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Cinco poderosas razones por las que fracasó el proyecto de salud republicano

Siete años de votos republicanos para “derogar y reemplazar” la Ley de Cuidado de Salud Asequible (ACA) se desmoronaron el martes 18 de junio, cuando quedó claro que el Senado no podría reunir los votos necesarios para ninguna de las tres propuestas separadas que se estaban considerando.

El fracaso, al menos por ahora, rompe una de las promesas clave que los republicanos vienen haciendo a sus votantes desde 2010, cuando ACA se convirtió en ley.

“Esta ha sido una experiencia muy desafiante para todos nosotros”, dijo el líder de la mayoría del Senado Mitch McConnell (republicano de Kentucky) a periodistas el martes a la tarde. “Está bastante claro que no hay 50 republicanos en este momento para votar por un reemplazo del Obamacare”.

La declaración de oposición que hicieron el lunes los senadores republicanos conservadores Mike Lee (Utah) y Jerry Moran (Kansas) desterró incluso la oportunidad de iniciar el debate sobre la versión de un proyecto de ley presentado la semana anterior.

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McConnell agregó que el Senado votaría a principios de la próxima semana sobre un plan, originalmente aprobado en 2015 y vetado por el presidente Barack Obama, que derogaría partes de la ley de salud. Ese enfoque retrasaría la fecha efectiva de votación por dos años para dar a los legisladores el tiempo para proponer un reemplazo.

Sin embargo, la oposición de los republicanos moderados Susan Collins (Maine), Shelley Moore Capito (West Virginia) y Lisa Murkowski (Alaska), garantiza que esta votación también fracasará.

“Sólo para decir “derogamos la ley y confíe en nosotros, que vamos a arreglar esto en un par de años’, eso no va a proporcionar consuelo a la ansiedad que muchas familias de Alaska están sintiendo en este momento”, dijo Murkowski a periodistas.

En retrospectiva, la incapacidad de los republicanos para reemplazar la ley de salud no debería ser una sorpresa. Estas son algunas de las razones:

1. Es difícil quitarle las cosas a la gente

Una vez lanzados, los programas federales que proporcionan a las personas beneficios que consideran importantes y valiosos son muy difíciles de quitar. En el caso de la atención de salud, la vida de las personas puede estar en juego. En el debate actual, los pacientes que temían lo que sucedería con su cobertura de salud si se derogaba el Obamacare le hicieron saber sus preocupaciones a los legisladores, en voz bien alta.

2. Los republicanos están divididos desde hace tiempo en el tema de la atención médica

El recóndito secreto que los republicanos guardaron estos últimos siete años es que, fundamentalmente, en lo único que acordaron sobre la atención de salud fue en el eslogan “derogar y reemplazar”. Hay una razón por la cual no tuvieron un plan cuando Donald Trump fue elegido presidente. Hasta ahora, todos los esfuerzos por lograr un consenso fracasaron.

“No vine a Washington para herir a la gente”, dijo Capito en un comunicado. “Tengo serias preocupaciones acerca de cómo seguimos proporcionando atención asequible a aquellos que se han beneficiado de la decisión de West Virginia de ampliar el Medicaid”.

Pero los miembros más conservadores, en particular el senador Rand Paul (republicano de Kentucky), tienen otras prioridades. “Todos nosotros prometimos que derogaríamos al Obamacare”, dijo Paul a periodistas el martes. “Si no está dispuesto a votar de la manera en que votó en 2015, entonces necesita regresar a casa y necesita explicarles a los republicanos por qué ya no apoya la revocación del Obamacare”.

3. El liderazgo presidencial en asuntos difíciles es importante

El presidente Trump dejó claro en todas partes lo que quería de un proyecto de ley de salud. Fue su insistencia original sobre que el “revocar y reemplazar” sucediera simultáneamente lo que alejó al Congreso de su estrategia de 2015 de derogar primero y reemplazar más tarde. Durante una celebración en el Jardín de las Rosas de la Casa Blanca, Trump aplaudió cuando la Cámara aprobó su proyecto de ley, pero luego lo llamó “maldito” durante una reunión de estrategia con senadores.

Cuando se hizo claro el lunes por la noche que el esfuerzo del Senado se estaba hundiendo, Trump twitteó: “Los republicanos deberían simplemente rechazar el Obamacare que está fracasando ahora y trabajar en un nuevo plan de salud desde cero”. “Como siempre han dicho, dejar que Obamacare fracase y luego diseñar un gran plan de salud”, agregó.

El presidente “les dio una tarea imposible con sus promesas (más, mejor, más barato para todos). Pero ni las políticas ni el púlpito bully ayudan en el momento crucial”, dijo Len Nichols, profesor de política de salud en la Universidad George Mason. “Y ahora los culpará por fracasar”.

Thomas Miller, del conservador American Enterprise Institute, agregó: “Ahora tenemos un ensayo clínico aleatorio que demuestra que uno no puede dirigir y gobernar a través de Twitter”.

4. El cuidado de la salud es complicado. De verdad

La atención de salud no ha sido tradicionalmente un tema de votación importante para los republicanos, y por lo tanto ha sido una prioridad menor -en comparación con cuestiones como los impuestos y el comercio- a la hora de elegir a sus representantes.

Agrega complejidad el hecho de que el conocimiento de los republicanos no es tan profundo como el de los demócratas cuando se trata de experiencia en políticas de salud. Los demócratas han trabajado en estos temas durante años. Incluso antes de la Ley de Cuidado de Salud Asequible, muchos ya habían servido en el Congreso durante décadas y habían aprendido de los errores que se cometieron en esfuerzos como el fracasado proyecto de ley de salud del presidente Bill Clinton.

5. Algunas partes del Obamacare son realmente populares, incluso entre los republicanos

El requisito de que la mayoría de las personas tengan un seguro a riesgo de pagar una multa -conocido como mandato individual- ha sido muy poco popular entre los votantes de todos los signos políticos. Pero muchas otras disposiciones importantes de la ley de salud, como garantizar la cobertura para las personas con condiciones preexistentes, siguen siendo ampliamente populares.

De hecho, en los últimos meses, el Obamacare ha ido creciendo en popularidad. La mayoría de las encuestas muestran que es más de dos veces más popular que el esfuerzo republicano por cambiarlo.

“Los republicanos tienen que admitir que realmente nos gustan algunas de las cosas de ACA”, dijo Murkowski.

Eso abrió una gran brecha entre los republicanos que querían mantener los beneficios populares y los que querían derogar la ley por completo. Una brecha que, hasta ahora, los republicanos han sido incapaces de zanjar.

Rachel Bluth contribuyó a esta historia.

Obamacare Exchanges In Limbo

California’s Obamacare exchange scrubbed its annual rate announcement this week, the latest sign of how the ongoing political drama over the Affordable Care Act is roiling insurance markets nationwide.

The exchange, Covered California, might not wrap up negotiations with insurers and announce 2018 premiums for its 1.4 million customers until mid-August — about a month later than usual. Similar scenarios are playing out across the country as state officials and insurers demand clarity on health care rules and funding, with deadlines fast approaching for the start of open enrollment this fall.

“It’s insane,” said John Baackes, CEO of L.A. Care Health Plan, which has about 26,000 customers on the California exchange. “Here we are in the middle of July and we don’t even know what rules we will be operating under for open enrollment. It is not how you want to run a business.”

Use Our ContentThis KHN story can be republished for free (details).

Consumers could face sharply higher premiums and fewer choices if more health insurers leave the insurance marketplaces due to lingering uncertainty. State and industry officials around the United States are concerned that the federal government could stop funding so-called cost-sharing subsidies that reduce out-of-pocket costs for low-income consumers. And they worry the Trump administration won’t enforce the individual mandate that requires people to purchase health coverage or pay a penalty.

The National Association of Insurance Commissioners has called on the Trump administration and Congress to fully fund the cost-sharing subsidies. And the insurance commissioners of Washington state and California have warned that premiums will rise without enforcement of the ACA’s coverage mandate.

Amid those concerns, there was a sense of relief Tuesday among many exchange officials and insurers after the U.S. Senate’s latest attempt to replace the Affordable Care Act failed.

Two large insurer trade groups bluntly warned last week that parts of the Senate plan were “unworkable” and could plunge the market into chaos. In a letter to the Senate, America’s Health Insurance Plans and the Blue Cross Blue Shield Association particularly objected to an amendment by Sen. Ted Cruz (R-Texas) that would have allowed insurers to sell bare-bones health plans to people who wanted cheaper premiums. That provision, the insurers said, would split the market between the healthy and the sick, driving up costs for people with preexisting conditions.

However, the Republicans’ failure to pass that ACA replacement plan did not resolve questions swirling around the current health law.

Tuesday, President Donald Trump expressed disappointment at the outcome in the Senate, telling reporters, “We’ll let Obamacare fail and then the Democrats are going to come to us and they’re going to say, ‘How do we fix it?’”

Some Senate Republicans struck a more conciliatory tone, suggesting that lawmakers should work on a bipartisan measure that would help stabilize the individual insurance markets.

Sen. Lamar Alexander (R-Tenn.), chairman of the Senate Committee on Health, Education, Labor and Pensions, said he plans to hold hearings in the coming weeks on ways to shore up the individual insurance market. Lawmakers may look at creating a new stabilization fund that helps compensate insurers for higher-cost patients. Such a fund would be similar to one that existed during the first three years of the ACA exchanges.

Some insurance industry executives welcomed the talk of bipartisanship, but they said action must be taken quickly to resolve key issues affecting consumers.

“We are running out of time and we need a resolution on what we are charging for 2018,” said Gary Cohen, vice president of public affairs at Blue Shield of California in San Francisco, the largest Covered California insurer by enrollment.

Cohen, who helped launch the exchanges in 2014 as an official in the Obama administration, noted that the Republican bills in both the House and Senate included money for reinsurance that can help lower premiums industrywide. Those provisions are among the “immediate steps Congress and the Trump administration need to take in order for markets to provide coverage that is affordable.”

A federal reinsurance program helps compensate insurers for the high costs incurred by the sickest patients. That, in turn, allows health plans to keep their overall premiums lower and attract healthier customers into the insurance pool.

Lawmakers could also appropriate federal funds for the cost-sharing subsidies, which have a price tag of about $7 billion a year. Those payments, made directly to insurers, help reduce deductibles and other out-of-pocket costs for policyholders who earn up to 250 percent of the federal poverty level. This year, that’s up to about $29,000 for an individual or around $61,000 for a family of four. More than half of the people enrolled on exchanges nationwide qualify for this financial assistance.

Without it, many consumers would face annual deductibles of $2,000 or more when visiting the doctor or undergoing medical tests. That would make people far less likely to sign up with participating insurers.

Conservatives in Congress oppose the subsidies, calling them a bailout of the insurance industry and arguing that the Obama administration didn’t have the authority to pay them. Trump has repeatedly threatened to cut off those cost-sharing subsidies as well.

With their future up in the air, some states, including California and Pennsylvania, allowed insurers to submit two sets of proposed premiums. One filing reflects continued federal funding of those subsidies, and a separate one assumes they are eliminated and their cost is included in health plan premiums.

In Pennsylvania, premiums next year without the subsidies would increase by an average of 20 percent, compared with 9 percent if they remained intact.

Pennsylvania Insurance Commissioner Teresa Miller said the market in her state would be in good shape without the uncertainty over federal policy. “The only thing right now keeping everyone on edge is what’s going to happen in Washington, D.C.,” Miller said. “If things calm down in D.C. and if we don’t see further changes, then Pennsylvania’s market really is stabilizing.”

On Tuesday, Covered California said the two different rate filings its health plans submitted will be released Aug. 1. The exchange may announce that same day what the final premiums are, or it could postpone the decision for several more weeks if Congress has begun to pursue fixes to the ACA.

“This decision is based on the ongoing federal uncertainty around the repeal and replacement attempts of the Affordable Care Act and the dramatic potential impacts such uncertainty has on the rates and on California consumers,” the exchange said in a statement.

A recent analysis commissioned by Covered California estimated that premiums for silver-tier plans would jump by 16.6 percent if the federal government stopped paying for the cost-sharing subsidies. That would be in addition to normal increases meant to cover rising medical costs. An exchange spokeswoman declined to comment further Tuesday, citing the ongoing developments in Washington.

In the Florida exchange market, health insurers have sought an average rate increase of nearly 18 percent. But Florida Blue, the state’s largest health insurer, said those rates would go even higher if the cost-sharing reduction payments disappeared.

Robert Laszewski, an industry consultant in Virginia and a frequent ACA critic, said the exchange markets aren’t imploding, despite what the Trump administration has often said. But their premiums will continue to rise unless more young and healthy people are persuaded to buy coverage, he said.

“I think most insurance companies will at least break even, or even make a profit, in 2018,” Laszewski said. “Coverage will be ‘stable,’ but it will stabilize at a horrific premium rate level.”

Eric Whitney, Abe Aboraya and Ben Allen contributed to this story.

Latinos Left Out Of Clinical Trials … And Possible Cures

Two decades ago, Luis Antonio Cabrera received devastating news: He likely had only three months to live.

The Puerto Rican truck driver, then 50, had attributed his growing leg pain to spending so many hours on the road. The real culprit was a malignant tumor in his left kidney that was pressing on nerves from his lower spine.

His initial treatment involved removing the organ, a complex surgery that, by itself, proved insufficient, as the cancerous cells had already spread to his lungs. Therefore, his primary care physician in Puerto Rico contacted doctors at the National Institutes of Health (NIH), in Bethesda, Md., and managed to enroll Cabrera in a medical study to test an innovative therapy: transplanting blood stem cells to destroy the cancer cells.

Today, at 70, Cabrera, a father of five and grandparent who moved to West Virginia with his wife to be closer to NIH, feels strong and healthy. “I come to do tests every six months — I’m like a patient at large,” he said.

This KHN story also ran in USA Today. It can be republished for free (details).

However, Cabrera is one of a relatively small number of Hispanics who participate in clinical trials. “Only less than 8 percent of enrollees are Hispanic, even though Hispanics comprise 17 percent of the population,” said Dr. Eliseo Pérez-Stable, director of NIH’s National Institute on Minority Health and Health Disparities.

That means not only do Hispanics have less access to experimental cutting-edge treatments but researchers have less data on how a drug works in that population. Studies have shown that different ethnic groups might respond differently to treatments. The lack of patients from minority groups is an endemic problem in clinical trials; minorities typically are represented at a very low rate.

“Studies should represent the demographics of the country,” said Dr. Jonca Bull, an assistant commissioner on minority health at the Food and Drug Administration. “We need to close that gap so we can better understand how a particular drug or therapy works in different communities.”

Two Pioneering Initiatives

One of the few studies focused 100 percent on the Hispanic community has been the The Hispanic Community Health Study of Latinos, led by the National Heart, Lung and Blood Institute. This study has been analyzing a group of more than 16,000 Hispanics of different backgrounds in five cities since 2006, helping researchers learn more about the incidence of conditions such as diabetes, cholesterol, smoking and depression within the community.

In addition, an NIH-led initiative of the 21st Century Cures Act, a law in force since December, is compiling a database of about 1 million potential volunteers for medical studies, with a goal of including thousands of Hispanics.

There are many reasons why Latinos do not enroll in these studies, Perez-Stable said: lack of information, disparities in access to health care and not being fluent in English are among main factors. Dr. Otis Brawley, chief medical officer with the American Cancer Society (ACS), said Latino families are open to participating in clinical trials, especially to help treat a sick son or daughter, but they need advice from a doctor to navigate the process.

Federal officials aim to augment these numbers. In March, the FDA launched a campaign to educate Hispanics about medical studies. “Primary care physicians have to be the champions. … In addition, the community health centers can help, because they are places of care that people trust,” said Bull.

As of July 5, there were 94,545 ongoing clinical trials in the United States, according to the NIH’s official website, clinicaltrials.gov. As in Cabrera’s case, the primary physician usually helps a patient find a medical study, although the advent of the internet in recent decades has meant a growing number of patients discover trials themselves online. To participate, the person must meet the researchers’ criteria for eligibility: age, gender or condition. Often, the center conducting the study covers related costs of drugs, treatments and tests.

For Brenda Aldana, receiving care at Holy Cross Hospital in Silver Spring, Md., made all the difference.

Luis Antonio Cabrera, 70, during his appointment at the NIH Clinical Center in Bethesda, Md., in June.
Two decades ago, he was told he likely had only three months to live, due to a kidney cancer. He
was enrolled in a clinical trial that saved his life. (Paula Andalo/KHN)

Aldana, 34, arrived in the United States from Zacatecoluca, El Salvador, nine years ago. During her first year in the U.S., she began to feel tired and her hair began to fall out. She initially thought those were symptoms of the stress of starting a new life in a new country, but while visiting her sister in Frederick, Md., Aldana fainted. It turned out she was suffering more than nerves: She had a pulmonary embolism. Within two weeks of tests, she was diagnosed with lupus, a debilitating chronic condition with a high incidence among Latinas.

Resources

Those interviewed agreed that Latinos should ask their doctors if a condition or illness experienced by themselves or a loved one could make them eligible for a medical study. “Do not be afraid,” said Luis Antonio Cabrera, a patient who felt lucky to participate in a clinical trial. “Even if you do not speak English, there are interpreters who will help.”

Among websites to search for information about clinical studies:

“At Holy Cross, the doctors told me that they were going to help me get into a medical program for a medication to treat arthritis [caused by her lupus],” said Aldana, who has three children, ages 17, 6 and 5.

Aldana travels from Olney, Md., to the NIH Clinical Center once a month to receive intravenous medication.

These days, “Hispanics receive less quality medical care, so it’s important for them to be more involved in clinical trials,” said Brawley, noting that enrolling in a clinical trial gives patients access to a high-quality physician they might not otherwise see.

“In a medical study, instead of having the opinion of a single doctor, you’ll get the opinion of a group of highly qualified doctors who can say, ‘This is good for people like you,'” Brawley said. The American Cancer Society has an information service to help patients find clinical trials that match their medical condition. This service is also available in Spanish.

John Vasquez, 21, of San Antonio, Texas, needed only internet access and a cellphone to find the medical study that could change his life. In September 2015, while on his way to his brother’s football game, he lost feeling in his leg, arm and right part of his face. “I thought I was having a stroke,” he said.

He had aplastic anemia, a potentially deadly rare blood disorder that was destroying his red and white cells, and platelets, which aid the body’s clotting mechanism.

In a Facebook group for people with severe blood conditions, he was advised to contact the NIH, which sent him a kit for blood tests. After analyzing his clinical history, they told him he was eligible to participate in a medical study, which opened the gates to an innovative transplant that could change the course of his disease. Temporarily living with a sister in Maryland, he is scheduled for a bone marrow transplant on Aug. 1. His donor: his 14-year-old brother.

Secretary Price: “The status quo is not acceptable or sustainable”

HHS Gov News - July 19, 2017

Health and Human Services Secretary Tom Price, M.D. issued the following statement regarding ongoing efforts to provide Americans with relief from Obamacare:

“Obamacare is flawed, failing, and harming the American people with higher costs and fewer healthcare choices. The Trump Administration is, and always will be, focused on putting patients, families, and doctors in charge of healthcare.

“The Department of Health and Human Services has already begun providing relief to Americans who are paying more and getting less as a result of Obamacare’s broken promises. We will continue to build upon this progress as Congress debates the best path forward to fix our broken healthcare system.

“The status quo is not acceptable or sustainable. We will work tirelessly to get Washington out of the way, bring down the cost of coverage, expand healthcare choices, and strengthen the safety net for future generations.”

Click here to visit hhs.gov/relief where you can learn more about HHS actions to lower premiums and protect patients. This site highlights the regulatory and administrative actions the Department is taking to relieve the burden of the current healthcare law and support a patient-centered healthcare system.

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