NPR’s Michel Martin speaks with Julie Rovner, Chief Washington Correspondent at Kaiser Health News, about the Senate GOP health bill and what it could mean for programs funded by Medicaid.
NPR’s Michel Martin speaks with Lynn Cooper, director of the Drug and Alcohol Division at Pennsylvania’s Rehabilitation and Community Providers Association, about the Senate GOP healthcare bill.
President Trump is praising the Senate’s health care bill. But the bill lacks a mechanism requiring people to have continuous coverage, which could create problems in the individual health care market.
Andy Slavitt was in charge of running the federal agency that oversees the Affordable Care Act from 2015 to 2017.
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Evan Vucci/AP
Andy Slavitt understands the inner workings of the U.S. health care system better than most. From 2015 to 2017, he ran the Affordable Care Act, sometimes called Obamacare, as head of the Centers for Medicare and Medicaid Services. Since leaving that post in January, he’s been an outspoken critic of the Republican proposals to dismantle it.
Yesterday, shortly after the release of the Senate bill, he tweeted, “It’s the ugly step-sibling of the House bill.” And this morning his message was, “We must start over. It’s too important.”
The Senate discussion bill is out. It’s the ugly step-sibling of the House bill.
Analysis to follow shortly. Follow if interested.
— Andy Slavitt (@ASlavitt) June 22, 2017
Slavitt spoke with All Things Considered host Kelly McEvers about the latest Republican plan, called the Better Care Reconciliation Act, and where the Affordable Care Act goes from here. This interview has been edited for length and clarity.
Fair to say there isn’t anything you like in this new plan?
Well, it’s hard to say that you like the uniforms of the team that’s got the guns pointed at you, trying to kill you. And I don’t mean to exaggerate, but in the main, it’s very hard to be supportive of something that takes health insurance away from 20 million or so Americans. The details that we’ve seen, at least so far, aren’t particularly good for people with lower incomes. They’re not particularly good for people who are sicker, and they’re not good for people who are older.
Supporters of the Republican plan say the Affordable Care Act’s individual mandate forced people to do something they often didn’t want to do. And that this new proposal would allow people to have more choice. True?
Well, the individual mandate is about as popular as vegetables are with my kids. We know that. And we know that there needs to be something that helps keep healthy people in the pool, because if we leave people to their own devices to buy health insurance when they get sick, that will just drive the cost up for everybody.
There are choices and trade-offs made within [the Senate] bill that we should acknowledge. If you are a 27-year-old person who makes $70,000 a year and has no illness, this is a good bill for you. If you are younger and don’t get your insurance through your employer, your insurance will be cheaper. It will cover a lot less, but that may not be a problem to you. You may be OK with that.
The challenge of course is that if you’re over 50, or if you’re sick, or if you live in rural areas and if your income is low, you pay the price. In fact, people who are over 50, many of them would be asked to pay as much as 50 percent of their income [for health insurance], and that’s all in order to make the policies cheaper for younger people.
The problem our country has is how to help people who are in the lowest economic straits, who have the most health challenges, get access to affordable coverage and, indeed, get well. The problem we don’t have is how to help 27-year-olds get cheaper insurance. That’s just not a national concern for us right now.
You’ve talked about how the Affordable Care Act isn’t perfect. If the Republican proposal does not pass, what could and should be done to strengthen what’s already there?
This is really an interesting question because I actually am a big believer in bipartisanship, in large part because I don’t think our country deserves to go through the back-and-forth of changing our health care system every election cycle.
But the only way bipartisanship happens is if partisanship fails. If this legislation fails in the Senate, I do think we’ll have an opportunity.
There are a number of things that we can work on constructively to make insurance more affordable for people, to make insurance more competitive.
I think if the people who drafted the ACA had it to do over again, there may be some things that would have been done differently. I think people would have liked to have had more enforcement of competition, more affordability for people in the middle class. I think there are plenty of practical solutions. The hard part is getting people to trust each other once again.
The vast majority of contingent or independent workers in the U.S. do not receive employee benefits, though some companies and lawmakers are trying to change that.
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The list of perks Dan Teran’s company offers sounds pretty dreamy.
Anyone working 120 hours a month gets employer-sponsored medical, dental and vision insurance. His company, Managed by Q, also offers a matching 401(k) retirement program, paid time off, a stock option program for all employees, and 12 weeks of paid parental leave.
Those are highly unusual perks, considering most are part-time workers who work only when they’re available. Also, Teran’s company does janitorial, building maintenance and temporary secretarial work, where such benefits are almost unheard of.
But, Teran says, he didn’t want to run a business with the kind of very high client and employee turnover that can run as high as 400 percent in his industries.
“In order to deliver the best service we need the best people, and to attract and retain the best people we need to be the best employer,” he says.
A growing number of Americans rely on gigs for income — driving a car, writing bits of code, or doing tasks for hire on a project-by-project basis, and this kind of contingent work is spreading to more industries as well. The vast majority of the estimated 54 million to 68 million contingent or independent workers in the U.S. do not receive employee benefits, though some companies and lawmakers are trying to change that.
Lawmakers in Congress and at least four states are considering proposals aimed at funding and creating new systems to deliver benefits to contingent or contract workers.
Sen. Mark Warner, D-Va., last month proposed a bill to fund experimentation with portable benefits programs — ones that travel with the individual, regardless of where they work.
“We need to rethink the social contract for the 21st century; that social contract has to be updated to a much more portable form,” he says.
As contract work goes mainstream, companies are looking to perks to get better work out of their contract workers, says Ravin Jesuthasan, managing director and talent expert at Willis Towers Watson.
“It’s very difficult to motivate that person to go above and beyond and to feel committed to your mission and cause, so that’s a key part of it,” he says. “How do we ensure we’re attracting the very best, we’re engaging them, and we’re equipping them to represent the best of who we are?”
The biggest reason most companies do not offer their gig workers benefits: They don’t want to have them categorized as “employees.”
Under the law, employees have more rights than independent contractors — for benefits, to unionize, and other worker protections. With the growth of contingent work, that legal distinction between employee and contractor blurs, and courts and regulators are now wrestling with questions of classification and worker rights.
Rich Meneghello is a Portland, Ore., lawyer who represents employers.
“There’s a real solid concern that if they offer benefits packages towards their workers that these workers would then be classified as employees,” he says.
As gig work grows, this debate will intensify, and the question of benefits for these workers will take on more importance, says Sara Horowitz, executive director of the Freelancers Union, which representing 360,000 members.
“I think we also want to start imagining the next era of a safety net, where people can do the work they enjoy and need to do, and can get the benefits that they need,” she says.
Stride Health, a San Francisco firm, has built software that allows independent workers who can afford it, to buy health care and financial benefits on their own. Noah Lang, Stride’s CEO, says he’s hoping to capitalize on the growing demand, and be ready for when public policy shifts.
“Where we’re driving change is going ahead and building up the systems to allow independent workers to get on equal footing,” he says.
He says he hopes Stride can offer a model for how more companies can get the flexibility of working with contingent workers, with the security of receiving benefits.
Following the Senate releasing its own version of the Republican health care bill, Steve Inskeep talks with Republican Rep. Charlie Dent, who voted against the GOP bill in the House.
Rachel Martin talks with David Barbe, a family doctor in rural Missouri and president of the American Medical Association, about the Senate health care proposal.
Women have gotten conflicting advice from doctors about when to have mammograms.
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Women in their 40s at average risk for breast cancer should talk to their health care provider about the risks and benefits of mammography before starting regular screening at that age, according to guidelines released Thursday by the American College of Obstetricians and Gynecologists.
The group had previously recommended annual mammograms starting at age 40. But the advice has changed to better incorporate input from the woman being screened, says physician Christopher Zahn, vice president of practice activities at ACOG. “A patient’s preferences and values need to be an important part” of the decision, he says.
Now the group says providers should offer the test when a woman enters her 40s, and that after a discussion, she may opt to start screening. If she doesn’t, she should start by age 50, ACOG says. Zahn says the guidance intentionally encompasses advice from other major groups.
The U.S. Preventive Services Task Force says women should start regular mammograms at 50, and that women in their 40s should make an individual decision about whether or not to screen. The American Cancer Society says screening should be offered starting at age 40, and outright recommends starting at 45. And the National Comprehensive Cancer Network, an alliance of major cancer centers, recommends starting at 40.
The question all these groups have wrestled with is how to balance the benefits and harms of mammography; their different recommendations reflect differences in how they interpreted and weighed the available data. “All three [schedules] are reasonable approaches to take,” says Zahn.
Mammography clearly saves lives for women over 50 and likely does so overall for women in their 40s, says Otis Brawley, chief medical officer at the American Cancer Society. But the benefits in those younger women are smaller, and they come at the cost of false alarms, unnecessary biopsies and overdiagnosis, when cancer that is detected and treated never would have threatened a woman’s health had it gone undiscovered. (The ACS says estimates of overdiagnosis vary widely, from 0 percent to 54 percent of breast cancers, in part depending on whether cases of ductal carcinoma in situ — abnormal cells that sometimes turn into cancer — are included.)
Once a woman starts mammography, she can be screened every one or two years, again after a discussion about the pros and cons of the different schedules, ACOG advises. The American Cancer Society recommends annual screening for women through age 54 and every other year for older women, with the option to continue annual tests, while USPSTF says every other year is sufficient and the network of cancer centers recommends annual screening.
A statistical model from the USPSTF finds that if 1,000 women are screened every other year from age 40 to 74, there will be eight fewer breast cancer deaths compared with no screening, 213 unnecessary breast biopsies and 21 overdiagnosed breast tumors. Meantime, if 1,000 women are screened every other year from 50 to 74, there will be seven fewer breast cancer deaths compared with no screening, 146 unnecessary biopsies and 19 overdiagnosed tumors.
Some women may decide that the small additional benefit doesn’t outweigh the increased risk of biopsy or possibly being treated for a cancer that didn’t need attention. There’s as yet no sure way to know which tumors are harmless and can be left alone. Others may choose differently. “There’s more of a respect for the individual person,” says Brawley about the new ACOG guidelines and the 2015 changes by his own organization. “You’re starting to hear, ‘Let the woman decide.’ “
“If a woman is told to get a mammogram starting at 40, it’s very reasonable to question that and ask, ‘Why? I’ve read that there are conflicting guidelines,’ ” says Deanna Attai, assistant clinical professor of surgery at the David Geffen School of Medicine at UCLA.
She says women should know, or ask about, the risk factors for breast cancer so they can have the screening conversation with some understanding of where they fall on the spectrum. And don’t stop the risk-reduction discussion at screening. “Ask what lifestyle or health habits can help reduce risk,” she says. (For example, research suggests exercise can cut breast cancer risk.)
On the question of when to stop routine mammograms, ACOG says screening beyond age 75 should be based on a conversation about a woman’s health status and longevity. The group also recommends against regular breast self-exams but says women should be aware of the normal feel and appearance of their breasts so they can report any changes.
Keep in mind that these recommendations are for average-risk women who are not experiencing symptoms. Many factors can increase risk, including a family history of breast or ovarian cancer and certain genetic mutations. So those women should check with their physician about when, how and how frequently they should be screened. There’s also not enough evidence to make recommendations on whether women with dense breasts should be screened differently.
Katherine Hobson is a freelance health and science writer based in Brooklyn, N.Y. She’s on Twitter: @katherinehobson
NPR’s Kelly McEvers talks with Pam Morris, CEO and President of CareSource, about the new health care bill from Senate Republicans. CareSource is the largest provider of Medicaid managed care services for Ohio.
