After a short summer hiatus, the battle over health care policy reemerged with a passion last week when Senator Sanders introduced a version of “single payer” universal health care coverage and Senators Cassidy and Graham introduced yet another bill attempting to repeal Obamacare. These are just the latest eruptions of a longstanding war both for and against government supported comprehensive healthcare coverage and quality health care. It is an on-going war—a war that began with Teddy Roosevelt’s 1912 presidential campaign and the Progressive Party, extended through the Roosevelt and Truman administrations, erupted with Medicare and Medicaid during the Johnson administration, faltered with HillaryCare during the Clinton administration, and exploded into the 21st century with the struggle over Obamacare.
This article will examine the Republican side of this war. Republicans hate government supported health care in general and Obamacare in particular for a number of reasons: ideological opposition to any major government program expenditures not directly benefitting big business and support for supposed “free” market policies that maintain private sector control and corporate domination; opposition to taxes on the wealthy and large corporations especially when those taxes are used to fund government programs that support moderate and low-income families including the Obamacare taxes that subsidize the cost of insurance to make it more affordable; a focus on limiting and eliminating the availability of contraception and abortion; or a mix of all of these.
Given such opposition, Republicans have been engaged in a four-pronged attack against governmental programs that seek to improve the health of all Americans: introducing legislation to repeal and replace Obamacare; sabotaging and killing Obamacare through administrative fiat and court cases; significantly slashing funds for government health care programs; and eliminating environmental and workplace regulations and programs that protect people’s health. There is a sense of urgency to complete this offensive because Republicans apparently want to register some kind of “win” in order to fulfill long-standing promises to gut Obamacare, roll back government supported health care programs and grant billions of dollars in tax cuts to large corporations and the wealthy—no matter the cost in human suffering.
THE LEGISLATIVE ATTACK ON GOVERNMENT SUPPORTED HEALTH CARE
Not one of the Republican-sponsored bills to repeal/replace Obamacare included any plan to improve the health and welfare of most Americans. Not one of their bills sought to increase comprehensive coverage for the 28 million Americans who are still uninsured or to reduce premiums and out of pocket expenses for comprehensive coverage. Instead, every one of their proposed legislative bills would have led to the deaths of thousands of people and adverse impacts on the health of everyone—especially women, infants, and children. The only real beneficiaries of their health care schemes would be large corporations and wealthy individuals whose taxes would have been reduced.
Yet, these bills passed the House with the support of more than 90% of the Republican caucus and lost by just 1 vote in the Senate. Senators Cassidy and Graham introduced a new repeal bill last week proving that any of these bills can be resurrected at almost anytime subject to the legislative rules in each of the chambers. Here are just two examples to remind us of the disastrous consequences of these bills.
- The House and Senate repeal and/or replace bills would cause the deaths of an additional 170,000 to 294,000 Americans in the first ten years. The Congressional Budget Office estimated that the House health care bill would result in the loss of coverage for 23 million people. An analysis by the Center for American Progress estimated that the House bill would result in 217,000 additional deaths just over its first ten years relative to current law. Using the same methodology the so-called Skinny Repeal that was defeated in the Senate would have resulted in 16,000,000 people losing their insurance with an additional death toll of 170,000. The worst option proposed but defeated in the Senate would have been the repeal-only bill that would have resulted in 32,000,000 people losing coverage leading to 294,000 additional deaths over the first ten years. The CBO has not yet completed an analysis of the Cassidy-Graham bill; however, initial indications are that it is quite similar to the previous repeal-only bill.
- Waiving essential benefits would have especially undermined the health of millions of women and children. Obamacare requires all insurance plans to cover ten essential benefits including maternity insurance coverage for pregnancy, labor, delivery, and newborn baby care. Every one of the Republican House and Senate bills effectively allows states to waive these benefits. Nine million women gained maternity coverage after 2014 when Obamacare made it an essential benefit. Before then, only 12% of plans sold on the individual market included this coverage. Obamacare maternity coverage includes outpatient services such as prenatal and postnatal doctor visits, diabetes screenings, lab studies, medications, etc.; inpatient services such as hospitalization, doctor fees, etc.; newborn baby care; and lactation counseling and breast-pump rentals. This coverage also reduces maternal and infant mortality by improving the health of women before and during pregnancies and by preventing unintended pregnancies. Conversely, the lack of decent maternity coverage places the health of women and newborns at risk. The House and Senate bills also would adversely impact women and children by undermining other Obamacare essential benefits such as prescription drugs (women are more likely than men to need prescription drugs to meet their daily health care needs); lab tests such as Pap smears and mammograms; doctor visits (women account for 60% of outpatient visits); emergency room visits (women make 60% of emergency room visits); and hospitalization (women are 70% more likely than men to have had an inpatient hospital stay).
THE ADMINISTRATIVE AND JUDICIAL CAMPAIGN TO SABOTAGE OBAMACARE
Even if their legislative strategy of repeal/replace fails, Republicans are continuing their seven-year campaign to sabotage and kill Obamacare. This effort was begun in Congress, supported by19 Republican Governors, reinforced by court rulings and joined by Trump after he was elected. Here are some examples of the sabotage that have already taken place.
- Destabilizing the Private Obamacare Exchanges
- Republicans have undermined and sabotaged the Obamacare cost-sharing program that provides government payments to insurance companies in order to reduce the premiums and deductibles for low-income people. These cost-sharing payments to insurers were challenged in court by House Republicans and are now on appeal. In the meantime, the Secretary of Health and Human Services is distributing the funds on a month-to-month basis. President Trump has threatened to stop the payments altogether. He noted that withholding the cost-sharing reduction payments could seriously damage the individual market and that market turmoil would increase his leverage in seeking repeal of Obamacare. The Kaiser Family Foundation estimated that stopping these payments would lead to an estimated average 19% increase in premiums. This deliberate strategy of sabotage destabilizes the health exchanges and pressures insurance companies to raise premiums just in case the payments stop or to decide to leave the market altogether.
- Starving Obamacare by cutting enrollments
- The period during which people can enroll in Obamacare has been cut in half – from 91 to 44 days.
- The administration has terminated contracts with groups that increase enrollment by guiding people through the enrollment process.
- Advertising to inform people about Obamacare during the enrollment period will be cut from $100 million in 2017 to just $10 million in 2018.
- The Department of Health and Human Services that is supposed to administer Obamacare is using taxpayer money to produce and distribute videos and other media that discredits Obamacare.
- Raising premiums by denying Medicaid expansion and reducing tax credits
- Implemented rules that effectively reduced the tax credit that people receive to pay for premiums. This raises premium costs and out of pocket expenses for millions of middle and low-income families.
- While upholding the constitutionality of Obamacare itself, the Supreme Court ruled that states could opt out of expanding Medicaid to cover the poorest residents. Subsequently, 19 Republican governors refused to expand Medicaid coverage. The Urban Institute estimated that 5 million people would obtain coverage if these 19 states decide to expand Medicaid. A study by Charles Galva cited in the Los Angeles Times, calculated that premiums in non-expansion states increased 31% more than premiums in expansion states.
All of these tactics have deliberately caused greater increases in premiums and reductions in the number of people able to obtain coverage as well as destabilizing the health care exchanges. As a result, these tactics have caused widespread pain and suffering for millions of people.
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THE BUDGETARY WAR AGAINST PROGRAMS THAT IMPROVE HEALTH CARE – ESPECIALLY FOR WOMEN, INFANTS AND CHILDREN
While the media and public have focused attention on the attack against Obamacare, President Trump and House Republicans have also proposed budget plans that will cut trillions of dollars from health programs and basic assistance while promising massive tax cuts that will largely go to large corporations and the most wealthy members of our society. Children and women are among the groups that will be most harmed by these budget cuts. Here are some examples.
- Undermining the health of 49% of the children in the U.S. Thirty-six million children below 18 years of age are enrolled in Medicaid and the Children’s Health Insurance Program (CHIP). This amounts to 49% of all children in the U.S. Ninety-five percent of children with Medicaid or CHIP coverage have a regular source of care compared to just 69% of children without coverage. Increased coverage means better health, lower mortality and decreased costs overall. Yet, President Trump and the House Republicans are targeting these children.
- Slashes $610 billion from Medicaid in addition to the $877 billion cut contained in the House health bill. This amounts to a total cut of $1.4 trillion or 47% over ten years. Medicaid cuts will adversely impact the health of pregnant women, newborns, infants and children. Medicaid pays for a significant portion of births in the U.S. The highest rate is New Mexico where Medicaid covers 72% of births while New Hampshire has the lowest rate of 27%. Half the states report that Medicaid covers more than 50% of births. Medicaid also is the single largest health insurer for children providing coverage for more than 30 million low-income children and children with disabilities. Dr. Steve Allen the CEO of Nationwide Children’s Hospital in Columbus Ohio neatly sums up the issue: “Significant cuts to Medicaid will reduce access to health care for children who have it now, deny access or adequate care to children not yet born and lead to greater future medical costs by denying access to preventive care.” Children with disabilities will be especially impacted. The Children’s Hospital Association stated “The effects [of the budget cuts] on children are likely to be even more dramatic when considering those enrolled in Medicaid due to disability who have greater use of long-term care services and whose per enrollee costs are much higher than the traditional children group.”
- Slashes the CHIP by 19% or $3.2 billion in just one year. The Trump budget only specifies one year of funding for CHIP – a program with a. approximately 6 million enrolled low-income children. This program covers well-child visits, immunizations, prescriptions, dental and vision care, in- and out-patient hospital care, X-rays, lab work and emergency services. Obviously, these services will be cut if Trump’s budget is passed and millions of children will suffer.
- Denying food to 46 million needy people including 20 million children. The Trump budget proposes to cut $193 billion or 29% from the Supplemental Nutrition Assistance Program (food stamps) that feeds 46 million people including almost 20 million children. In 2012, this program helped keep 2.1 million children out of poverty. A Northwestern Institute for Policy Research brief states that “Mothers who receive food stamps while pregnant have a reduced risk of having a low-birth weight infant. Low birth weight is a major cause of infant mortality in the U.S."
- Making life more difficult for severely disabled children and their families. The Children’s Defense Fund states that Trump’s budget will slash $72 billion over ten years from the Supplemental Security Income Program (SSI), which covers more than 8 million children and adults with the most severe disabilities. SSI benefits are quite low – less than $650 per month for a disabled child. But these payments help the families of 1.2 million children meet the costs of child care or lost parental income due to caring for the child at home rather than an institution.
- Undermining the nutrition and health of women, infants and children. The Trump budget cuts $200 million from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). But this may be just the opening salvo. In 2011, Republicans proposed a whopping 10% cut to WIC. WIC serves over 9 million mothers and young children, over 1.5 million pregnant and breastfeeding mothers, more than half of America’s infants, and one-quarter of its children 1 to 5 years of age. WIC has been shown to improve birth outcomes and reduce risk factors for infant mortality – especially pre-term births. Preterm birth – babies born too soon and too small -- is the leading overall cause of U.S. infant mortality. The Institute of Medicine estimates that, in 2005, the annual societal economic cost associated with preterm birth was at least $26.2 billion in direct and indirect costs. The CIA World Fact Book for 2016 ranks the U.S. as having the 57th lowest infant mortality rate – a rank much worse than almost all other developed countries and a number of developing countries. Even though we rank poorly, our infant mortality rate has been declining. This decline is due to more comprehensive health care and services especially for low-income women such as the neonatal care and maternal health and nutrition services provided through WIC. But this progress may be reversed with less coverage and fewer services.
- Eliminating the Teen Pregnancy Prevention Program. The Trump administration has ended the TPP program by slashing $214 million from its budget. The Centers for Disease Control reported that “in 2010, teen pregnancy and childbirth accounted for at least $9.4 billion in costs to U.S. taxpayers for increased health care and foster care, increased incarceration rates among children of teen parents, and lost tax revenue because of lower educational attainment and income among teen mothers.” The TPP was a targeted program to prevent teen pregnancies especially in high-risk communities. This was accomplished by grants to various institutions around the country to conduct counseling, education and research. But in July the Center for Investigative Reporting broke the story that the administration “quietly axed” the remaining two years of the TPP grants. The TPP grants were supposed to serve approximately 1 million teenagers in high-risk communities over five years. This action is consistent with the House appropriations subcommittee plan to eliminate teen pregnancy prevention.
THE ATTACK ON ENVIRONMENTAL AND WORKPLACE PROGRAMS AND REGULATIONS THAT PROTECT EVERYONE’S HEALTH
The administration and Congressional attack on any government program to support health quality is also taking place through the elimination or slashing of environmental and workplace programs and regulations. The attack on environmental programs is not only an attempt to assist corporate polluters and pad the profits of large corporations but also a means to make room for the coming massive tax breaks that will be proposed for large corporations and the wealthy. But guess who suffers from this dismantling of environmental programs and protections? Christine Todd Whitman, the EPA administrator under President W. Bush even wrote an article for The Atlantic entitled “I ran George W. Bush’s EPA and Trump’s Cuts to the Agency Will Cost Lives.” Here is a small sample of what is taking place and who will suffer.
- Giving more freedom to corporations to pollute while making taxpayers pay the costs and forcing workers and communities to suffer the health consequences. Funding for EPA will be cut by $2.6 billion or 31% with the loss of a quarter of the EPA workforce. The proposed budget cuts will significantly limit the EPA’s ability to fulfill its purpose to “ensure that all Americans are protected from significant risks to human health and the environment where they live, learn and work.” Especially hard hit will be programs that monitor air and water quality, enforce rules and regulations, penalize polluters, and clean up superfund sites and regional watersheds. The administration is thus cutting the ability of the EPA to protect people and hold corporations accountable for their actions. Corporations will be given much more freedom to pollute with impunity – they no longer will have to fear that the EPA has the ability to properly monitor pollution or impose penalties. Instead, the costs of pollution will be born by taxpayers and by the workers and communities that suffer from worse health.
- Approving dirtier air. Funding for the Clean Air Act will be cut by 50%. The budget cuts to the Clean Air Act are taking place despite evidence in favor of the economic and health benefits of the Act. According to the American Lung Association, nearly 40% of the U.S. population lives in counties where they are “exposed to unhealthful levels of air pollution in the form of either ozone or short-term or year-round levels of particles. Pregnant women and children are especially affected. For example, a Harvard University study released in 2013 concluded that pregnant women living in areas with elevated levels of air pollution “were up to twice as likely” to have an autistic child compared with women in low-pollution locations.” Furthermore, children living with air pollution are more likely to develop asthma.
- Sanctioning dirtier tap water and lead contamination. Grants to help states monitor the quality of public water systems will be cut by $31 million or 30%. In addition, the Trump budget would eliminate the Lead Risk Reduction Program, which spends $2.5 million every year to train workers to renovate buildings that contain lead paint and provide public education. Lead exposure can cause irreversible brain damage in children and disproportionately affects low-income families.
- Enabling dirtier sources of clean water. Funding for clean water in the Great Lakes Restoration Initiative (GLRI) will be cut by 90% from $300 million to just $10 million. The Great Lakes provides drinking water for 40 million residents of the U.S. and Canada. Former EPA Administrator Whitman stated, “cutting the GLRI will result in significant increases in pollution and a return to some of the same problems that plagued this significant source of clean water for years to come. Surely in the wake of the Flint water crisis—where lead leached into the Michigan city’s water supply after officials switched its source to the Flint River to cut costs—we can recognize this is not a risk worth taking.” The Chesapeake Bay Program will also be eliminated leading to poorer water quality, unhealthy fish and seafood and the decimation of industries that depend on the Bay’s seafood and water.
- Authorizing less chemical safety and less pollution prevention. Trump’s budget would cut funding for the Office of Chemical Safety and Pollution Prevention from $7.5 million to just $445,000, making it impossible for the program to continue to function. The program screens and tests for endocrine disruptors, chemicals that threaten reproductive health and development.
- Less testing for radioactive radon in homes. The Trump budget cuts the federal radon program by 80 percent. This program promotes radon testing in homes. Radon, a naturally occurring radioactive gas, is believed to cause lung cancer and is linked to 21,000 deaths annually. An estimated one in 15 homes has high levels of the gas.
- Permitting the use of a pesticide known to damage children’s brains. EPA Director Scott Pruitt took this action even though his own agency recommended that the pesticide, chlorpyrifos, be banned. An article in Mother Jones reported that “a number of studies found strong evidence that low doses of chlorpyrifos inhibits kids’ brain development, including when exposure occurs in the womb, with effects ranging from lower IQ to higher rates of autism.” The studies also found that ”babies and fetuses are particularly susceptible to damage from chlorpyrifos because they metabolize toxic chemicals more slowly than adults do. And “many adults” are susceptible, too, because they lack a gene that allows for metabolizing the chemical efficiently.” Dow Chemical – the primary producer of the chemical - has actively fought against limiting the chemical’s use and gave $1 million to Trump’s inaugural committee.
- Ensuring that polluters DON’T pay. Federal Criminal and Civil Enforcement Cut by 40% and Enforcement Grants to States by 45%. The cuts will significantly curtail the ability of the federal enforcement office to ensure that corporations comply with federal regulations by monitoring polluters and imposing penalties. But the budget also cuts the grants that allow states to do that enforcement. The result will ensure that enforcement of environmental rules and regulations will be significantly reduced at both the federal and state levels.
- Halting the cleanup of many Superfund sites. The Superfund cleanup program will be cut by 25%. The Superfund program identifies and cleans up sites that have been contaminated by hazardous substances and pollutants. These sites such as abandoned industrial sites, city landfills and military depots have been linked to higher incidences of cancer and other diseases. These cuts will halt the cleanup of many public health hazards.
- Slashing workplace health and safety. According to the Bureau of Labor Statistics, private sector employers reported 2.9 million non-fatal injuries and illnesses in U.S. workplaces. Public sector employers reported 753,000 non-fatal injuries and illnesses. There were 4,836 reported U.S. workplace fatalities in 2015. The Occupational Safety and Health Administration (OSHA) is responsible for monitoring workplace health and safety to ensure that employers meet minimum standards for health and safety. Yet, there are only 1,838 federal and state inspectors who have to cover over 8 million workplaces under OSHA jurisdiction. The proposed House budget plan would cut the enforcement budgets of OSHA by 6.5% and the Mine Safety and Health Administration by 7%. The budget cuts will reduce the number of inspections by the thousands. The Trump administration also proposed a massive $135 million or 40% cut to the budget of the National Institute of Occupational Health and Safety (NIOSH) that is a part of the Center for Disease Control. NIOSH is responsible for researching and making policy recommendations to prevent and reduce work-related injury and illness. The Administration also proposes a series of deregulatory actions including the delay of the implementation of a new beryllium standard and the enforcement of a new silica standard that will lead to 160 worker deaths. The administration also is weakening rules for keeping accurate records for injuries and illnesses and for disclosing health and labor violations.
SO FAR, THE REPUBLICAN OFFENSIVE HAS BACKFIRED
The Republicans have implemented a strategy to undermine Obamacare and destroy all vestiges of government support for comprehensive health coverage and health care quality. So far, this strategy has backfired. The Republican repeal/replace bills energized a significant, broad and active opposition by citizen groups and health care institutions and experts around the country. This opposition forced Democrats to hold the line and made it possible for at least three Republican Senators to vote against the Republican repeal/replace bills this past spring and summer. This was a narrow margin but a significant victory. Such mass activity will again be required to enable at least three Republican and all Democratic Senators to oppose the Cassidy-Graham repeal bill. This broad based opposition will continue whether or not the Cassidy-Graham bill passes and could be an important factor in the 2018 and 2020 elections.
The Republican offensive also sought to forestall any efforts to “improve” Obamacare. However, it actually stimulated a number of Republicans and Democratic Senators to discuss reforms that might strengthen Obamacare. The Republicans leading this effort have pulled back during the fight over the Cassidy-Graham bill. Yet, such discussions may be revived if the latest repeal effort is defeated.
Finally, the Republican offensive was an attempt to deliver a generational deathblow to any proposals that would create a government-sponsored health care system requiring universal and comprehensive coverage. Yet, the Republican strategy apparently awakened a sleeping giant – a progressive movement to establish a truly universal health care system. It is now up to progressives to implement a strategy to achieve this goal.