Background on Health Care
CORONAVIRUS (facts as of Sept./Oct. 2020)
- The coronavirus pandemic started in Wuhan, China, in December 2019 (hence the name "COVID-19", for "coronavirus disease of 2019"), and quickly spread to the rest of the world, with the United States implementing major shutdowns in March 2020.
- Coronavirus testing has been key to slowing the spread of the virus, and the U.S. exceeded 85 million tests as of Sept. 2020.
- The U.S. has tested about 25% of the population as of Sept. 2020; that's a lower testing rate than many countries (some exceed 100%, which means every person has been tested more than once), and increasing the testing rate (or not) is a hot topic in the 2020 election.
- The U.S. has left pandemic restrictions up to each state, with mixed policies on wearing facemasks and re-opening businesses and schools, for example. Other large countries have made more severe restrictions, with more consistent results: China, for example, has seen near-zero infections and deaths since March, while the U.S. has not.
- President Trump suffered a coronavirus infection in October 2020, along with dozens of other White House officials and numerous members of Congress (mostly Republicans who attended Trump's large-scale events without facemask restrictions).
- NEWS: Latest statements on coronavirus from presidential candidates and political pundits
- As the coronavirus pandemic took hold, states instituted "lockdowns" which crippled the economy. Balancing "re-opening" the economy vs. risking further infections has become the core issue of the 2020 election.
- Airline travel mostly stopped in March 2020 to avoid spread; professional sports were suspended to avoid public gatherings; schools were conducted in "virtual classrooms"; restaurants could only serve customers outdoors (and later, at quarter-capacity indoors to allow "social distancing").
- The unemployment rate peaked in May 2020 at over 14%, the worst since the Great Depression (unemployment peaked at just under 10% in the Great Recession of 2009). Trillions of dollars were distributed in extra unemployment payments for several months afterwards.
- The economy contracted by 31% annualized rate in 2020 Q2, the largest negative growth in U.S. history (for comparison, the worst annualized quarterly contraction in the Great Recession was 8%, and the worst previously ever recorded was 10% in 1958).
- Trillions were spent in direct payments to individuals ($1,200 checks to millions of people) and to small businesses (and, some would say, to too many large businesses) to stave off massive bankruptcies, mortgage foreclosures, and economic collapse.
- Unemployment slowly fell, to 8% in Sept. 2020, as people switched to "virtual work-from-home"; restaurants and businesses re-opened with facemask requirements; and professional sports maintained "bubbles" where only athletes could enter under quarantine.
- In general, Republican governors (and Trump) pushed to re-open economies, removing restrictions based on public health, while Democratic governors (and Biden) pushed for federal relief funding to allow keeping longer-term restrictions in place.
- The news media has done a bad job reporting on vaccine progress, leaving many people confused about whether there is a coronavirus vaccine (there is no widely available vaccine, as of Nov. 2020) and when one might be expected (by November 2020, according to President Trump; by the second quarter of 2021, according to the CDC).
Some facts about the vaccine process, and why the news media is confused:
- Vaccines go through several phases of testing; the news media (and some government officials) often report on a vaccine candidate passing one phase as if it's released to the public. The phases to get to a vaccine are:
- Phase i (safety): Dozens of people are given a vaccine candidate, under close supervision, to test for toxicity and safety.
Human testing only occurs after animal testing has proven safe. There are over 100 vaccine candidates in "Phase i" as of Sept. 2020.
Russia's "Sputnik-V" vaccine candidate was declared "ready for the public" in July 2020, when in fact it only passed Phase i results in August.
- Phase ii (efficacy): Hundreds of people are given a vaccine to determine if it actually prevents infection or diminishes symptoms.
To speed up the process under emergency circumstances, efficacy testing is sometimes combined with safety testing ("Phase i/ii") or widespread testing ("Phase ii/iii").
There are 4 vaccine candidates in "Phase ii" as of Sept. 2020 (2 in Germany and 2 in China).
- Phase iii (widespread testing): Thousands of people are given the vaccine, and tracked over time to confirm widespread effectiveness and find side-effects.
There are another 4 vaccine candidates in "Phase iii" as of Sept. 2020 (Moderna in the US; CoronaVac and Sinopharm in China; AstraZeneca in the UK).
Because tens of thousands of people are involved, phase iii testing can cost a billion dollars, and can take many months to years to complete.
This phase can be greatly shortened for emergencies such as coronavirus, at the expense of "full-scale" testing (like, allowing commercialization after 10,000 people are vaccinated rather than 30,000).
- Phase iv (commercialization): FDA approval means the vaccine can be mass-produced and distributed, but the FDA stays involved to look for long-term side-effects.
The federal government (and other national governments) will likely subsidize the mass production effort, as they have subsidized the earlier steps, to speed up this process, which can also take months.
Producing and distributing 320 million doses to vaccinate all Americans (or 640 million, if the vaccine requires two doses, as many do) is a major long-term effort, so prioritizing who gets the vaccine first will be the next major issue.
Only after commercialization and distribution do most people actually start getting vaccines; this is the meaningful definition of "vaccine availability", as opposed to passing any earlier phases.
- Widespread availability: In November 2020, Pfizer announced successful completion of a "Phase iii" trial; they will immediately begin government-subsidized commercialization.
Pfizer estimates widespread availability by late 2021;
perhaps 50 million doses by the end of 2020 (that's only 10% of the US population, since two doses are required); and 1.3 billion doses by the end of 2021 (that's still only 10% of the world population).
Widespread vaccination approaches "herd immunity" at around 350 million doses in the US, or 9 billion doses worldwide.
- Herd Immunity: Vaccines create "herd immunity" when about 70% of the population is vaccinated, and hence unable to infect others.
Herd immunity can be achieved without vaccines, if 70% of the population get infected and recover -- that is the basis for President Trump's claim that the pandemic could "miraculously disappear"
(as well as the possibility that warmer weather would allow enough social distancing to reduce the infection rate, but that was proven untrue as infections continued to rise in summer 2020).
Much political controversy came from widely disparate estimates of infection recovery rates -- after New York City recovered as the world epicenter of the virus in May 2020, testing estimated the infection rate at 30%.
Younger adults and children are likely to have "asymptomatic infections" (which would mean a higher percentage infected, and hence more closely approaching herd immunity levels), but the mortality rate would mean millions Americans would die, to reach herd immunity levels without a vaccine.
- Mortality Rate: COVID-19 causes death in about 3.4% of people infected.
The mortality rate has fallen as better treatments are found, but would rise again if hospitals are overwhelmed with patients.
To achieve herd immunity without a vaccination, 70% of the U.S. population would have to be infected, which at 3.4% mortality rate would mean 7.6 million deaths.
- WHO: The UN World Health Organization has coordinated efforts in all phases and plans to coordinate worldwide distribution; the U.S. under President Trump has opted out of participating with the WHO.
- NEWS: Latest statements on Vaccinations from presidential candidates and political pundits
- Many Americans question the severity of the pandemic, or question whether the lockdown response is warranted or worth the economic cost.
This difference of opinion is likely to be a decisive factor in the 2020 presidential race and many down-ballot races too, so we present some background facts:
- Scale of recent virus pandemics: (number of deaths)
- 2019-2020 coronavirus: 1.3 million deaths worldwide; 245,000 in U.S. (as of November, 2020)
- 2013-2016 Ebola: 11,000 deaths worldwide; 1 in U.S. (contact tracing 2014; vaccine produced 2016)
- 2009-2010 Swine Flu: 150,000 to 575,000 deaths worldwide; 12,500 in US (vaccine produced Dec. 2009)
- 1981-2012 HIV/AIDS: 36 million deaths worldwide; 700,000 in U.S. (no vaccine; PrEP reduces risk of infection)
- 1968-1970 Hong Kong Flu: 1-4 million deaths worldwide; 100,000 in U.S.
- 1956-1958 Asian Flu: 1-2 million deaths worldwide; 70,000 in U.S.
- 1918-1920 Spanish Flu: 20-50 million deaths worldwide; 675,000 in U.S. (facemasks common in 1919)
- 1916-1955 Polio virus: millions paralyzed/deaths worldwide; 55,000 deaths in US (widespread behavior changes 1952; vaccine produced 1955)
HMOs & MANAGED CARE
- ‘ObamaCare’ refers to the Patient Protection and Affordable Care Act (PPACA) of 2010, which reformed healthcare insurance with the goal of near-universal coverage.
- Critics refer to ObamaCare as socialized medicine -- which could mean the government runs the healthcare system, as in the United Kingdom, but more accurately in the United States means that the federal government mandates individual health coverage.
- ‘Managed Care’ is a euphemism for partial privatization. As defined by Medicaid.gov: "Managed Care is a health care delivery system organized to manage cost, utilization, and quality. Medicaid managed care provides for the delivery of Medicaid health benefits and additional services through contracted arrangements between state Medicaid agencies and managed care organizations (MCOs) that accept a set per member per month (capitation) payment for these services."
- Major Supreme Court cases involving ObamaCare:
- 2012 Sebelius case: Upheld the ObamaCare individual mandate as a form of taxation
- 2014 Hobby Lobby case: Corporations exempted from ObamaCare contraception mandate if they have religious objection
- 2015 King v. Burwell case: state "healthcare exchanges" receive same subsidies as federal exchange
- 2017 Tax Cuts and Jobs Act: eliminated the individual mandate
- 2020 California v. Texas case: ObamaCare constitutionality with individual mandate removed (pending in Sept. 2020)
- Pre existing conditions means that health insurers cannot turn away patients for past illnesses, and is enforced under ObamaCare.
- Prior to ObamaCare, every HMO made a list of rejectable conditions, such as cancer; diabetes; hepatitis; mental disorders, pregnancy, and many more [JKAG please Cite https://www.firstquotehealth.com/health-insurance-news/pre-existing-conditions-before-aca]
- Both Biden and Trump promise to keep pre-existing condition guarantees, but Trump has worked with lawsuits in the past to remove such protections
- The core Republican Party stance is still to overturn ObamaCare; but most also say they would keep THIS provision; it's unclear exactly how pre-existing protections would be maintained if ObamaCare were overturned.
- Individual Mandate: The crux of the opposition to ObamaCare is whether the federal government can mandate that individuals purchase health insurance -- that was tested in a Supreme Court case in 2012 (but removed legislatively in 2017).
- The Supreme Court decided the case “National Federation of Independent Business v. Sebelius” on June 28, 2012, on the constitutionality of ObamaCare’s individual mandate. Justices Roberts and Kennedy were very skeptical that the mandate was justified under the “commerce clause.” But the government’s lawyer made a strong case for the government’s taxing power—that argument eventually won the day—because the mandate would be administered by the Internal Revenue Service, paid on your Form 1040 on April 15th. The president had argued that the mandate was not a tax; the court decided it was.
- ‘TrumpCare’ refers to the post-mandate ObamaCare from 2017 onwards (still under development).
- ‘HillaryCare’ refers to the Health Security Act of 1993, for which Hillary Clinton chaired the task force devising the plan. The plan was attacked, and ultimately failed, for several reasons:
ObamaCare (and RomneyCare) borrowed many features from HillaryCare but attempted to correct those fatal shortcomings.
- The Health Care Task Force met behind closed doors rather than in public hearings;
- The plan was considered too “top-down,” with too much federal bureaucratic control instead of state & local control and personal choice;
- The plan focused on regulating HMOs and hence on federal regulation of the private healthcare market.
- ‘RomneyCare’ refers to the Massachusetts state version of mandated healthcare initiated under Gov. Mitt Romney -- its principal difference being a STATE mandate instead of a FEDERAL mandate.
- ‘Single Payer’ refers to replacing private insurance companies with federal or state payments to hospitals and doctors. The 'public option' in ObamaCare would have been a voluntary opt-in to single-payer. 'Medicare-for-All' is a form of single-payer, by expanding the Medicare system to cover all Americans.
- Opponents of ObamaCare suggest replacing it with the following list of reforms: cross-state purchasing; tort reform; Health Savings Accounts; small business pooling; and transparency for better patient choice.
- Tort Reform refers to changing the rules about civil litigation, typically to cap damage awards. In a political context, it usually applies to medical malpractice lawsuits, but in a legal context, it also applies to personal injury and product liability lawsuits. The term "tort" means "at fault;" when a doctor is found at fault, a jury can currently award unlimited damages. Awards in the millions of dollars put upward pressure on malpractice insurance rates; hence many conservatives favor tort reform as a means to reduce healthcare costs. Proposed solutions include capping lawsuit compensation or restricting "frivolous lawsuits." Trial lawyers--the recipients of legal fees from tort awards--heavily favor Democratic candidates, so Republicans would like to limit their legal fees.
- Mental Health ObamaCare suggested some mental health coverage but the details are left to each state. Mental health is one of ObamaCare’s“10 Essential Health Benefits.”
This is an example of healthcare issues that were not fully worked out under ObamaCare.
- NEWS: Latest statements on coronavirus from presidential candidates and political pundits
PATIENT’S BILL OF RIGHTS
- Prior to ObamaCare, comprehensive national health care reform had died in Congress in 1994 (after a report by a commission run by Hillary Clinton, hence the moniker "HillaryCare").
19% of Americans (49 million people) had no health insurance prior to ObamaCare
(and hence paid for health services in full, or receive hospital charity).
The number of uninsured bottomed out in 2016 at 28 million, and has returned to 31 million in 2020.
- 14% of Americans receive some form of public health care or health insurance (70% have private health insurance).
- 20% of Americans are members of Health Maintenance Organizations (HMOs).
- ObamaCare ensures that mental health services are available as part of health insurance services, but leaves implementation to the states, and leaves all aspects of mental health coverage as optional. An estimated 25% of American adults suffer from a diagnosable mental illness, but stigma and funding cuts often prevent diagnosis and care. The current focus in on youth mental health, in the wake of several school shootings, and veteran mental health, in the context of PTSD in those returning from war zones.
Congress and the Presidential candidates are debating a ‘Patient’s Bill of Rights’ which would establish rules of dealing with HMO managed care. The buzzwords in this debate are:
MEDICAID / MEDICARE
- External Appeal: Patients cannot currently appeal an HMO’s decision to deny coverage, even if the HMO doctor agrees with the patient. The ‘Bill of Rights’ would establish some form of expert appeal board external to the HMO.
- Medical Necessity: At issue is whether the doctor or the HMO management determines what is necessary. Determination of ‘necessity’ may become subject to expert review as well, or it may become measured against established standards of ‘generally accepted practices.’
- Legal Liability: Patients would be granted the right to sue HMOs for medical costs and damages, which is not a right under current law. Generally, liberals supoprt the right to sue HMOs while conservatives do not. This is the primary distinction between Republican and Democrat versions of Patient Bill of Rights proposals.
- Scope of Coverage: Some states regulate HMOs in ways similar to those described here; a ‘Bill of Rights’ could apply to them, to all HMOs, or to all patients.
- Prevention: Advocating prevention implies support for removing government from health care, or opposition to more federal health care funding or national insurance.
- Consumer Choice: Advocating consumer choice or reduction in healthcare bureaucracy implies support for removing government from health care, or opposition to national insurance.
- Medicaid is the federal health insurance program for people whose income is insufficient to pay for health insurance privately, including their children. Medicaid is "means-tested."
- Medicare is the federal long-term health insurance program. It provides insurance for elderly non-working people, as well as younger people with disabilities who are unable to work.
- CHIP: (originally called SCHIP, the State Children's Health Insurance Program): CHIP is the federally-funded and state-run program for health insurance for children whose families earn over the Medicaid means-testing limits.
- Means Testing: The limit for qualifying for Medicaid is 130% of the poverty line. The poverty line is $23,050 for a family of four in 2012 (it goes up each year, and goes down for fewer kids).
- Medicaid Expansion:
Under ObamaCare, the limit for qualifying for Medicaid is raised from 130% to 133% of the poverty line, with subsidies for families earning up to 150% of the poverty line.
As of September 2014, 27 states have adopted the Medicaid expansion.
For states that do expand Medicaid, the federal government pays for 100% of the expansion through 2016, and the subsidy tapers to 90% by 2020.
Several opposing states argue that their 10% responsibility of funding the expansion will be too much for their states' budgets.
As of 2016, sixteen states rejected Medicaid expansion; of those, 15 have Republican governors and only one (Missouri) has a Democratic governor.
- Medicare Part D: The most recent major change to Medicare was to include prescription drug coverage, which is called "Part D". The four parts of Medicare are:
- Part A: Hospital insurance
- Part B: Supplementary medical insurance
- Part C: Medicare Advantage plans
- Part D: Prescription drug plans
- Coverage Count: Medicare covers 49 million Americans; Medicaid covered 58 million people prior to ObamaCare's expansion.
- Medicaid Expansion: The Patient Protection and Affordable Care Act (ObamaCare) expands Medicaid eligibility beginning Jan. 1, 2014.
Under pre-ObamaCare rules, eligibility varied from 100% to 130% of the poverty line; under ObamaCare, eligibility is increased to 133% (and 138% for most cases).
The expansion of Medicaid and CHIP make 6.3 million additional Americans eligible for coverage.
States individually decide whether to accept additional federal funds for Medicaid expansion; many Republican-run states which oppose ObamaCare have turned down the funds.
Federal funding fully covers the Medicaid expansion initially, but scales down to 90% over a decade.
- Medicare and Medicaid background is covered from a financial/budgetary perspective in the Social Security section (with many excerpts cross-referenced here).
- The Supreme Court ruled unanimously in June 1997 that there is no constitutional right to euthanasia, but that states can allow euthanasia without federal intervention.
- ‘Euthanasia’ means ‘good death’ in the context of terminal illness. Buzzwords:
- Passive Euthanasia: Hastening death by withdrawing life support.
- Active Euthanasia: Causing death in response to a request from that person.
The best-known examples are by Dr. Jack Kevorkian, who was found guilty of 2nd degree murder in March 1999.
- Physician Assisted Suicide: A physician supplies information and/or the means of committing suicide so that a patient can easily terminate their own life.
- Involuntary Euthanasia: A synonym for murder; used by anti-euthanasia activists.
- Right to Die: Establishing suicide as a civil right; used by pro-euthanasia activists.
- The state of Oregon passed a Death With Dignity law, which was active until the federal Department of Justice reversed its enforcement policy in November 2001.
- In Nov. 1998, 46 states settled the cases they had filed against the tobacco companies.
(The other 4 states had previously settled, on similar terms)
- Now, the state legislatures are debating the best use of the settlement funds, which totals $246 billion to be paid over the next 25 years
($5 to $9 billion per year starting in April, 2000).