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Opinion: We’ve lost one of the clearest voices on health care, Uwe Reinhardt

All journalists have a list of experts they can call to explain complicated theories and policies, but few if any could explain things as clearly and with such distinct humor as Uwe Reinhardt.

When news broke this week of Reinhardt’s death at the age of 80, it quickly reminded us of just how important and valuable Uwe had been to so many over the years. Friends and colleagues began tweeting memories of how Reinhardt had helped them, and how Uwe (pronounced OO-va) tried to change the thinking and conversation around health care in this country.

For many years, Reinhardt was an occasional guest on our program (and a number of others). And when I (or my colleagues) brought Reinhardt on as part of a panel on the show, it meant we were going for the big guns, intellectually. We called him when we needed a thinker to weigh in on the health care conundrums of the time; someone who was pressing for a higher aspiration for the country, yet was sober enough to understand its political and economic realities, and resolute enough to leave cynicism at the door.

Uwe, who wrote prolifically and served as an advisor to many government agencies, seemed to be all of that and more.

I was not especially close to Uwe, but our experiences at the program over the years march right in sync with the high praise you read elsewhere, including in these tributes. He would make the case for a fairer system that would cover more of the uninsured. He’d extol the virtues of the German system where he had grown up. He spent a considerable amount of his time breaking down why American prices were so high for health care and highlighted the lack of transparency around them.

All the while, he was extraordinarily patient and generous with his time. I think it’s safe to say this professor from the Woodrow Wilson School at Princeton University enjoyed teaching to journalists, too. Hospital readmissions? Sure, Uwe could break that down for you — or, lay out the folly, as he saw it, of the employer-based insurance system in America and its origins. All the while, he would punctuate a point with dry and sometimes acerbic humor.

Uwe Reinhardt spent a considerable amount of his time breaking down why American prices were so high for health care and highlighted the lack of transparency around them.  Photo courtesy of Princeton University, Office of Communications, Brian Wilson.

Uwe Reinhardt spent a considerable amount of his time breaking down why American prices were so high for health care and highlighted the lack of transparency around them. Photo courtesy of Princeton University, Office of Communications, Brian Wilson.

His opinions and commentary were not limited to health care. During the Iraq and Afghanistan wars, he spoke eloquently and wrote passionately about the small percentage of Americans fully appreciating the burdens of the military on those who served and their families. He was among them; his son, a Marine, was wounded in Iraq. In this op-ed in the Washington Post in 2005, he wrote about why, he thought, “the general public is so noticeably indifferent to the plight of our troops and their families.”

Several writers, experts and leaders have described Uwe as a powerful voice who served as a kind of conscience about how the American health care system operated, who it left behind and what it could strive to be. He articulated those views elegantly during the debate over “Hillarycare” in the early 1990s. And in an era before “Obamacare” became a much-debated reality and example of our polarized politics, Reinhardt never lost sight of his hopes and goals, or his gentle and civil tone.

We were grateful that he brought his insights to our viewers, too.

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Middle-Class Families Confront Soaring Health Insurance Costs …

And even though he does not need an assistant for his work as a developer of mobile apps, Ian Dixon, 38, said he might hire an employee just so he could buy health insurance as a small business, at a cost far below what he and his family would have to pay on their own.

“If one word captures all this, it’s ‘helpless,”’ Mr. Dixon said. “There’s rage and anger and all that stuff in there, too. Any reasonable person would agree that this should not be happening. And there’s no one to go talk to about it. There’s no hope that this is going to get fixed.”


Sara Stovall said she might try to reduce her hours and income, so her family could qualify for subsidies on offer to poorer families to help pay for premiums.

Matt Eich for The New York Times

The situation here in Charlottesville is an extreme example of a pattern that can be seen in other places around the country. The Affordable Care Act is working fairly well for people who receive subsidies in the form of tax credits, said Doug Gray, the executive director of the Virginia Association of Health Plans, which represents insurers. But for many others, especially many middle-class families, he said, “the premium is outrageous, and it’s unaffordable.”

Congress’s repeated efforts to repeal President Barack Obama’s signature health law have rattled insurance markets. Actions by President Trump and his administration have added still more uncertainty. Now, Senate Republicans have attached a provision to their $1.5 trillion tax cut that would repeal the health law’s mandate that most Americans have health insurance or pay a penalty.

All of those actions — along with flaws in the law itself — are having real-world impact.

“We share their pain,” Michael M. Dudley, the president and chief executive of Optima Health, said of his Virginia customers now shopping for policies on the health law’s online exchange. “The rate increases are very high. We can’t minimize that because it’s a fact.”

The Dixon family, which includes two girls ages 1 and 3, has been paying $988 a month this year for insurance provided by Anthem Blue Cross and Blue Shield. But Anthem plans will not be available in Charlottesville next year. The company told customers that uncertainty in the insurance market “does not provide the clarity and confidence we need to offer affordable coverage to our members.”

The online federal marketplace,, recommended another plan for Mr. Dixon in 2018. The new plan, offered by Optima Health, has premiums of $3,158 a month — about $37,900 a year — and an annual deductible of $9,200.


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Alternatively, Mr. Dixon could pick a lower-cost plan offered by Optima with premiums of about $2,500 a month, or $30,000 a year. But the deductible would be much higher. The Dixons would need to spend $14,400 a year for certain health care services before Optima would begin to pay.

The Stovalls are facing similar mathematics.

“Our premiums will triple to $3,000 a month, with a $12,000 deductible, and that is far, far out of reach for us,” Ms. Stovall said after researching the options for her family of four on “We are not asking for free health insurance. All we want is a reasonable chance to buy it.”


Mr. Dixon credited the Affordable Care Act with encouraging him to work for himself as a mobile app developer.

Matt Eich for The New York Times

Subsidies are available to help low- and moderate-income people pay premiums, but no financial assistance is available to a family of four with annual income over $98,400.

Optima, a division of Sentara Healthcare, invited customers to share their personal stories on its Facebook page, and they obliged, with a fusillade of plaintive and sardonic comments.

Bill Stanford, who works for a floor-covering business in Virginia Beach, said, “Optima Health Care just raised my premium from an absurd $1,767 a month to an obscene $2820.09 per month,” which is more than the mortgage payments on his home for a family of four.

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“At an average of $60 per visit,” Mr. Stanford said, “I could visit the doctor’s office 45 times a month for the premium that I’m paying. I think we will probably drop our insurance and get a gap policy.” Such short-term insurance is meant to fill temporary gaps, but typically does not cover maternity care or treatment for pre-existing medical conditions.

Mr. Dudley said in an interview that Optima, a Virginia company, felt an obligation to continue serving Virginians when larger national insurers were pulling back. But, he said, Optima is affected by the same factors destabilizing insurance markets elsewhere. These include President Trump’s decision to terminate certain federal subsidies paid to insurers and doubts about the future of the requirement for most Americans to have insurance — the individual mandate, which would be eliminated by the Senate Republicans’ tax bill.

And in the Charlottesville area, Mr. Dudley said, costs are high because many people receive care from an expensive academic medical center at the University of Virginia.

Carolyn L. Engelhard, director of the health policy program at the university’s School of Medicine, acknowledged that teaching hospitals often charged more. But another factor, she said, is that Virginia has not regulated insurance rates as aggressively as some other states.

Did You Sign up For Insurance Under the Affordable Care Act? Share Your Experience.

The Times would like to hear from Americans who are signing up for insurance under the Affordable Care Act.

Consumers are feeling the effects.

“Obamacare helped me,” Ms. Griffith said. “I had a pre-existing condition, could not get insurance and had to pay cash, nearly $30,000, for the birth of my first baby in 2010. For my second pregnancy in 2015, I was covered by Obamacare, and that was a huge financial relief.”


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But the costs for next year, she said, are mind-boggling.

She and her husband, both self-employed, expect to pay premiums of $32,000 a year for the cheapest Optima plan available to their family in 2018. That is two and a half times what they now pay Anthem. And the annual deductible, $14,400, will be four times as high.

“I have no choice,” Ms. Griffith said. “I agree that we need to make changes in the Affordable Care Act, but we don’t have time to start over from scratch. We are suffering now.”

Jill A. Hanken, a health lawyer at the Virginia Poverty Law Center, said, “People who qualify for premium tax credits are finding very affordable plans with low premiums, and those consumers are quite pleased.” But she added: “For people who don’t qualify for tax credits, the cost of plans has truly skyrocketed. They can’t afford or don’t want to pay the high premiums.”

When the Affordable Care Act was adopted in 2010, Democrats like Nancy Pelosi, who was then the House speaker, said the law would make it easier for people to switch jobs or start their own businesses because they would not have to worry about losing health insurance.

“We see it as an entrepreneurial bill,” Ms. Pelosi said, “a bill that says to someone, if you want to be creative and be a musician or whatever, you can leave your work, focus on your talent, your skill, your passion, your aspirations because you will have health care.”

And for a few years, Mr. Dixon said, that idea was appealing. “I would not be an entrepreneur if it were not for Obamacare,” he said.

With soaring premiums, that option is less attractive.

“When I saw the insurance prices for 2018, my initial instinct was to try and go back to my previous employer,” Mr. Dixon said. “But that would just smell of desperation.”

Continue reading the main story

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Health IQ raises $34.6 million for life insurance for healthy people

People who work out and eat healthily shouldn’t have to pay as much for life insurance.

That’s the concept behind Health IQ, a startup that’s been making headway in the “insureTech” category.

Venture capitalists have been betting that insurance is ready for change and Health IQ has convinced investors to put another $34.6 million in the startup for its Series C. Andreessen Horowitz is leading the round with participation from Charles River Ventures, First Round Capital, Foundation Capital and others.

Munjal Shah, co-founder and CEO of Health IQ, said that said he was inspired to start the business after encountering a health issue, right after he sold his last startup, Riya, to Google.

It started out as an online health quiz and after a million people took the test, Shah believed that he had “accidentally built the largest new mortality table in 100 years of life insurance.”

Now that quiz, which has questions about diet and exercise, is used to determine whether someone should get a discount on their policy.

Health IQ provides life insurance with a 4% discount for people who pass the quiz. Users are eligible for another 4% discount if they meet certain thresholds like running an eight-minute mile.

And he says that because it’s based on healthy lifestyle instead of family history, for some people it could save them another 25% to what they would be paying elsewhere.

“Those who have taken responsibility should get a special rate,” said Shah.

Health IQ is paid a commission by insurance carriers every time it sells someone a policy.

Shah said he would like to move beyond life insurance and expand to health insurance, but he laments that the current U.S. system doesn’t allow for healthy people to pay a lower rate.

He hopes that will change someday and that he can execute on a concept that he believes promotes “meritocracy.”

Health IQ has raised $81 million since it was founded in 2014.

Featured Image: Ascent Xmedia/Getty Images

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Coffee-Rich, Plant-Based Diets May Be Best For Heart Health

Coffee drinkers probably don’t need any additional data to support their habit, but a new study presented at the American Heart Association meeting brings some happy news anyway: It finds that each additional cup of coffee a person drinks is associated with a measurable reduction in heart risk. Also presented at the conference this week, a plant-based diet seems to be best for the heart, compared to various alternatives.

Neither of these studies offers any great revelations—earlier research has certainly revealed the same connections—but they do offer some more evidence and more specifics. And perhaps more reason for coffee-drinkers and veggie lovers alike to feel good about their routines.


The first study looked at data from the Framingham Heart Study, which has been following participants for decades, tracking their lifestyle habits and health outcomes. Using machine learning to analyze the data, the team found that coffee was strongly associated with heart health: for each additional cup of coffee consumed per week, the risk of heart failure dropped by 7%, and the risk of stroke by 8%. The benefit seemed to extend up to a whopping six cups per day, which was the most people in the study tended to drink. For those of us who drink multiple cups per day, this is great news.

The other study, on dietary habits and heart health, used data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, which has been tracking people middle-aged and older over time. The researchers also looked for correlations, this time between five different types of diet and heart health. The plant-based diet, which consisted largely of leafy vegetables, fruits, beans and fish, sounds a lot like the Mediterranean diet. There was also the “convenience diet,” made up of red meats, pasta, fast foods and fries. The “sweets diet” was carb- and sugar-heavy. The “Southern diet” consisted was heavy on fried foods, organ meats, processed foods, eggs, and sugar-sweetened drinks. Finally, the “alcohol/salads diet” was marked by consumption of leafy vegetables, salad dressings, butter, wine and liquor.

The plant-based diet was linked to a reduction in risk for heart failure (up to 42%), compared to those which consisted of the fewest vegetables. Unsurprisingly, the other types weren’t associated with any heart benefits.

For coffee, it’s likely the antioxidants that may account for much of the heart benefit. As for a plant-based diet, aside from the rich antioxidants, vitamins and minerals, the fiber and healthy fats may add to the benefit.

Keep in mind these were both presentations at a conference, so haven’t been peer-reviewed or published in a journal. They’re also just correlations, and although potentially confounding variables were accounted for, it’s possible that there’s more to the story than what we see here. But because both findings agree strongly with previous research, it’s probably OK to take them as more evidence for a plant-based and coffee-rich lifestyle.

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Could The U.S. Pursue A Public Health Response To Gun Violence …

More than 30,000 people a year are killed by gun violence, including 50 killed near the Los Vegas strip last month where this makeshift memorial stands.

Drew Angerer/Getty Images

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Drew Angerer/Getty Images

More than 30,000 people a year are killed by gun violence, including 50 killed near the Los Vegas strip last month where this makeshift memorial stands.

Drew Angerer/Getty Images

When U.S. officials feared an outbreak of the Zika virus last year, the Department of Health and Human Services and state officials kicked into high gear.

They tested mosquitoes neighborhood by neighborhood in Miami and other hot Gulf Coast communities where the virus was likely to flourish. They launched outreach campaigns to encourage people to use bug spray. And they pushed the development of a vaccine.

“The response was swift,” says former Surgeon General Vivek Murthy, and was even faster during the Ebola outbreak a year earlier.

But last month when 50 people died and more than 400 were injured in Las Vegas, and weeks later another 26 died in Texas of the same cause, public health officials have had almost no role.

Texas Shooter's History Raises Questions About Mental Health And Mass Murder

That’s because the victims in Las Vegas and Texas were killed with guns. And over the last three decades, Congress has made it clear that they don’t want the public health community looking too hard into the causes of the violence.

“If you look at the number of people who have died or been injured from gun violence, that dwarfs the number of people who have been affected by Zika or Ebola. There’s absolutely no comparison,” Murthy says.

More than 30,000 people are killed with guns in the U.S. every year. That’s more than die of AIDS, and about the same number as die in car crashes or from liver disease. But unlike AIDS or car crashes, the government doesn’t treat gun injuries or deaths as a public health threat.

Murthy and other public health experts say it should.

Funding For Research On Gun Violence Compared To Other Leading Causes Of Death

Funding represents the total funding awarded over the years 2004 to 2015. Dollar amounts have not been corrected for the year in which they were reported. (Note: Funding and mortality rate values are plotted on a logarithmic scale.)

funding chart

Source: JAMA

“It should be no different than the approach we take to cancer, heart disease or diabetes,” he says.

But such an approach would have to start essentially from scratch. The government spends only about $22 million a year on research into gun violence — a tiny fraction of what it spends on other major health threats.

That’s because of Congress. Back in 1997, lawmakers added a provision in the bill that funds the Centers for Disease Control and Prevention barring the agency from doing anything that would “advocate or promote gun control.” At the same time, they cut CDC’s budget by the exact amount it had been spending in gun violence research up until then.

So government research into the causes of gun deaths virtually stopped.

The issue comes up routinely after mass shootings. Two years ago, after a young man killed nine people in a church in South Carolina, a reporter asked former Republican House Speaker John Boehner about the CDC restrictions.

“The CDC is there to look at diseases that need to be dealt with to protect the public health. I’m sorry but a gun is not a disease,” he said at the time.

After the most recent shootings, Democrats in Congress have called for more restrictions on guns while Republicans, including President Trump, say the problem is mental health.

Gun Violence: How The U.S. Compares With Other Countries

But neither conclusion is backed by research, says Dr. Georges Benjamin, the executive director of the American Public Health Association.

“When a new disease, particularly an infectious disease, enters the community … we have a mechanism to anticipate it, track it, get our arms around it,” he says. “We do that when he have measles, mumps, chicken pox, zika. But firearm-related death and disability, we don’t.”

That kind of prior knowledge could lead to policies that reduce the toll of gun injuries without cutting off access to them.

“Firearms are a tool, and … a consumer product. And unlike other consumer products, we’re not working hard to make that consumer product safer,” he says.

Take cars for example. Benjamin points to the combination of safety features — airbags and seat belts — and safety policies like requiring licensing and banning drunk driving — that have made cars less lethal, while ensuring they’re still available.

A similar strategy with guns could lead to some laws or regulations that make them safer.

That could involve barring large ammunition clips to limit the number of shots a person could take, or requiring trigger locks that open by fingerprint, allowing only the gun owner to fire a weapon.

“We could think about where firearms ought not to be,” he says. “Alcohol and firearms and people who might get a little rowdy probably are not a good combination. There are solutions to that.”

Creating more shooting ranges may be a good idea so gun owners have a safe place to use their weapons, he says.

Today, Benjamin says, there is no data to show whether people are safer in communities with more or fewer guns.

Something has to change, because up until now, “We have done everything we can to ensure that this epidemic of death and disability from firearms is only going to get worse,” he says.

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Indulgent grandparents ‘bad for children’s health’

Grandmother and grandchildrenImage copyright

Indulgent grandparents may be having an adverse impact on their grandchildren’s health, say researchers.

The University of Glasgow study, published in PLOS One journal, suggests grandparents are often inclined to treat and overfeed children.

The study also found some were smoking in front of their grandchildren and not giving them sufficient exercise.

Lucy Peake, of the charity Grandparents Plus, said grandparents needed to be “better recognised and supported”.

“Grandparents want the best for their grandchildren, and the more they’re informed and enabled to play a positive role in their grandchildren’s lives the better things will be,” said Ms Peake.

  • Children with obesity ‘need NHS help’
  • Parents ‘may be overfeeding infants’

The researchers looked at 56 studies with data from 18 countries, including the UK, US, China and Japan.

The report focused on the potential influence of grandparents who were significant – but not primary – caregivers in a child’s early years.

The review considered three key areas of influence:

  • diet and weight
  • physical activity
  • smoking

Image copyright
Getty Images

In terms of both diet and weight, the report concluded that grandparents’ behaviour had an adverse effect.

Grandparents were characterised by parents as “indulgent” and “misinformed”, and accused of using food as an emotional tool.

Many studies found they were inclined to feed grandchildren high-sugar or high-fat foods – often in the guise of a treat.

Parents felt unable to interfere because they were reliant on grandparents helping them out.

The study also found that grandchildren were perceived to be getting too little exercise while under the care of their grandparents.

Physical activity levels appeared to be related to whether grandparents were active themselves, or whether there was appropriate space where children could be active.

Some grandparents actively promoted exercise by taking grandchildren to sporting events or the park.

But where grandparents were sedentary, children were likely to be too.


Smoking around the children, even when they had been asked not to, became an area of conflict between grandparents and parents.

Conversely, in certain cases, the birth of a grandchild became a catalyst to a grandparent giving up smoking – or changing their habits.

Lead researcher Dr Stephanie Chambers said: “From the studies we looked at, it appears that parents often find it difficult to discuss the issues of passive smoking and over-treating grandchildren.

“While the results of this review are clear that behaviour such as exposure to smoking and regularly treating children increases cancer risks as children grow into adulthood, it is also clear from the evidence that these risks are unintentional.

“Given that many parents now rely on grandparents for care, the mixed messages about health that children might be getting is perhaps an important discussion that needs to be had.”

According to Grandparents Plus, grandparents are “the largest provider of informal childcare” in the UK.

The charity’s chief executive, Ms Peake, said: “We know that children benefit enormously from having close relationships with their grandparents right through childhood into adolescence.

“What this study shows is that the role they’re playing in children’s lives needs to be better recognised and supported.

“We’d like to see more focus on ensuring that information available to parents about children’s health reaches grandparents too.”

Prof Linda Bauld, from Cancer Research UK, which part-funded the study, said: “With both smoking and obesity being the two biggest preventable causes of cancer in the UK, it’s important for the whole family to work together.

“If healthy habits begin early in life, it’s much easier to continue them as an adult.”

Are you a grandparent or parent? Do you agree with the findings of the study? Please share your experiences with us by emailing

Please include a contact number if you are willing to speak to a BBC journalist. You can also contact us in the following ways:

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Obamacare’s Insurance Mandate Is Unpopular. So Why Not Just Get Rid of It?


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There’s a reason Democrats put the provision in the bill. Eliminating it would reduce insurance coverage and drive up premiums. How much is up for debate.

No one likes being forced to eat broccoli, or buy health insurance. But vegetables are still part of a healthy diet.CreditNicole Bengiveno/The New York Times


Nov. 14, 2017

In a bill with many unloved parts, the Affordable Care Act’s individual mandate has long been the most loathed.

For years, critics of the bill have said the law’s requirement that Americans either obtain insurance or pay a fine was coercive and unfair. The mandate brought about a Supreme Court case that nearly toppled the whole Affordable Care Act. Public opinion polls consistently show that ordinary Americans dislike it.

Even many of Obamacare’s authors had to be talked into the mandate. As a presidential candidate, Barack Obama campaigned on a health plan that didn’t punish people who went without health coverage. Mitt Romney, whose Massachusetts health reform bill was the blueprint for Obamacare, had also initially hoped for a plan without a mandate.

Now it turns out that getting rid of the mandate could help Republicans as they tackle the difficult math of tax reform. According to a recent Congressional Budget Office estimate, eliminating the mandate could lower the deficit by $338 billion over a decade. A third of a trillion dollars can help pay for a lot of tax cuts. Which is why Senate Republicans, trying to find funding and keep their promise to dismantle Obamacare, are now vowing to add a mandate repeal to their tax bill.

But there’s a reason that Obamacare’s authors kept a provision so unpleasant and unpopular. And there’s a reason the budget office said that cutting it would save so much money. Without the mandate, economic studies have suggested, fewer healthy people would buy health insurance. Their exit from the market would raise insurance prices, driving out still more healthy people in an unhappy spiral of rising prices and lower rates of insurance coverage.

The mandate was often compared to one support in a three-legged stool that made Obamacare work: Knock it out, and the whole apparatus would tip over, broken and useless.

That was the logic that persuaded Mr. Romney to put the mandate in his health bill, and the thinking that persuaded President Obama to change his mind and put it in the Affordable Care Act.

Without the mandate, the C.B.O. has said for years, premiums would spike, and millions fewer Americans would have health insurance. The budget office’s most recent estimate, published last week, said that the ranks of the uninsured would rise by 13 million over 10 years, and that average premiums would be 10 percent higher than under current law.

If you wanted health reform to work, the thinking went, you needed to eat the broccoli of the individual mandate, so you could then enjoy the dessert of a health care system accessible to people with pre-existing illnesses. (Much of the debate during oral argument at the Supreme Court focused on hypothetical broccoli-purchase mandates.)

The insurance industry, concerned that it will be left operating in an unsustainable market, has been particularly exercised in emphasizing this point at every turn. On Tuesday, it sent a letter to congressional leaders urging them to preserve the mandate.

For years, conservative health care analysts have said the budget office has erred in assuming that the insurance requirement has so much power over who gets health insurance. Under the budget office’s estimates, eliminating the mandate doesn’t just drive people out of the individual insurance market, where people pay premiums to buy coverage; it also sharply lowers the number of people enrolled in Medicaid, a program that low-income Americans can access largely without cost to them. Republican critics have said that the Medicaid estimates are unrealistic and unfair to any health reform plan that doesn’t include a mandate.

But now Republicans are embracing what they have long described as the mandate’s overstated importance. That’s because the only way the measure could achieve $338 billion in savings is by causing many fewer Americans to have government-subsidized health insurance. Most of the savings in the budget office’s calculations regarding repealing the mandate come from lowering Medicaid enrollment. If the budget office took the Republican critiques to heart, the mandate would be much less useful as a component of tax reform.

And it appears the budget office has, indeed, heard their complaints. In the recent report, its economists indicated that the office was re-evaluating its assessment of the mandate.

“The agencies have undertaken considerable work to revise their methods to estimate the effects of repealing the individual mandate,” the report notes near its end. While that work was not completed in time to assess the current tax proposal, new estimates should be ready soon. Under the new model, “the estimated effects on the budget and health insurance coverage would probably be smaller than the numbers reported in this document,” the report says.

That will make the mandate less central to the success of future health care overhaul ideas. And less valuable as a means to pay for tax cuts.

The Upshot provides news, analysis and graphics about politics, policy and everyday life. Follow us on Facebook and Twitter. Sign up for our newsletter.


President Robert Mugabe and his wife, Grace, arrived at the headquarters of the governing ZANU-PF party last week during a rally to back Mrs. Mugabe as the next vice president.
Jekesai Njikizana/Agence France-Presse — Getty Images
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Tasneem Alsultan for The New York Times

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GOP Plans to Repeal Obamacare Mandate for Health Coverage

WASHINGTON — To help pay for the GOP tax bill, Republican Senate leaders announced Tuesday that they plan to repeal the Affordable Care Act’s requirement that Americans maintain health coverage.

The announcement comes one day after President Donald Trump urged Senators to eliminate the Obamacare mandate and use the savings to reduce the top income tax rate to 35 percent, a move that would exclusively benefit individuals earning over $500,000 and couples earning over $1,000,000 under the current Senate bill.

“We’re optimistic that inserting the individual mandate repeal (into the tax bill) would be helpful,” Senate Majority Leader Mitch McConnell, R-Ky., told reporters after a caucus meeting.

It was not immediately clear what Senate Republicans planned to do with the savings, although a Senate GOP aide said they would be used to “provide more relief for middle-class families.”

Senator Rand Paul, R-Ky., suggested earlier in the day that Republicans should use the money to help taxpayers who would be affected by the loss of the state and local tax deduction, which the Senate bill currently eliminates.

The Congressional Budget Office estimates repealing the mandate penalty would save $338 billion over the next 10 years, which would help Republicans pay for their $1.5 trillion tax bill. But ending the mandate would only save money because the CBO projects 13 million fewer people would have health insurance by 2027, meaning the government would spend less money subsidizing coverage through private insurance or Medicaid.

Premiums on the individual insurance market would also go up 10 percent as a result.

In a joint letter, the top industry groups representing insurers, hospitals and doctors came out strongly against repealing the mandate, arguing it was necessary to attract enough healthy patients to offset the cost of insuring Americans with pre-existing conditions.

“There will be serious consequences if Congress simply repeals the mandate while leaving the insurance reforms in place: millions more will be uninsured or face higher premiums, challenging their ability to access the care they need,” the letter read, which was signed by America’s Health Insurance Plans, the American Hospital Association, the American Medical Association, the Blue Cross-Blue Shield Association, the American Academy of Family Physicians and the Federation of American Hospitals.

Senate Minority Leader Chuck Schumer, D-N.Y., said in a statement that Republicans were “so determined to provide tax giveaways to the rich that they’re willing to raise premiums on millions of middle-class Americans and kick 13 million people off their health care.”

Democrats in the Senate Finance Committee marking up the Senate bill were livid at the news, especially after the chairman, Sen. Orrin Hatch, R-Utah, said it was premature to discuss the changes until they were made official.

“We’re talking about a whole new subject, a subject that, as I’ve indicated, can raise health insurance premiums on millions of people,” Sen. Ron Wyden, D-Ore., said.

Senate Republicans tried to pass a narrow “skinny repeal” bill that would have repealed the individual mandate earlier this year, but it failed after three of them — Susan Collins of Maine, Lisa Murkowski of Alaska and John McCain of Arizona — voted it down. It was not immediately clear whether they would support including a similar measure in the tax bill.

Sen. John Kennedy, R-La., told reporters that some members on Tuesday indicated they were unsure about returning to the health care debate, but that they had not signaled they were a hard “no” if the measures were included.

“There are some people who are concerned about including the mandate in the tax legislation, but my gut tells me we will reach a consensus on doing that,” he said. “It makes too much sense.”

House Republicans are planning to vote soon on their own tax bill, which so far does not include a repeal of the individual mandate, despite a push from House conservatives to add the measure. Republican leaders in both chambers are hoping to complete a final bill before the end of the year.

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WHO initiative aims to tackle health impacts of climate change

Dr. Tedros Adhanom Ghebreyesus, director-general at the World Health Organization. Photo by:


BONN, Germany — World Health Organization officials have announced a new initiative to address the health impacts of climate change on small island developing states. The global health body called for a tripling of international support for those nations’ health systems and for more evidence on the link between climate change and health.

The initiative, launched over the weekend at the 23rd Conference of Parties, or COP23, is focused specifically on small islands whose health systems often have difficulty grappling with the impacts of major climate events.

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That can be anything from drinking water that becomes contaminated during a hurricane or flood, to infectious diseases that spread among people who are displaced, to malnutrition caused by changing agricultural patterns. Between 2030 and 2050, the WHO predicts that climate change could be responsible for roughly 250,000 additional deaths per year.

WHO officials said only 1.5 percent of all funding for climate change adaptation goes toward shoring up the health response. And only a fraction of that money goes to small island developing states, despite their particular vulnerability.

“The level of investment at the moment is so low,” Dr. Diarmid Campbell-Lendrum, WHO’s team leader on climate change and health, told Devex. “It’s in the order of millions per year, when we should be talking in the order of tens of millions, if not more.”

“We owe it to these people to do everything we can to help them prepare for a future that is already washing up on their shores,” said WHO Director-General Dr. Tedros Adhanom Ghebreyesus during the launch of the initiative in Bonn, Germany.

In addition to increased funding and evidence, the four-part initiative calls for the amplification of the voices of health leaders from small island developing nations and the promotion of health policies to improve preparedness for catastrophic climate events.

The risks facing this group of countries are a special focus at COP23, which is being hosted by the small island developing state, Fiji. WHO officials said the strategies — and many of the solutions they are hoping to get funding to implement — come directly from the experience of those island nations.

“We in Fiji know all too well that climate change poses a serious threat to the health of our people.”

— Frank Bainimarama, Fijian prime minister and COP23 president

“We in Fiji know all too well that climate change poses a serious threat to the health of our people,” Fijian Prime Minister and COP23 President Frank Bainimarama said at the launch.

Campbell-Lendrum told Devex the initiative grew out of earlier conversations with health ministers from the Pacific and Caribbean. Those discussions were marked by the frustration the officials felt with the lack of financing and their eagerness to have their concerns about health fears amplified.

“It’s been clear from the start that this initiative will respond to what they want, not what the United Nations tells them they want,” he said.

The process will begin with designing country-level programs that draw on existing evidence and the lessons of individual initiatives that are already in place, including several that have been piloted by small island developing states.

“It’s been clear from the start that this initiative will respond to what they want, not what the United Nations tells them they want.”

— Dr. Diarmid Campbell-Lendrum, WHO team leader on climate change and health

Campbell-Lendrum pointed to efforts such as a smart hospitals approach, which looks to build facilities that can withstand climate events, while also not contributing to climate change. That means constructing them around renewable energy sources, especially solar power.

WHO can assist with capacity building and technical support to facilitate these efforts. It can also help build up evidence and take other steps to strengthen requests for funding.

“There are a certain amount of things that countries can do at no or low cost,” Campbell-Lendrum said. “But many of these countries are definitely going to need additional financial support. We will be working with them to try to facilitate access to international climate financing streams.”

He said there was a particular push from small island developing states for WHO to become accredited to the Green Climate Fund, which supports the efforts of developing countries to respond to climate change.

Within WHO, Campbell-Lendrum said there is significant momentum behind the initiative. “It is being proposed as one of the indicators of WHO’s success over the next five years.”

Read more Devex coverage on the COP23 and sign up for our daily briefings.

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Pence’s health care power play

Vice President Mike Pence is exerting growing influence over the American health care system, overseeing the appointments of more than a half-dozen allies and former aides to positions driving the White House’s health agenda.

On Monday President Donald Trump nominated Alex Azar, a former Indianapolis-based drug executive and longtime Pence supporter as HHS secretary. If confirmed, Azar would join an Indiana brain trust that already includes CMS Administrator Seema Verma and Surgeon General Jerome Adams. Two of Verma’s top deputies — Medicaid director Brian Neale and deputy chief of staff Brady Brookes — are former Pence hands as well, as is HHS’ top spokesman, Matt Lloyd.

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Yet another Pence ally — Indiana state Sen. Jim Merritt — is in the running to be White House drug czar.

Pence’s sway with the policymakers controlling Obamacare, Medicare and Medicaid comes at a time when Trump and Congress continue to struggle with the repeal of the Affordable Care Act. But Pence and his cadre are driving a national agenda dominated by the kinds of conservative, anti-regulatory policies he embraced as Indiana governor.

“The vice president feels like these are some of the people responsible for the success of his state,” said Indiana Rep. Larry Bucshon. “I do think, behind the scenes, he has a lot of influence with the president.”

Pence has assumed a lead role on health with Trump’s blessing, Republicans who speak with the president and vice president emphasized. He remains one of Trump’s steadiest confidantes in a White House marked by intra-office power struggles, and established himself early on as a main envoy to congressional Republicans on Obamacare repeal.

“He really is the lead liaison between the White House and Congress in terms of legislation,” Sen. John Hoeven said. “Clearly he has a big part in trying to shape the policy.”

It was Pence who brought Freedom Caucus Chairman Mark Meadows and Tuesday Group moderate Tom MacArthur together on a compromise that brought the House’s repeal bill back to life.

And it was Pence, along with Verma, who offered Senate Republicans a steady sounding board during their fraught work on health care.

Associates said Pence’s involvement is a product of his intensive focus on health care as a governor, and the need to fill out Trump’s positions with policy details. And he has been able to offer up a network of political and policy contacts with deep credentials to a novice president who has struggled to fill positions with well-qualified candidates.

“People who don’t have a history with Donald Trump, but did have a history with Mike Pence — the fact that Mike was there was a reason to serve because they trust him, they know him and they want to make him successful,” said Ryan Streeter, who served as then-Gov. Pence’s deputy chief of staff for policy.

The White House directed questions to Pence’s office, which did not respond to requests for comment.

Given a national stage, Pence’s allies are pushing some of the conservative ideas they experimented with in Indiana.

Verma, for instance, is proposing sweeping changes to allow state officials to push Medicaid in a more conservative direction by tying some enrollees’ benefits to work requirements and imposing policies aimed at limiting costs.

That’s an outgrowth of the path Verma — along with Neale and Brookes — charted as a consultant to then-Gov. Pence, where she helped win federal waivers allowing Indiana to add conservative features to its Medicaid program in exchange for expanding coverage. At the time, the Obama administration blocked Indiana’s attempts to impose a work requirement — an idea that’s now become a centerpiece of the Trump administration’s Medicaid initiative.

“For this population, for able-bodied adults, we should celebrate helping people move up, move on, and move out,” she said in a speech last week.

She is also eliminating or rewriting reams of regulations on doctors and hospitals that she heralds as a return to conservative, free-market principles designed to promote competition by loosening federal requirements on the industry.

Pence and another pair of former aides — White House legislative affairs director Marc Short and special assistant Paul Teller — also provided the push behind Trump’s move to satisfy the religious right by gutting Obamacare’s contraception mandate.

The change, which allows employers to object on moral grounds to covering birth control, stirred controversy even among some Trump administration advisers — but proved Pence’s influence within the White House.

“Everybody knows where Mike stands on these issues,” Streeter said of the vice president’s evangelical and anti-abortion track record. “Whereas I would suspect there would be people in Trump’s White House who would rather tone down on those issues.”

Short had served as chief of staff during Pence’s time as a congressman. Teller was executive director of the Republican Study Committee when Pence chaired the conservative caucus.

The expected addition of Azar should further deepen Pence’s ties with the health department. Azar spent nearly a decade at Indianapolis-based drug-maker Lilly USA, where associates said he was well known in the city’s tight-knit political and policy circles.

“His credentials are not based on his geographic location,” one Azar ally said, highlighting his past experience as a general counsel and deputy HHS secretary in the George W. Bush administration. “But I sure wouldn’t dispute the idea that it probably doesn’t hurt that he’s known and respected by the vice president’s team.”

On perhaps one of the biggest health care issues still facing the administration — drug prices — Azar is likely to break from Trump’s calls to crack down on the pharmaceutical industry and import drugs from other countries. Instead, he’s so far favored the more traditionally conservative, pharma-friendly position that emphasizes a broader look at what’s driving up health costs — and sidesteps a shakeup of the status quo.

“The first thing is, the issue shouldn’t be just to focus on drug prices,” Azar said on Fox Business Network in June, dismissing the idea of drug reimportation. “The U.S. distribution system is a crown jewel. Let us not mess that up.”

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