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Coffee CAHC policy round-up: December 20, 2017

Coffee CAHC is a twice-weekly newsletter where we round up and comment on the latest health coverage policy developments both nationally and here in Maine. We hope you find these updates helpful!

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Coffee CAHC

115th Congress, 1st session

128th Maine Legislature, adjourned


Wednesday, December 20, 2017


Hello, readers! Well, I’ve now seen Star Wars: The Last Jedi, and it was everything I hoped it would be and then some. How’d the rest of you like it?

I have to confess that I’m ever-so-slightly disappointed that nobody placed my “daaaaanger zooooone!” reference, which I was taking from the TV series Archer. I forgive you, readers! It’s probably a good thing that none of you spend quite as much time memorizing lines from TV shows and movies as I apparently do.

I want to let you all know that today will be our final Coffee CAHC of this year. Now that the [spoiler alert] tax reform package has passed (grrrr), [spoiler alert] Congress is punting action on CHIP and FQHCs to next year (double grrrrr), and given the holiday schedule over the next week and a half, I expect that there would be very little to report and nobody around to read it.

Coffee CAHC will return in 2018, of course, and I expect a breakneck ramp-up in news to report from the state level once the legislature reconvenes.

For now, however, I simply want to say what a pleasure it has been building this newsletter for you all this year. I can’t believe that Coffee CAHC is about to turn 1! Your feedback and insight have been so helpful, and so welcome.

From myself, and all of us here at CAHC, I want to wish all of you and your loved ones the warmest, happiest holiday season and a wonderful start to your new year.

Your humble author,



National level

Well…what can I say? We lost this one.

Considering our track record all year, I’d say we can still be pretty darn proud of how much we accomplished in preventing even more (and worse) damage from being done to America’s health care system.

As you’ve no doubt heard by now, the tax reform package, which included the repeal of the ACA’s individual mandate effective in 2019, has passed in both chambers of Congress by very narrow margins – particularly in the Senate, where it was as razor-thin as it’s physically possible for a razor to get.

From Maine’s delegation, Congresswoman Chellie Pingree and Senator Angus King voted against the bill; Congressman Bruce Poliquin and Senator Susan Collins voted in favor of it.

I do want to take a moment to discuss Senator Collins’ support. We are disappointed, to say the last, that she ultimately voted to repeal the individual mandate: an idea that, as recently as August, she thought was terrible enough to vote against.

Of course, as she is fond of pointing out recently, she only did so by exacting “ironclad” promises from GOP leadership to move the two bills that she feels (we think incorrectly) will mitigate the damage they are doing by repealing the mandate: the Alexander-Murray and Collins-Nelson bills.

Last night, when reporters asked her, just before the vote, to respond to pronouncements made by GOP leaders in the House saying that those two bills were “dead on arrival” in their chamber, she reacted quite forcefully.

Today, mere hours after the vote, she issued a public statement trying to explain why it’s ok that Senator McConnell has already announced delays on any votes on any of the bills that she wants to see passed. Neither Alexander-Murray, nor Collins-Nelson, will be taken up this year.

Neither, by the way, will CHIP or FQHC funding. GOP leadership is pushing everything off to January. After pushing it off from this week. After pushing it off from earlier in December. After pushing it off from, what, September?

But don’t worry: sure, kids are now actively losing health coverage while Congress can’t find the will to renew a ridiculously popular and vital program like CHIP, but Congress does have the time to start the drumbeat on setting Medicare and Social Security on fire. #lifegoals

I can’t sugarcoat this one, folks. Wish I had more holiday cheer for you today, but, this is where our country is at today.

Of course, what keeps me up at night – and I honestly mean that – is knowing that the ones who are really losing out right now are 13 million Americans who will see their coverage disappear over the next decade, the thousands of dollars of increases people will see in premiums, the millions of kids whose coverage is in peril because of the CHIP limbo, and the millions of Americans who rely on community health centers which are now on the brink of closure.


State level

The Health Care Task Force had its first meeting today. I went to sit there and listen in, but was surprised to find the room overflowing with people who were interested in keeping an eye on that committee and their findings. I briefly had a seat, but gave it up so that a member of the public who had come for the day could sit. I listened in from afar instead.

I don’t have a real takeaway for you yet. Today was basically a “setting cards on the table” meeting. I will say that, based on the composition of the committee, voices of “industry” players – hospitals and insurers – are very prominent, which certainly came across today.

One concept that was brought up over and over and over again is this idea that health care costs are out of control, at least in part, because of consumer behavior – that consumers “need to take more responsibility”, or “have more skin in the game”, or “have more cost transparency because that way they can comparison shop for services and competition will fix everything.”

I’m going to do a deep-dive on those topics in my next Coffee CAHC, because they are worth exploring in depth. But long story short, we disagree – almost completely. At least about the impact that consumers play in driving costs, and the role they can (or should) be expected to play in containing them.

We do think that there is a moral obligation to make sure that consumers have more transparency in health care costs. But the reality is that a very, very narrow slice of total spending in health care is on services that are both shoppable (that is, you can find equivalent services in your area in advance) and consumer-directed (that is, the consumers are the ones footing the bill and thus have the incentive to “comparison shop”) – about 7% overall. Saving as much money as we can in that 7% is important, obviously, but it is incorrect to think that it is either the reason that health care costs keep rising, or the best approach to keeping cost growth down.

It’s also absolutely vital to make sure that health care quality is part of the equation, because there’s research showing that when consumers are presented with only price data in health care services, they may actually pick the more expensive service on the assumption that higher cost=higher quality.

And, let’s be honest with ourselves: if you needed open heart surgery, and you were given a choice based only on price, would you pick the Cadillac plan or the bargain basement lowest bidder? If your kid needed a brain operation, and your doctor says “this surgeon is the best”, are you going to go “gee, doc, thanks, but I want to get some other bids first” and then go with the discount rate? Probably not.

It’s also the case that, when consumers are asked to shoulder more of the cost burden, they don’t make wiser health care choices – they just go to the doctor less, period (that same Slate link just above here gets into this a bit). They don’t become savvier consumers, they become reluctant consumers. There’s the (in)famous story from the Harvard researcher, a doctor himself, who switched himself and his family to a high deductible plan. Despite being a family of significant financial means, and a leading expert himself, when he had heart palpitations – even though he was well aware that he had a chronic cardiac condition – he skipped the ER. It worked out fine, but as both he and his cardiologist admit, he got lucky, not smart.

Like I said, I’ll be doing a deeper dive (probably dives, plural) on this topic in the future, but at least based on what we heard from the group today, we think it’s going to be absolutely vital to keep the consumer perspective and the consumer reality grounded in future conversations of that task force. We’ll be doing everything we can to make sure that that happens.



Would you like to know more?

Overachievers (you’re secretly my favorites, don’t tell) should take a look at all of the resources that the Healthcare Value Hub has made available. They’re really top-notch, and very accessible and easy-to-digest. Here’s a good place to start.


Until next time, friends, I remain,


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