those changes?

LISA DESJARDINS: This is a massive change in health care spending. It would shift money to the states.

Let’s look at it specifically. So, right now, under the Affordable Care Act, the federal government pays tax credits for premiums. These are for lower- and middle-income people. Also pays cost-sharing subsidies to help with deductibles. And, in addition to that, there’s the Medicaid expansion.

That’s a lot of money. The Graham-Cassidy bill would shift all of that money and all of those things and shift it all to states, $1.4 trillion worth. Now, Republicans say that gives states many more options. But without the limits, there is also no guidance, there’s no plan right now for what to do with that money.

JOHN YANG: Sarah, this morning, you wrote that of the four repeal bills that Congress has considered so far, that this is the most radical of them all.

Explain that in terms of the protections, the benefits and coverage that this bill would afford.

SARAH KLIFF, Vox: Yes, I think part of it has to do with what Lisa was saying, that there is really no requirement that this money go to health insurance.

It could be sent to hospitals. It could be put into high-risk pools. There’s very few guardrails around how this money gets spent. And one of the other things you see going on is a return of preexisting conditions.

Health insurance plans could once again charge people higher premiums because they have a cancer diagnosis or something like asthma if a state applies for a waiver to let its insurance companies do that.

So it really goes beyond the other Republican repeal plans. Those ones, I kind of saw as poorly funded versions of Obamacare. The tax credits go down, Medicaid expansion gets less money, but the framework is there.

Like Lisa was saying, this gets rid of the framework entirely. It makes this lump of money. It distributes it in a very, very different way. It really disadvantages any state that has embraced Obamacare. It would be very, very disruptive if it were to become law.

JOHN YANG: And, Lisa, what are the timelines for this? When would these changes take effect? When would the programs end, the current programs end?

LISA DESJARDINS: That is another big difference.

The Medicaid expansion in other bills was phased out in different ways. But in this bill, it would have a hard end in 2020. And there also would be some changes that would affect — be in effect immediately in 2018. And it’s not clear how insurers would deal with those right away.

JOHN YANG: Now let’s turn to the politics of all of this.

This is now being opposed by a slew of patient groups, of provider groups, the American Medical Association, the American Heart Association, the AARP, some hospital groups, late-night talk show Jimmy Kimmel, who became a voice on all of this debate in May when he talked about his son, who was born with a congenital heart defect.

Last night, he joined the criticism.

JIMMY KIMMEL, Host, “Jimmy Kimmel Live!”: If the bill passes, individual states can let insurance companies charge you more if you have a preexisting condition.

You will find that little loophole later in the document, after it says they can’t. They can, and they will.

But will it lower premiums? Well, in fact, for lots of people, the bill will result in higher premiums. And as far as no lifetime caps go, the states can decide on that, too, which means there will be lifetime caps in many states.

So, not only did Bill Cassidy fail the Jimmy Kimmel test. He failed the Bill Cassidy test. He failed his own test.

JOHN YANG: Lisa, you have got governors coming out against this. You have got all these groups.

What are the chances of this passing?

LISA DESJARDINS: We should point out, there are also some governors who came out in favor of it, Republican governors.

I think the chances are still long, because it comes down to four key Republicans. We already know that the Senate Republicans can only lose two of their members on this vote. Rand Paul is already a no. Then you get the three Republicans who voted no the last time, Susan Collins, Lisa Murkowski, and John McCain.

They need two of those three. And that’s going to be hard to do. John McCain said just today to reporters that he still wants regular order, he doesn’t want this to be rushed through.

But they have got this September 30 deadline, and McConnell seems to want to meet it.

JOHN YANG: And, Sarah, why are some people so enthusiastic about this?

SARAH KLIFF: I think Obamacare repeal has been such a goal for Republicans.

If you talk to senators on Capitol Hill, as my colleagues at Vox have been doing, a lot of them will say, this is our last chance. We have promised this in elections. We have said we need to deliver.

Pat Roberts of Kansas told one of my colleagues, this is the last car leaving, and we want to get in it.

So, it seems very much it is less about the actual policy. It’s more about this being last plan left standing and the last option to move forward with 50 votes this year.

JOHN YANG: And the leaders have made this the last option in a certain way. There was an attempt at bipartisan — to fix the problems with Obamacare. But what’s happened to that?

LISA DESJARDINS: That’s right.

Democrat Patty Murray has been working with Lamar Alexander of Tennessee, Republican, to try and craft a bipartisan compromise. Different versions on that. The Republicans say they just couldn’t get there. The Democrats say they came a long way.

It’s hard to say, but I think one other answer to what Republicans like about this, they do want more options for state. They want more power to states. And some specific states win in this deal, red states.

The states that lost the most are states like California and New York. States that gain the most seem to be states like Kansas, Alabama, Mississippi. Those are Republican red states and it’s a significant shift in resources.

JOHN YANG: And, Sarah, what would this do for insurers? If states — every state could write is own rules, what do insurance companies think about this?

SARAH KLIFF: They are very nervous.

They have generally come out against this bill. If you remember, when launched in 2013, it was a big mess. It didn’t work. And that was with four years to build one system for the entire country.

Graham-Cassidy asks all 50 states to build their own health insurance system, some new framework in just two years. So I think insurance companies, they have just gotten used to the Affordable Care Act. The marketplaces, they’re finding their legs there. They are not enthusiastic about the idea of having 50 new systems that they would have to learn to navigate in just two years from now.

JOHN YANG: Sarah Kliff, Lisa Desjardins, we have an interesting week-and-a-half ahead. So, thank you very much.


The post What you need to know about the GOP’s Graham-Cassidy health care bill appeared first on PBS NewsHour.

WATCH: Obama speaks at global health event

Watch former President Barack Obama speak at the event on Wednesday.

Former President Barack Obama spoke at the Bill and Melinda Gates Foundation Goalkeepers event in New York on Wednesday to measure the progress of global health over the past 25 years.

This event is timed to the U.N. General Assembly and the release of a report by Bill and Melinda Gates, which measures the world’s health according to 18 indicators. These include infant mortality, AIDS, vaccine use and smoking rates.

Other speakers at the event include Bill and Melinda Gates, Prime Minister Trudeau,, Malala and Stephen Fry.

The post WATCH: Obama speaks at global health event appeared first on PBS NewsHour.

GOP says there’s momentum for their Obamacare repeal bill, but hurdles remain

Healthcare activists protest to stop the Republican health care bill at Russell Senate Office Building on Capitol Hill
         in Washington, U.S., July 17, 2017. REUTERS/Yuri Gripas - RTX3BUB4

Healthcare activists protest to stop the Republican health care bill at Russell Senate Office Building on Capitol Hill in Washington, in July. Photo by Yuri Gripas/Reuters

WASHINGTON — Top Senate Republicans say their last-ditch push to uproot former President Barack Obama’s health care law is gaining momentum. But they have less than two weeks to succeed and face a tough fight to win enough GOP support to reverse the summer’s self-inflicted defeat on the party’s high-priority issue.

“We feel pretty good about it,” Sen. Bill Cassidy, R-La., a leader of the effort along with Sen. Lindsey Graham, R-S.C., said Monday.

“He’s the grave robber,” No. 3 Senate GOP leader John Thune of South Dakota said of Cassidy. “This thing was six feet under” but now has “a lot of very positive buzz,” Thune said.

With Democrats unanimously against the bill, Republicans commanding the Senate 52-48 would lose if just three GOP senators are opposed. That proved a bridge too far in July, when three attempts for passage of similar measures fell short and delivered an embarrassing defeat to President Donald Trump and Senate Majority Leader Mitch McConnell, R-Ky.

McConnell said he’d not bring another alternative to the Senate floor unless he knew he had the 50 votes needed. Vice President Mike Pence would cast the tie-breaking vote. On Tuesday, Pence planned to briefly leave his United Nations meetings in New York to attend the Senate Republican policy lunch in Washington, and then return to the U.N. later in the day.

For Senate Republican leaders, a victory would allow them to claim redemption on their “repeal and replace” effort. The House approved its version of the bill in May.

The 140-page bill would replace much of Obama’s law with block grants to states, giving them wide leeway on spending the money. It would let states set their own coverage requirements, allow insurers to boost prices on people with serious medical conditions, end Obama’s mandates that most Americans buy insurance and that companies offer coverage to workers, and cut and reshape Medicaid.

Democrats backed by doctors, hospitals, and patients’ groups mustered an all-out effort to finally smother the GOP drive, warning of millions losing coverage and others facing skimpier policies. Sixteen patients groups including the American Heart Association and the March of Dimes said they opposed it, as did the American College of Physicians and the Children’s Hospital Association.

Potentially complicating the GOP drive, the Congressional Budget Office said it won’t have crucial estimates on the bill’s impact on coverage ready for several weeks.

Special procedures protecting the GOP bill from filibusters — which take 60 votes to block — expire Sept. 30, and after that Democratic opposition would guarantee its defeat. Some wavering Republican senators could want the nonpartisan budget office’s analysis before feeling comfortable about the measure’s impact back home.

The Congressional Budget Office said it won’t have crucial estimates on the bill’s impact on coverage ready for several weeks.

All but daring Republicans to vote without the budget office figures, Senate Minority Leader Chuck Schumer, D-N.Y., said voting without that information would be “legislative malpractice at the highest.”

The budget agency’s evaluations of past GOP repeal plans concluded they would have caused millions of Americans to lose insurance coverage.

Pence was calling senators to seek support, White House officials said. House Speaker Paul Ryan, R-Wis., said the House would vote on the bill if it passes the Senate. Speaking in Menomonee Falls, Wisconsin, Ryan called it “our best, last chance to get repeal and replace done.”

The sponsors say their proposal would let states decide what health care programs work best for their residents.

The bill would reduce spending gaps between states that expanded Medicaid under Obama’s law and the mostly GOP states that did not. Details on the measure’s exact state-by-state impact were murky.

Conservative Sen. Rand Paul, R-Ky., has said he’ll oppose the measure because it doesn’t do enough to erase Obama’s law. Sen. Susan Collins, R-Maine, said she was concerned the bill would make “fundamental changes” in Medicaid.

Other Republicans who’ve not yet lined up behind the bill include Alaska’s Lisa Murkowski, Shelley Moore Capito of West Virginia, John McCain of Arizona and Ohio’s Rob Portman.

Collins, Murkowski and McCain provided the decisive votes against the last measure Republicans tried to push through the Senate in July.

“It’s better but it’s not what the Senate is supposed to be doing,” McCain told reporters about the new package.

Arizona GOP Gov. Doug Ducey said he backed the new bill, putting pressure on McCain.

The revived drive comes as Sens. Lamar Alexander, R-Tenn., and Patty Murray, D-Wash., work toward a bipartisan deal to continue federal subsidies to insurers that are used to ease some costs for lower-earning customers. Trump has threatened to block the subsidies.

Murray spokeswoman Helen Hare said Murray is “hopeful and optimistic” a deal could come soon, a statement that came as Democrats tried peeling away GOP support from the Graham-Cassidy bill.

Associated Press writers Kevin Freking, Andrew Taylor and Richard Lardner in Washington and Scott Bauer in Menomonee Falls, Wisconsin, contributed to this report.

WATCH: Does the Democrats’ pitch for universal health care have a chance?

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End-of-life decisions can be difficult. This doctor thinks ‘nudges’ can help


Six states have aid-in-dying laws. But doctors and advocates say not all health care providers are willing to assist patients in dying. Photo by Flickr user Juan Munévar

For tax payments, “nudges” have helped municipalities increase revenues and decrease collection-related costs. For energy consumption, “nudges” have helped homeowners save money and utilities preserve capacity.

But in health care, the technique has been slower to catch on.

First described by the pioneering economists Richard Thaler and Cass Sunstein (who is also a legal scholar), a “nudge” is a way of framing a set of choices to essentially steer people toward a particular option without shutting out other options.

Dr. Scott Halpern, a critical care physician at University of Pennsylvania who studies the ethics and effectiveness of nudges in health care, believes the technique can play a greater role in improving the patient experience. This is especially true, he said, for those living with serious illnesses, and who often struggle to make sound decisions at times of great emotional and physical complexity.

Halpern, who is founding director of Penn’s Palliative and Advanced Illness Research Center, spoke with STAT recently by phone, from his office in Philadelphia. This conversation has been condensed and edited.

Can you give us an example of how a nudge might function in your work?

As med students, we are all taught it is important to have conversations about whether patients wanted a DNR (do not resuscitate) order. We’re told that the way to do that is to be neutral – to say something like, “In this situation, your loved one’s heart might stop. If so, would he want us to do chest compressions?” But that places an incredible burden on family members to feel like they have to know exactly what their loved one would want in this specific situation — something they rarely know with confidence. And in fact this isn’t all that neutral anyway — to say no to chest compressions requires giving up something, which is always hard to do.

READ NEXT: 5 ways to improve care at the end of life

That strikes me as problematic in cases where chest compressions would almost certainly do more harm than good. So as I developed more experience, I became comfortable saying, “In this situation your loved one’s heart may stop. If it did, we would not routinely do chest compressions, because they would be unlikely to work. Does this seem reasonable?” This way, I’ve set a default option, but I’ve not removed any options. I’ve now used this language several hundred times with the families of patients who were most certainly going to die, and only once has a family chosen CPR. Indeed, several families have thanked me for helping them understand what the norms are.

How commonly are these approaches used?

These ideas are still rarely considered in end-of-life setting, and yet that may be the space where they’re most powerful.

Why would that be?

Because most people only make end-of-life decisions once, and they don’t get feedback about what the alternatives might’ve felt like. We all may have deep-seated preferences about whether we prefer vanilla or chocolate ice cream, because we’ve made that choice hundreds of times and know what each tastes like. But it’s reasonable to posit that patients and family members and even clinicians don’t have deep-seated preferences about end-of-life choices because there’s no way they can be equipped with the same lived experiences. And choices about which we don’t have deep underlying preferences are exactly the ones on which nudges are likely to exert their greatest effects.

Where else in the end-of-life context might be fertile ground for nudges?

Clinicians frequently offer seriously ill patients the option of completing an advance directive, to help establish their goals of care. Most patients end up not doing so, because inertia gets in the way. But framing can help a lot.

The normal way of motivating patients to complete advance directives is by extoling the virtue of being able to control your future care. But by instead helping patients see that by completing an advance directive they’ll reduce decision-making burdens for their loved ones, many more patients will end up doing it because that’s of such great importance to people.

This approach obviously puts more of an onus on clinicians to develop a new skill set, at a time when a lot of them already feel like they’re barely treading water.

It presents a huge responsibility for clinicians, because they’re now in the position of heavily influencing the choices their patients and family members will make. But clinicians already have that responsibility, whether or not they choose to recognize it or not, because there’s always an option that will be listed first, or that exists as the default. So the task for the conscientious clinician isn’t to avoid influencing choices, but rather to avoid restricting choices. And better to influence choice mindfully in a way that likely promotes good outcomes for your patients than to continue doing so haphazardly.

READ NEXT: A lesson on life’s end: How one college class is rethinking doctor training

At the same time, some clinicians worry about this possibly representing a return to the old paternalistic approach of medicine.

Right. Clinicians appropriately wonder if something unethical is going on here. If nudges influence choice, how can we justify it? Traditionally, nudges have been justified when they help promote the things people actually want deep down. But as we’ve discussed, in the end-of-life space, it’s hard for patients to know what exact types of medical care will best help them achieve their goals. In such cases, clinicians should rely on a standard that they have historically relied on anyway: the “best interests” standard, where, absent compelling evidence about what a patient would truly want, we should act in a way that we believe — or know, based on evidence — would promote their best interests.

This article is reproduced with permission from STAT. It was first published on Sept. 14, 2017. Find the original story here.

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