Our Constitutional Right To Health

This speech was given by Gary M. Votour at the Healthcare For All rally held by Our Revolution South Carolina on April 15, 2017

constitutional“We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness. — That to secure these rights, Governments are instituted among Men, deriving their just powers from the consent of the governed, — That whenever any Form of Government becomes destructive of these ends, it is the Right of the People to alter or to abolish it, and to institute new Government, laying its foundation on such principles and organizing its powers in such form, as to them shall seem most likely to effect their Safety and Happiness.”

This is the second paragraph of the Declaration of Independence. Written in 1776, the Declaration stated the fundamental truths that our country was founded upon. It included specific concepts that everyone has a right to have: life, liberty, and the pursuit of happiness.

Without a doubt, our founding fathers also felt that health was something everyone had a right to. Even if the actual word itself was absent, the inclusion of life as a human right clearly implies the need for health.

Thomas Jefferson even wrote about it in 1787: “health, without which there is no happiness.” The Constitution of our country specifies that we “promote the general welfare” of our citizens in its very first sentence.

Health care and health care insurance was not specifically mentioned for a good reason… Neither existed yet. 250 years ago, humans had not yet discovered germs, and illness and disease were treated by barbers using leeches and bloodletting. It would be another 100 years until antiseptic surgery and hospitals would begin the transition to health care we know today.

Yet these are the words that have helped shape the greatest nation on the planet Earth, and the United States of America has stood for these things since its founding. Despite epidemics of disease, wars both abroad and at home, terrorist attacks from within and without, economic depressions and recessions this country has held several fundamental beliefs. These include that all people are equal and that everyone has the right to live, to be free, to pursue happiness… and to be healthy.

Most importantly, we believe we all must work together for the common good and welfare of ourselves and future generations. Our government exists for the sole purpose of helping us realize these goals. We also believe that if our government works in ways contrary to the authority we have given it, we have the right to alter it.

These goals, including health, have evolved in step with our society’s growth. As our country grew, these words, written by our founding fathers, have been reinterpreted often. We have always focused on the conceptual meaning of the Declaration and the Constitution. A perfect example of this is the right to own firearms, which when written would have pertained to muskets. Now we recognize that as weapons evolved, so to have the rights of individuals to own them.

Unfortunately, the extreme partisanship of the last decade being exhibited amongst our elected leaders has led our government astray from many of these goals, in particular the right of everyone to have access to healthier lives.

Let’s start by looking at how we, as a country, compare to other countries around the globe. The Gross Domestic Product, or GDP, is the total amount of goods and services produced by a country withing a specific time period, usually a year. It is a way to measure how the money being spent by the people living in that country goes to different types of things.

As a large country with ample resources and production capability, the U.S. ranks first in GDP globally. The percentage of our GDP we spend on health care also tops the worldwide list. Looking at the % of GDP spent on health care for the top countries, we top the list at 17%.

In fact, if you look at the average amount the rest of the world spends on health care per person, the U.S. spends twice as much at nearly nine thousand dollars per person.

A FINAL how the US compares 01

With all of that money being spent, wouldn’t you think we’d have the best health care in the world? We don’t.

When compared to the other developed nations spending high percentages of their GDP on health care, we rank poorly.

A FINAL how the US compares 02Our infant mortality rate is nearly twice that of the leading country, France. Our obesity rate is more than four times greater than the first ranked, Switzerland. Our lives are shorter as well. In the U.S. the life expectancy at birth is less than 77 years, as compared to France and Canada at over 80 years.

When you combine these and other factors globally, we do even worse.

When compared globally the U.S. is consistently near the bottom of the list for chronic lung disease, drug-related deaths, general disability, heart disease, low birth weight, obesity and diabetes.

A FINAL how the US compares 03

How can this be happening in the country that spends more than any other nation on health care? The answer is simple… it’s not about how much we spend, but who we spend it on. These scores are all based on averages within each country. Averages take into account everyone, and not everyone in the U.S. has equal access to health care.

The high-ranking countries like England, Canada, France, and Germany all have health care systems which provide health insurance that provides access to healthcare for 100% of their population.

A decade ago, the U.S. percentage of people with health insurance was only 86%. Despite the major advances we have made in ensuring everyone in this country has access to healthcare, we fall short when it comes to our poor.

Now, thanks to the Affordable Care Act of 2010 (The ACA or more commonly called Obamacare) in 2016 the number of uninsured in this country dropped to a historic low of 9%.

A FINAL the successes of the ACA

The ACA included a mandate that required everyone to have health insurance and included generous subsidies for many who could not. The ACA was designed to include a complementary mandate that all 50 states would expand their Medicaid programs to include the poor.

Medicaid is a U.S. policy program that provides health care insurance to our nation’s poor, elderly and disabled. Administered by States and paid for by a mix of federal and state funds, it was established in 1965 as a part of the Social Security Act, which also created Medicare.

Medicare is a federal program of health insurance that covers the elderly and disabled, regardless of income. This is different than Medicaid, which provides a different level of health insurance to the elderly, disabled and poor.

Because of partisan political opposition to the ACA, 19 states have refused to expand their Medicaid programs, despite the fact that for the last several years the federal government is paying for 100% of the cost. This has prevented the ACA from being as effective as it could have been if they had all expanded.

Almost all of these states refusing to expand Medicaid are on the top ten list for percentage of uninsured nationwide. In descending order, the ten states that have the highest uninsured rates are Texas at 17%, Georgia, Oklahoma, Florida, Louisiana, South Carolina at 13%, Mississippi, North Carolina, Utah, and Alabama at 11%. Of these, only one (Louisiana) has expanded their Medicaid program to include their poor under the ACA.

A FINAL how the US compares 04

When it comes to health care, we rank poorly as a nation because we don’t let everyone who lives here have equal access to it. We are ignoring the fundamental rights our country was founded upon: life, liberty, happiness and health.

That right is being denied to millions of U.S. citizens based on the geography of where they live. Let’s take a quick look at one example of the geographical inequality in health care that has resulted from this ongoing political battle.

The twin cities of Fulton, Kentucky and South Fulton, Tennessee lie on the border between their states, neatly bisected by the state line which runs through it horizontally.

Around 1900, Fulton, KY was known as “The Banana Capital of the World”, because the rail lines moving bananas north from New Orleans all stopped there to get fresh ice for their cargo. South Fulton, TN, whose town motto is “Becoming Better Together”, co-hosts the “Twin City Banana Festival” each year with its sister city, and a 2,000-pound banana pudding is the star of the annual event.

Despite a colorful history, the economy of the area is depressed. The largest employer in the area is now the Walmart distribution center north of Fulton.

These two adjacent cities have nearly identical demographics. Both cities have about 2400 residents, and about 1 in 5 families live in poverty.

Kentucky expanded Medicaid under the ACA in 2014, and about 700 non-elderly adults in Fulton became eligible for Medicaid. Tennessee has not expanded Medicaid, and nothing changed for those living in South Fulton.

The people in these cities are not being treated equally. The people in both cities pay taxes. They both work hard to make a living and struggle with poverty. Yet on the Kentucky side of the state line the poor get access to primary care, diagnostics and treatments for often fatal illnesses and preventative care that can help keep them healthier and live longer, more productive lives.

A hundred feet away, on the southern side of that same line in Tennessee, the same person would get none of those benefits. They will live shorter lives, be more likely to forgo preventative care because they can’t afford it, and more likely to go bankrupt paying medical bills if they fall ill than their neighbors to the north.

A FINAL A City Divided

This is not the equality our forefathers intended. How did we get to this? To understand, We need to look back in history for a moment.

In 1963, the United States grieved as a nation, shocked by the assassination of President John F. Kennedy. Vice-President Lyndon B. Johnson became President, and the following year he was elected in a landslide vote against his Republican opponent, Arizona Senator Barry Goldwater. As president, President Johnson pursued a liberal agenda he called “The Great Society” that attempted to address many social issues: civil rights, voting rights, poverty, arts, education issues, and most importantly for us… health care insurance.

President Johnson’s first speech to Congress began the push to create a different federal approach to health care insurance. He opened that speech with the same quote by Thomas Jefferson that I started this out with, “Without health, there is no happiness. An attention to health, then, should take the place of every other object.”

In closing his address with the following words, he set the stage for the first of several significant federal legislative initiatives to address the need for health care and insurance in the United States.

“Whatever we aspire to do together, our success in those enterprises–and our enjoyment of the fruits that result–will rest finally upon the health of our people. We cannot and we will not overcome all the barriers–or surmount all the obstacles–in one effort, no matter how intensive. But in all the sectors I have mentioned we are already behind our capability and our potential. Further delay will only compound our problems and deny our people the health and happiness that could be theirs.”

Under President Johnson’s strong leadership, Congress began to push forward with the creation of Medicare, which created a national health insurance plan for everyone over the age of 65.

In 1965, they created two tiers of insurance. Medicare Part A, funded by employer and employee payroll taxes, provides hospital and some nursing home care for adults covered by the Social Security Act. Medicare Part B is a premium supported plan that is funded by general revenues and beneficiary co-payments, pays for physician visits and some services.

Congress worked with the opposition to gain their support. The plan left many service areas that insurers could still work within. Doctors would not be required to participate. Hospitals would receive direct payments for care.

The third tier of the plan was Medicaid, and it was defined as “welfare medicine” from the start. It was not “social insurance” like Medicare, and it connoted dependence on the goodwill of government to those in need. It paled in comparison to Medicare, but it was a beginning.

States were not required to offer Medicaid programs, but if they did they had to meet federal guidelines for some basic requirements. To satisfy state concerns about control, they were given great latitude over how these requirements would be met.

Eventually, the scope of services Medicaid provided would expand, as did the number of states deciding to join the program. By 1970, 48 states had committed to some form of acceptable Medicaid program.

medicare vs medicaid

Let’s skip ahead through 45 years of changes and additions, made by both parties that improved both Medicare and Medicaid. Medicaid was expanded to include pregnant women and children living in poverty. Medicare grew as enrollment increased as an entire generation began to live longer past retirement. Both programs became more expensive for the Federal and State governments that paid for them, using the taxes we pay. An entire branch of the Federal government was created to develop and administer both programs with efficiency. At the same time a for-profit industry grew to provide the same benefits to the rest of us, usually provided as a benefit by employers who competed to get the best employees by offering not just the highest pay but also the best insurance.

Then President Obama was elected and became president in 2008. Realizing there was a unique opportunity to make progress in the governmental role of improving the health of all Americans, he worked with Congress to create the Affordable Care Act, the ACA, also known as Obamacare.

This all fact. I know it is a bit boring, but in order to move forward, we need to understand where we’ve been, both as a nation and as individuals. I deliberately did not introduce myself yet, because I did not want my story to distract you from the far more important story of how health insurance, Medicare, and Medicaid came to be.

Now seems like a good point to remedy that shortcoming in my speech to you today.

I’m Gary Votour. I have lived here in Columbia, SC for the last six years. Although I am disabled, I volunteer my time as a personal health care advocate. As a Christian, I follow the teachings of my savior, Jesus Christ. I follow my calling to help my fellow men and women when they are dealing with complex medical issues by helping them prepare for life-threatening treatments. I assist them in getting second opinions, understanding informed consent, assigning health care proxies and preparing living wills.

It may seem to be an unusual calling to some of you, but I believe sometimes the Lord shapes our lives according to his plan for us and we are then called to follow His plan. He certainly has for me.

Over a decade ago, my first wife and I lived in Massachusetts. She was diagnosed with a rare form of bone cancer, and a high-risk surgery to arrest its development went horribly wrong.

Strokes during the surgeries left her almost completely paralyzed and in constant pain for the rest of her life. After 6 months in 3 different hospitals, we were fortunate enough to return to our rural home where she struggled to continue living in spite of what happened.

After 30 months of ICU level home care, she gave up and stopped eating and drinking. I held her hand as she took her last breath after nearly 30 years together.

Throughout the hospitalization and home care period, I never left her side. Her strength and determination inspired me to dedicate my life to helping others. After she died, I returned to school, obtained a Masters Degree in Health Care Administration and became the advocate for others I am today.

When her surgery went badly, her employer terminated her. For eighteen months, the Massachusetts Medicaid program, called MassHealth, reimbursed us for the COBRA payments needed to keep her private insurance. MassHealth also paid for virtually everything not covered by her HMO. This included visiting nurse visits several times a week, home care supplies, physical therapy, and most importantly funding for the staff we needed at home to help me care for her. A special program funded by MassHealth paid for 90 hours of staff weekly, that we could hire locally and train. Without MassHealth, her care at home would not have been possible.

After the 18 month COBRA period ended, her HMO would not insure her. Her “pre-existing” condition gave them the right to deny her coverage. Medicare became her primary insurer, and MassHealth continued to fund what they did not cover.

We were fortunate enough to be in the only state in the country that had adopted such a progressive Medicaid program. This was because our state legislation had passed what was known as Romneycare, named for our Republican governor Mitt Romney. That is the program, as I am sure you know, that the ACA was modeled after for the entire nation.

If we lived in South Carolina today, and this happened to us, the outcome for my wife would have been very different. Because this state has not expanded and strengthened their Medicaid program under the ACA, caring for my wife at home would have been nearly impossible. The best care we could have hoped for here would result in her being warehoused and left to die in a nursing home, with a standard of care far less than what we were able to provide for her at home.

Even that meager care for her likely shortened life would most certainly have meant foreclosure on our home and bankruptcy for me before she would have been eligible for any Medicaid assistance once her COBRA protected insurance ran out.

After the ACA was passed, I hoped that every state would expand their programs using the freely available funding provides by the ACA.

Unfortunately, a six-year political struggle between liberals and conservatives decided otherwise in 19 states, including the one I know call home.

The originally partisan ACA became a victim to political battles, and thousands of people, likely tens of thousands, have already died as a result in those states that did not expand Medicaid to cover their working poor.

Just a few weeks ago the Republican Party attempted to honor the current president’s campaign promise to repeal and replace the ACA with something they called the American Health Care Act (AHCA). I just call it NoCare, because that’s all it would have given anyone.

Put together in secret, literally written in the Congressional basement over a couple of weeks, the AHCA tried to tie together both the moderate and extremely conservative elements of the GOP in order to get the votes needed to move it forward without the support of a minority liberal congress.

NoCare included changes to the law that would allow insurers to charge extra for those who may have preexisting conditions. No one should lose their insurance when they become ill or are dying. The ACA made it mandatory that insurers offer affordable insurance to all, regardless of their medical condition.

Also, Medicaid is a vital program designed to protect all of us in times of trouble, whether it be financial or medical. We all know that if the presidential election was decided by popular vote, the 19 remaining states would likely now be expanding their programs to do more for the poor, not less.

Yet the GOP NoCare replacement would have instituted flat funded block grants for Medicaid that would have caused the eventual destruction of the program, as State’s would be forced to ration care to the needy.

They would have, in effect, been creating the mythical Obamacare “death panels” people theorized about years ago, but they would have been at the state level as they are forced to do less and less for the poor into the future.

When the initial draft of NoCare failed to garner enough support from the extremely conservative Freedom Caucus, they even proposed stripping out the essential health benefits required for all insurance by the ACA, even for insurance provided by employers. This would have left most of our country under the control of for-profit insurers, who would certainly have worked together to plunder those benefits away from everyone.

We must stay vigilant and pressure our elected representative to end the forward progress of the NoCare plan, no matter what form it comes back in.

We must force it to be tabled, not amended. When they renew their efforts to pass it again, and they will, we must demand that it be removed immediately from legislative consideration until both Democrats and Republicans can sit together and craft legislation that guarantees no one will be denied their right to insurance because of illness or income.

We must ensure that Medicaid programs in all 50 states are strengthened, not diminished. We must continue to create incentives for the remaining states to expand coverage, not reward them for allowing their citizens to die needlessly.

We have a unique opportunity to show everyone that America is indeed the most merciful nation on the planet. As President Kennedy said in 1961, “Today the eyes of all people are truly upon us—and our governments, in every branch, at every level, national, State, and local, must be as a city upon a hill—constructed and inhabited by men aware of their grave trust and their great responsibilities.”

Instead of embracing the slogan “Make America Great Again” let us agree that America is already a great country that can afford to do better for those who have less.

We can, indeed we must, do better.

A national health care plan is an option that is progressive and builds on our success as a country that believes in equality. Whether it be a Medicare for All shift away from private insurers OR a Public Option to let anyone who chooses to buy a Medicare policy OR an income based subsidized replacement for Medicaid… It should be up to us, the American people, to decide how we will interpret that constitutional mandate was written so long ago that has served us so well until now. Life. Liberty. Happiness. And now, health care. These must be our demands!

And if our elected government fails to listen, if they fail to do what we, the voters demand of them… we must then speak even louder at the voting booth.

Thank you!

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An Open Letter to the U.S. Congress

Dear Senators and Representatives of the United States Congress,

My name is Gary M. Votour. I have lived in Columbia, SC for the last six years. Although I am disabled, I volunteer my time as a personal health care advocate. As a Christian, I follow the teachings of my savior, Jesus Christ. I follow my calling and help my fellow men and women when they are dealing with complex medical issues by helping them prepare for life-threatening treatments. I assist them in getting second opinions, understanding informed consent, assigning health care proxies and preparing living wills.

That is not what I am writing to you about today. In 2006, my first wife and I lived in Massachusetts. She was diagnosed with a rare form of bone cancer, and a high-risk surgery to arrest its development went horribly wrong. Ischemic strokes during the surgeries left her almost completely paralyzed and in constant pain for the rest of her life. After 6 months in 3 different hospitals, we were fortunate enough to return to our rural home where she struggled to continue living in spite of what happened. After 30 months of ICU level home care, she gave up and stopped eating and drinking. She died in 2008.

Throughout the hospitalization and home care period, I never left her side. Her strength and determination inspired me to dedicate my life to helping others. After she died, I returned to school, obtained a Masters Degree in Health Care Administration and became the advocate for others I am today.

When her surgery went badly, her employer terminated her. For eighteen months, the Massachusetts Medicaid program, MassHealth, reimbursed us for the COBRA payments needed to keep her private insurance. MassHealth also paid for virtually everything not covered by her HMO. This included visiting nurse visits several times a week, home care supplies, physical therapy, and most importantly funding for the staff we needed at home to help me care for her. A special program funded by MassHealth paid for 90 hours of staff weekly, that we could hire locally and train. Without MassHealth, her care at home would not have been possible.

After the 18 month COBRA period ended, her HMO would not insure her. Her “pre-existing” condition gave them the right to deny her coverage. Medicare became her primary insurer, and MassHealth continued to fund what they did not cover. We were fortunate enough to be in the only state in the country that had adopted such a progressive Medicaid program. This was because our state legislation had passed what was known as Romneycare, named for our Republican governor Mitt Romney. That is the program, as I am sure you know, that the Affordable Care Act’s (ACA) Medicaid expansions were modeled after in 2009 for the entire nation.

If we lived in South Carolina today, and this happened to us, the outcome for my wife would have been very different. Because this state has not expanded and strengthened their Medicaid program under the ACA, caring for my wife at home would have been near impossible. The best care we could have hoped for here would result in her being warehoused and left to die in a nursing home, with a standard of care far less than what we were able to provide for her at home. Even that meager care for her likely shortened life would most certainly have meant foreclosure on our home and bankruptcy for me before she would have been eligible for any Medicaid assistance once her COBRA protected insurance ran out.

After the ACA was passed, I hoped that every state would expand their programs using the freely available funding provides by the ACA. Unfortunately, as you also know, a six-year political struggle between liberals and conservatives decided otherwise in 19 states, including the one I know call home. The originally partisan ACA became a victim to political battles, and thousands of people have already died as a result in those states that did not expand Medicaid to cover their working poor.

As an advocate for the ill, I can tell you there is no shortage of need here in South Carolina. As an advocate for those in need, I must urge you to reconsider giving any support to the American Health Care Act (AHCA).

The AHCA includes changes to the law that would allow insurers to charge extra for those who may have preexisting conditions. That alone should mandate your opposition, and I write to you today to remind you that what happened to my wife could happen to any of us at any time. No one should lose their insurance when they become ill or are dying. The ACA made it mandatory that insurers offer affordable insurance to all, regardless of their medical condition.

You must see that there, but for the grace of God, goes any of us.

Also, Medicaid is a vital program designed to protect all of us in times of trouble, whether it be financial or medical. We both know that if the presidential election was decided by popular vote, the 19 remaining states would likely now be expanding their programs to do more for the poor, not less. Block grants for Medicaid will cause the eventual destruction of the program, as State’s will be forced to ration care to the needy. You will, in effect, be creating the mythical Obamacare “death panels” people theorized about years ago, but they will be at the state level as they are forced to do less and less for the poor into the future.

I ask you from my heart to use all of your power as my elected representative to end the forward progress of the AHCA. Force it to be tabled, not amended. Require that it be removed immediately from legislative consideration until both Democrats and Republicans can sit together and craft legislation that guarantees no one will be denied their right to insurance because of illness or income.  Ensure that Medicaid programs in all 50 states are strengthened, not diminished. Create incentives for the remaining states to expand coverage, don’t reward them for allowing their citizens to die needlessly.

Our country is a great nation, a shining light on a hill to the rest of the world. We have a unique opportunity to show everyone that America is indeed the most merciful nation on the planet. As President Kennedy said in 1961, “Today the eyes of all people are truly upon us—and our governments, in every branch, at every level, national, State, and local, must be as a city upon a hill—constructed and inhabited by men aware of their grave trust and their great responsibilities.”  Instead of embracing the slogan “Make America Great Again” let us agree that America is already a great country that can afford to do better for those who have less.

In closing, I leave you with the biblical passage that guides my life in the hope that it will guide your thoughts on this issue.

When the Son of Man comes in his glory, and all the angels with him, he will sit on his glorious throne. All the nations will be gathered before him, and he will separate the people one from another as a shepherd separates the sheep from the goats. He will put the sheep on his right and the goats on his left. Then the King will say to those on his right, ‘Come, you who are blessed by my Father; take your inheritance, the kingdom prepared for you since the creation of the world. For I was hungry and you gave me something to eat, I was thirsty and you gave me something to drink, I was a stranger and you invited me in, I needed clothes and you clothed me, I was sick and you looked after me, I was in prison and you came to visit me.’

Then the righteous will answer him, ‘Lord, when did we see you hungry and feed you, or thirsty and give you something to drink? When did we see you a stranger and invite you in, or needing clothes and clothe you? When did we see you sick or in prison and go to visit you?’ The King will reply, ‘Truly I tell you, whatever you did for one of the least of these brothers and sisters of mine, you did for me.’” -Matthew 25, 31-40

I look forward to your reply.

Peace.

Gary M. Votour, MHCA
Columbia, SC 29223

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The Affordable Care Act: Why “Repeal and Replace” is Not the Answer!

gps-id-icon-94414The Republican party’s direction for health care has become the proverbial circus car with 20 clowns inside, none of them driving. President Trump is on the roof, shouting conflicting directions to no one.

The ACA is the GPS.

Donald Trump is now our country’s President. Despite the efforts of the Democrat party to gain control of the Senate, it remains in the hands of the Republican party, along with the House of Representatives. The reality is that for the third time since 1945, the conservative party has control of the Presidency, the Senate and the House (1). Since President Trump ran with an overwhelming number of campaign promises solely designed to gain voter support, we will likely find that a lot of what he promised will not happen.


The future of the Affordable Care Act (ACA) is now under attack.

From the start of the 8-year term of President Barack Obama in 2008, he was met with Republican opposition to almost everything he tried to accomplish (2). This has been particularly true for the ACA, which became law in 2010. The Republicans in the House of Representatives have voted over 60 times to repeal it, at a cost to taxpayers of $87 million (3). 19 states still refuse to expand Medicaid to include all of their working poor under the ACA, despite the ACA reimbursement of 100% for three years and the enhanced federal match of 90% to cover the costs. The ACA has met with great opposition, more than any other piece of health care reform in our country’s history. That political opposition has hindered its success more than anything else.

aca-iconOne of the most important things the ACA did was to reorganize the entire health insurance market for people who buy their own insurance. This included the establishment of online health care exchanges where people could shop for competitive prices for policies that fit their needs. Those same exchanges are where they
could find out if they were eligible for tax credits based on their income that has helped discount the cost of insurance. The ACA set new standards for health insurance to protect people from buying policies that were previously overpriced and provided little actual coverage of value.

The changes to the insurance industry brought about by the ACA were indeed disruptive. It left some people who were required to buy insurance upset and angry. Ineligible for subsidies because their incomes were too high, they feel they were forced to buy insurance with high deductibles to save money. They don’t feel the value of what they bought was worth it. (8)


Most people are pleased with the ACA

Most Americans are quite happy as they realize the value of the insurance they now have. The Commonwealth Fund, a Washington think tank, recently surveyed Americans on this issue. They have found that 77% of adults with marketplace plans purchased under the ACA and 88% of those newly enrolled in Medicaid were satisfied with their health insurance. When asked to rate their insurance, 66% of marketplace enrollees and 77% of new Medicaid enrollees said their coverage was good, very good, or excellent.

maThey also found that 7 out of 10 enrolled in a marketplace plan or newly enrolled in Medicaid said they had used their coverage to go to a doctor, hospital, or other healthcare provider or to fill a prescription. 6 out of 10 of them also said they would not have been able to access or afford this care prior to getting their new coverage. Among those who were previously insured, half said they would not have been able to access or afford this care before getting their new insurance. (9) The majority of self-insured Americans are happy with the ACA, and millions of people now have insurance they did not have a decade ago and are using it.

The number of uninsured is at an all times low, down to 8.6% from 9.2% last year, and from 15.7% before the ACA. This is the lowest uninsured rate in 45 years. Millions of lives have been extended and saved by newly found health insurance, particularly among our country’s poorest people in the 31 states that did expand Medicaid under the ACA. Households with incomes below $500,000 also benefited greatly from the ACA, their uninsured rate dropped as well to an all-time low of 7.4%. Health insurance premiums on average are actually 32% lower now than they would have been without the ACA if you account for annual historical increases and the higher benefit of the plans. (16)


The ACA is a success

The quality of care has improved, and the cost of health care is starting to stabilize as the expanded markets lower the rate of increase each year since the ACA was passed. People with pre-existing illnesses can get insurance now. Insurers can not drop you if you become sick. They can not cap your benefits annually or over your lifetime. Parents can keep their children on their insurance until they are 26. We have more rights when appealing insurance company denials. Businesses that offer health insurance to their employees get tax breaks. Subsidies help lower income families afford to buy their own insurance. (18)

The ACA also expanded Medicaid in 31 states that agreed to do so, bringing health insurance to over 10 million people, who are mostly the unemployed and working poor of our country. These are people who work in jobs that do not provide insurance and who do not make enough money to qualify for subsidies. They are also the children of poor parents, disabled people who weren’t eligible before the ACA, and people who have chronic health problems that limit their ability to work full time. Because of the ACA, they now have access to health care that provides them with a physician, diagnostic testing, and preventative care that will ensure they live longer, healthier and happier lives. (10)

All of these gains have come from the Affordable Care Act. Without the laws’ protection for those with pre-existing conditions and financial supports for those having trouble affording it, many Americans will find themselves without health insurance again. The Congressional Budget Office (CBO) has predicted the outright appeal of the law would increase the number of uninsured Americans by 22 million, and defunding the parts that make it work would likely have the same effect. (11)


Insurance Companies Will Become Broken

If Republicans are allowed to repeal the ACA, they would need to have an effective replacement to ensure the health insurance industry does not collapse financially. The ACA was a compromise that included insurers as partners, allowing them to stay profitable by increasing the risk they provide insurance for across a wider, healthier population. That’s how insurance works… the more people who have insurance, the cheaper it becomes for everyone.

downloadIf the individual mandate is repealed, millions of Americans will simply cancel their health insurance. Because they are healthy, they don’t think they should be forced to buy something they don’t need. What they do not understand is that the risk they take is that a single illness or accident can drive them into medical bankruptcy. They risk finding their care limited to emergency rooms and urgent care centers instead of the primary care physicians and the extended networks of specialists that insurance gives. Without preventative care, such as annual physicals and diagnostic screenings, they risk losing the benefits of early detection of often fatal illnesses, which decreases their chances of survival.

If healthy people stop buying health insurance, hospital costs will rise dramatically when some of them become ill or injured and they can not afford to pay their bills. Hospitals use cost-sharing practices to pass that cost on to insurers. Insurers will be forced to drastically raise premiums to cover those who still have insurance. As premiums go up, the number of enrollees will decrease, creating a feedback loop that will cause what is called a death spiral. The American Health Insurance Plans (AHIP), the health insurance industry’s largest trade group, has predicted that “That same dynamic would play out across different age groups, in different states, and in different low- and middle-income brackets. The ACA’s tools for balancing the risk pool would be ineffective, and, would resemble the ‘death spiral’ phenomenon accompanying the failed state reform efforts of the 1990s”. (12)


Medicaid will be block granted into oblivion

The Republican plan includes radical changes designed to force states to cut or limit enrollment in Medicaid. States that have not expanded Medicaid would no longer be eligible for ACA funding to expand. All states would have to choose between a block grant or a per capita cap that would severely limit federal reimbursement.

The latest version of the plan being drafted would phase out by 2020 the Medicaid expansion that has covered millions of people under the ACA. Instead, states would begin to receive a set dollar amount for each person covered by the program, a drastic change from the open-ended entitlement the program is now. (29)

bearish1600.jpgThe current plan is to replace the existing Medicaid program with grants to the states that let the money be spent with little if any, federal oversight. This is a long-term attempt to deprive the poor of the health care that Medicaid now provides. The grants amounts will likely be determined at a set rate of money per person living in poverty within each state.

A major problem with this is the lack of any provision to increase that rate as the cost of health care continues to increase in the future, effectively limiting state’s abilities to maintain their programs or increase the number of people covered in the event of a recession. State’s will be forced to do less for its poor, in fact, the Republican plan acknowledges it by stating that enrollment caps and waiting lists for new enrollees will be allowed. Medicaid will quickly become “dead on the vine”, and one of our country’s greatest safety nets for the poor will be torn to shreds.


The destruction of Medicare as we know it

The other federal program that provides health insurance is Medicare, which insures seniors over the age of 65 directly without state involvement. The ACA made significant improvements to Medicare, by eliminating a great deal of the existing fraud, waste, and abuse. This saving, estimated at $716 billion so far, has been reinvested back into Medicare to improve care for seniors. This included closing the Medicare Part D “donut hole”, which has saved Medicare recipients $11.5 billion since 2010 in prescription drug payments. Over the next 10 years, each Medicare beneficiary will save about $4,200 due to lower drug costs, free preventive services, and reductions in the growth of health spending (14). Either repealing or defunding the ACA will eliminate these savings to our nation’s elderly and those who are disabled.

Additionally, Republican Speaker of the House Paul Ryan has been pushing to phase out Medicare and replace it with private insurance for several years. Since the election, Ryan has stated “What people don’t realize is because of Obamacare, medicare is going broke, medicare is going to have price controls because of Obamacare, Medicaid is in fiscal straits. You have to deal with those issues if you are going to repeal and replace Obamacare. Medicare has serious problems because of Obamacare. Those are part of our plan.”

This is simply untrue. The ACA is not the problem with Medicare. In fact, the savings created by the ACA have extended the solvency of Medicare by at least ten years. Leftover from his failed run for Vice President with Mitt Romney four years ago, Ryan’s plan to privatize Medicare is not only unpopular with seniors it is also built on false assumptions. What do Republicans mean when they discuss plans to phase out Medicare?

According to Ryan’s website, “For younger workers, when they become eligible, Medicare will provide a premium-support payment and a list of guaranteed coverage options – including a traditional fee-for-service option – from which recipients can choose a plan that best suits their needs.” (15)  Allow me to translate that for you…. If you have Medicare now, you’ll keep it. If you aren’t old enough yet to be on Medicare, when you become 65 you’ll get a check that will allow you to buy health insurance from those same providers that are about to either drastically increase premiums or simply go out of business if they repeal or defund the ACA.


The GOP healthcare backpack is empty

bpdownload.jpgThe GOP plan is also short on the details that are necessary to develop an accurate estimate of its cost to taxpayers. The Congressional Budget Office (CBO) could determine the actual future cost of the Republican plan if they provided sufficient details about how it would be implemented, but they are deliberately not doing so. We have no idea whether or not what they propose will actually save any money, but we do know it will harm the poor. Speaker of the House Paul Ryan has stated, “Our proposal is like a health-care ‘backpack’ that provides every American access to financial support for an insurance plan chosen by the individual and can be taken with them job-to-job, home to start a small business or raise a family, and even into retirement years.” For anyone looking closely at their plan, the “backpack” appears to be empty, void of detail and substance. (13)

If you’ve followed this so far, by now you understand that the simplistic three-word promises of a campaign (“Repeal and Replace”) can not solve anything. The Democrat platform had a plan that would have repaired much of what was wrong with the ACA. Ranging from enhanced enticements for states that have not yet expanded Medicaid to tax credits to help Americans with high insurance deductibles, those options are gone now. All we can do now is protect the progress we have made in the last six years by defending the ACA.


President Trump speaks to Congress about the ACA

In his first Congressional address last week, President Trump made the following statements (19). I’ll explain how each and every one of them is patently false and deliberately misleading.

680918-200“Tonight I am also calling on this Congress to repeal and replace Obamacare with reforms that expand choice, increase access, lower costs, and at the same time provide better health care. Mandating every American to buy government-approved health insurance was never the right solution for our country. The way to make health insurance available to everyone is to lower the cost of health insurance, and that is what we are going to do. Obamacare premiums nationwide have increased by double and triple digits.”

maThe ACA includes a mandate that everyone should have health Insurance, but that mandate actually only affected a small percentage of Americans. In 2015, 49% of Americans get health care insurance through their employers, and 20% receive Medicare because they are either retired or disabled. This did not change much because of the ACA. 14% of Americans receive health insurance because they are income eligible for Medicaid, about 9% purchase their own insurance, and another 9% are uninsured. About half of those without insurance would be Medicaid eligible if their states expanded their programs to include the poor under the ACA. Lowering the cost of health insurance will not change those numbers. As I said before, the ACA has actually slowed the rate of health insurance premium increases by 32% if compared to what they would be without the ACA. What is meant by “lowering the cost of health insurance” is removing the minimum standards defined by the ACA and letting insurers sell inferior plans across state lines to employers and the self-insured that do not cover as much, have higher deductibles and impose limits on the care one can receive, both in terms of the actual care and the quantity of care.

680918-200“As an example, Arizona went up 116 percent last year alone. Gov. Matt Bevin of Kentucky just said Obamacare is failing in his state — and it is unsustainable and collapsing. One-third of counties have only one insurer, and they are losing them fast. They are losing them so fast, they are leaving, and many Americans have no choice at all. There is no choice left.”

Is this true? Yes and no. According to CNN, “The Department of Health and Human Services confirmed the Obamacare premium increases for 2017 in the final months of the Obama administration — an average of 25% in states served by the federal Obamacare exchange, healthcare.gov. Arizona was slated to see an average 116% premium increase, the highest of any state by far. These hikes are for the benchmark silver plan upon which subsidies are based.” (20) The premium increases cited by President Trump are before federal subsidies are accounted for, and for many middle and lower income families, the premium increase will be less than 2%. The ACA subsidies were designed to offset premium increases for those who could least afford them. (21)

As to the number of counties with “only one insurer”, although this is true it is deliberately misleading. The number of counties with just one health insurer selling on Healthcare.gov did rise from 182 counties in 2016 to 960 counties (out of a total of 3,142) in 2017. (22) Once again, remember that this affects only the 1 out of 10 Americans who purchase their own insurance plans. More importantly is the question of why insurers have dropped out of these state exchanges, and the answer to that has little to do with the ACA.

UnitedHealth announced in April that it would stop selling on the marketplaces after suffering more than $1 million in losses. Aetna followed in August, reducing the number of states where it sells from 15 to four. Although UnitedHealth’s decision to drop out seems based solely on profitability (24), Aetna’s decision has been found by a Federal judge to be a response to a federal lawsuit blocking its proposed $34-billion merger with Humana. Aetna threatened federal officials with the pullout before the lawsuit was filed, and followed through on its threat once it was filed. (23)

The ACA is having growing pains, but it certainly not imploding or failing. Despite all of the uncertainty being created by the rhetoric of the GOP, 12.2 million Americans signed up for coverage this year. Couple with Medicaid expansions in 31 states, these two arms of the ACA has brought health insurance to over twenty million people. (29)

680918-200“Remember when you were told that you could keep your doctor and keep your plan? We now know that all of those promises have been totally broken.”

Yes, before and during the roll-out of the ACA President Obama made this statement repeatedly. It was inaccurate but the reason why a very small number of people found their plans canceled by their insurers was because the insurers decided to cancel them. The ACA actually included provisions that allowed those plans to be grandfathered, basically exempting them from complying with the new law. That exemption also included a provision that grandfathered plans could not be altered. Once insurers decided to offer only plans that complied with the ACA standards, they canceled the plans.

Obama’s “promise” was intended to convey that those who already had insurance through their job or through Medicare would not be forced into the new health-care exchanges. At the same time, his statement did not convey the fact that those with skimpy coverage would likely be required to purchase upgraded plans that complied with the standards set by the ACA. (25)

Keep in mind that 3/4 of medical bankruptcies occurred with people who had health insurance plans that not only excluded people with preexisting conditions but also imposed caps on coverage, the very things that the ACA eliminated to protect patients from insurers. To put this in perspective, the best estimate of how many people were affected by this is around 2.6 million, about 10% of the 22 million people who buy insurance on the marketplace. That’s less than 1% of the 320 million people with insurance, and over half of them were likely eligible for federal subsidies because of the ACA. (26)

Let us look at the five guiding principles also mentioned by President Trump in his address.
680918-200“First, we should ensure that Americans with preexisting conditions have access to coverage, and that we have a stable transition for Americans currently enrolled in the health care exchanges.”

Access to coverage does not mean access to affordable coverage. Access to coverage does not mean a right to have coverage. Both as President and as a candidate for President, Donald Trump repeatedly pledged that his plan to replace Obamacare would involve “insurance for everybody.” What he did not say to Congress was that he wants to ensure that health plans can’t discriminate against Americans with preexisting conditions. Instead, he says he wants to make sure that those people have “access to coverage.”

2009-10-14-denied_iconIn fact the leading plans on Capitol Hill, which require insurers to offer coverage to everybody, also lets health plans charge higher prices to people with preexisting conditions who have a break in coverage. That is a lot of people: Before the ACA, the Commonwealth Fund in the mid-2000s estimated that about 36 percent of Americans had a gap of coverage at least one month long in an average year. Although the Republican replacement plan for the ACA may include some protections for those with preexisting conditions, it will be weaker than what exists now, under the ACA. (27)

680918-200“Secondly, we should help Americans purchase their own coverage through the use of tax credits and expanded health savings accounts. But it must be the plan they want, not the plan forced on them by our government.”

The ACA already includes tax credits (and subsidies) to help make coverage more affordable for low- and middle-income Americans. The tax credits are on a sliding scale, giving more financial help to the Americans who earn the least. Republicans are battling amongst themselves on this issue. Centrist congressional leaders favor continuing the tax credits, though some would favor basinimagesg them on age rather than income. Other more conservative republicans in Congress are opposed to any tax credits. They worry that this will create another level of entitlement programs, without doing anything to decrease insurance premiums. This is the currently the biggest battle going on within the Republican party. President Trump’s comment to Congress is a deliberate attempt to shift that battle, but it remains to be seen how responsive to it the conservatives will be. (28)

680918-200“Thirdly, we should give our state governors the resources and flexibility they need with Medicaid to make sure no one is left out.”

Medicaid now provides health insurance to 73.5 million Americans in all 50 states. Medicaid expansions in 31 states funded by the ACA have brought health insurance to 14.5 million people, 3 million of which were already eligible for Medicaid before the ACA but just did not know it. The President’s language is deliberately vague, as many Republican Governors and Senators are pushing to maintain the Medicaid expansions. If Medicaid is altered, the leading plan likely to gain majority support is the conversion to block grants I mentioned before.

Cd99c4b93321e61c40d15c4cf41e90806hanging how Medicaid functions and how money is brought to the state level by the federal government is an incredibly complex and politically risky issue. Currently, the feds reimburse states for a certain percentage of their state Medicaid expenses. Only those new enrollees (11 million people) are reimbursed at a higher rate (90% in 2020) under the ACA. The other 64 million people covered by Medicaid are reimbursed by the feds using a percentage that varies from state to state, depending on economic factors.

Looking at how that money is currently spent is a glimpse into how complicated it would be to simply convert the program to block grants that would “make sure no one is left out”. Breaking down Medicaid’s $530 billion annual budget shows us that 42% goes to managed care organizations (Health Maintenance Organizations and Prepaid Health Plans), 30% goes directly to fee for service acute medical care (hospitals and doctors), 21% goes to fee for service long term care (nursing homes). A small percentage goes to Medicare (3%) to pay for Medicare premiums for those enrolled in both programs, and Direct Hospital Subsidies (3.5%) are paid directly to hospitals which provide large amounts of charity care to those with no insurance. (30)

Converting this program to a simple per capita block grant system will be a complete disaster. States are currently required to contribute between 30% and 50% of the money their programs use, and under a block grant-style of federal funding, those requirements would certainly be weakened. Coupled with the lack of flexibility in block granting the funds into the future to match unexpected growth during times of economic recession or drastic increases in health care costs due to an unstable health insurance system, it is a recipe for disaster.

680918-200“Fourth, we should implement legal reforms that protect patients and doctors from unnecessary costs that drive up the price of insurance and work to bring down the artificially high price of drugs, and bring them down immediately.”

The first part of this point seems to be a reference to medical malpractice reform, which actually has not been a major part of the Republican effort to replace the ACA. The Congressional Budget Office does not even score medical malpractice reforms like capping payments to patients as meaningful in lowering health care premiums in any fashion.

d_1xThe second part, regarding the cost of prescription drugs, is interesting. Previous statements by President Trump have included “We’re the largest buyer of drugs in the world. And yet we don’t bid properly. We’re going to start bidding.” Unfortunately, the prescription drug coverage provided by Medicare Part D, which was passed under President Bush in 2003, does not allow Medicare to bid or negotiate drug prices with pharmaceutical companies. This was partly resolved by the ACA when a 55% discount was negotiated for Medicare Part D recipients with the pharmaceutical providers that includes most medications. Also, because of the ACA, the infamous “donut hole” where recipients are required to pay high prices for medications until huge annual deductibles are reached is being closed and will be gone by 2020. (31) In the meantime, the “Extra Help” program was implemented as part of the ACA to provide financial assistance for those Medicare recipients making less than $13,000 a year and provides up to $4,000 of help annually in purchasing medications. (32) Simply put, repealing the ACA will actually result in higher prices for drugs for Medicare recipients.

680918-200“And finally, the time has come to give Americans the freedom to purchase health insurance across state lines, which will create a truly competitive national marketplace that will bring cost way down and provide far better care. So important.”

Since the start of his campaign, President Trump has called for an end to the ACA restrictions that prevent health insurers from selling insurance across state lines. He has repeatedly stated that he wants to be able to allow insurers in one state to be able to sell insurance in other states, even if the plan they are offering does not meet the other states mandates and regulations. This does not really make any sense, since health insurance plans rely heavily on having a local network of providers, both hospitals, and doctors, in order to keep costs lower and profit high. There is zero evidence that this would bring down costs or actually increase consumer options. Most state level officials do not even like the idea, as it would limit their own ability to regulate the market within their own states. (28)


What President Trump did not say to Congress

He didn’t say anything about how this would be paid for. Repealing the ACA means repealing the funding mechanisms that were a part of it. More importantly, he did not even mention the most controversial and contested part of the ACA- the mandate that everyone should have health insurance. The currently proposed Republican plan disguises the mandate as a requirement maintain continuous coverage or face much higher costs for pre-existing conditions if they don’t. (28) President Trump’s choice of Tom Price to head the Department of Health and Human Services gives us an idea of what they have planned. As a Senator, Price has proposed to change the pre-existing conditions exemption in the ACA to a qualified restriction that allows insurers to deny or charge more for anyone who has had a break in insurance coverage in the previous 18 months. This means that losing your job can not only lose your employer provided insurance, but if you develop a “pre-existing” condition you will be once again at the mercy of insurers who will likely deny you insurance. It will change the right to insurance guaranteed by law under the ACA to a penalty imposed on people who become sick.

Before the ACA, 30% of all adults under the age of 65 were uninsured due to conditions like cancer, heart disease, diabetes, and obesity. Millions more had premiums that made their insurance unaffordable. Women were routinely charged more than men for the same health insurance. The ACA ended all of this, by requiring that everyone must have insurance. This spread out the cost of insuring those with illnesses or other reasons for higher costs across a larger, healthier population. This allows insurers to provide the insurance required to cover everyone and still stay profitable. We can not have guaranteed coverage for everyone regardless of pre-existing conditions without the mandate that everyone has insurance, one can not exist without the other. (33)


So now you hopefully see what I meant at the beginning…. The Republican party finally has the ability to repeal and replace the ACA, but they are hesitant. Now that it is within their grasp, all they really need is leadership. All they are getting is confusion and conflict. Their party leadership shouts turn right, the President shouts turn left, and all those satisfied voters are shouting go straight ahead.

It is up to us to tell them to turn on the GPS and follow the directions set by the ACA. We need to be united in telling them we, the people, think America is already great. Equal access to health care is where we begin, and we are almost already there.

We can do better. Together, we will.


How you can help protect the ACA

First of all, share this blog. Follow it so you can get updates.Talk about it with your friends and family.

Follow the links I’ve included below and learn more about the different parts of this issue.

Most importantly, schedule a few minutes this week to make a few phone calls to your state senators and representatives. Better yet, if they hold a Town Hall meeting go and ask them questions.

Tell them you will hold them accountable if the ACA is repealed or defunded. They are the ones who actually can make or break President Trump and Speaker Ryan’s plans to damage Medicare, Medicaid and the ACA.

Let your elected leaders know that you are promising to vote against them in 2018 if they do not stand with you.

They respond to this threat, in fact, it is the one thing that motivates them the most… our votes.

Send postcards to them as well. Buy a card that has your state name on it, or buy the ones I’ve created at CafePress (see below). Write them a short message, letting them know you will not vote for them and their party at the next election if they repeal or damage the Affordable Care Act.

And if you live in one of the 19 states that have not expanded Medicaid, call you Governor and elected state congresspeople and tell them to start caring for the working poor of your state… and fight to be able to expand Medicaid for the working poor in your state! Thousands of people across the country are literally dying from preventable diseases and illnesses every year that they use this issue for partisan purposes.

expansionmap.jpg


Important Information

Find out who your congresspeople are, along with their addresses and phone numbers.
https://www.usa.gov/elected-officials

To buy ready-made postcards with this message pre-printed.
http://www.cafepress.com/fierceadvocacy.2046100784

To find Town Hall meetings near you that you can attend.
https://townhallproject.com/

To find Protests that you can attend.
https://www.resistancecalendar.org/

To get even more involved in changing the future.
http://www.commoncause.org/

I am leaving comments on for this post. If you have questions, ask. I’ll answer.
If you prefer to do so privately my personal email is garyvotour@gmail.com.

Tell Congress…
Keep Your Hands of Our Healthcare!

Let them know you want them to
Preserve Medicare!
Expand Medicaid!
Repair the ACA!

References

(1) http://wiredpen.com/resources/political-commentary-and-analysis/a-visual-guide-balance-of-power-congress-presidency/
(2) http://www.pbs.org/wgbh/frontline/article/the-republicans-plan-for-the-new-president/
(3) https://www.healthinsurance.org/obamacare-repeal-votes/
(4) https://www.donaldjtrump.com/positions/healthcare-reform
(5) http://www.cnn.com/2016/11/13/politics/kellyanne-conway-trump-special-session-congress/
(6) https://www.washingtonpost.com/news/monkey-cage/wp/2016/11/14/this-is-why-senate-republicans-might-not-go-nuclear/
(7) http://www.foxbusiness.com/politics/2016/11/14/did-trump-just-endorse-obamacares-most-harmful-provision.html
(8) http://www.nytimes.com/2015/11/15/us/politics/many-say-high-deductibles-make-their-health-law-insurance-all-but-useless.html
(9) http://www.commonwealthfund.org/publications/issue-briefs/2016/may/aca-tracking-survey-access-to-care-and-satisfaction
(10) http://obamacarefacts.com/sign-ups/medicaid-enrollment-numbers/
(11) https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/costestimate/hr3762senatepassed.pdf
(12) https://www.healthinsurance.org/blog/2015/03/04/anatomy-of-a-true-health-insurance-death-spiral/
(13) https://fierceadvocacy.wordpress.com/2016/09/23/handwriting-on-the-wall/
(14) http://obamacarefacts.com/obamacare-medicare/
(15) http://talkingpointsmemo.com/edblog/ryan-plans-to-phase-out-medicare-in-2017
(16) http://www.motherjones.com/kevin-drum/2016/07/another-obamacare-success-its-cut-premiums-30-50
(17) http://www.motherjones.com/kevin-drum/2016/07/another-obamacare-success-its-cut-premiums-30-50
(18) http://obamacarefacts.com/obamacare-facts/
(19) http://www.vox.com/a/trump-speech-transcript-joint-session-of-congress-annotated
(20) http://www.cnn.com/2017/02/28/politics/donald-trump-joint-address-fact-check/
(21) http://www.ncsl.org/research/health/health-insurance-premiums.aspx#Exchange_premiums
(22) http://www.vox.com/science-and-health/2016/10/26/13407610/obamacare-counties-one-insurer
(23) http://www.latimes.com/business/hiltzik/la-fi-hiltzik-aetna-obamacare-20170123-story.html
(24) http://money.cnn.com/2016/04/19/investing/unitedhealthcare-obamacare-exchanges-aca/
(25) http://nymag.com/daily/intelligencer/2013/10/you-like-your-plan-you-can-keep-it-sort-of.html
(26) http://healthaffairs.org/blog/2014/03/03/how-many-nongroup-policies-were-canceled-estimates-from-december-2013/
(27) http://www.commonwealthfund.org/Publications/In-the-Literature/2012/Aug/Gaps-and-Transitions-in-Health-Insurance.aspx
(28) http://www.vox.com/policy-and-politics/2017/2/28/14771954/trump-congress-obamacare-plan
(29) http://www.pbs.org/newshour/rundown/ap-fact-check-trumps-first-address-congress/#.WLbadA-2JP4.facebook
(30) http://kff.org/medicaid/state-indicator/distribution-of-medicaid-spending-by-service/
(31) https://www.medicare.gov/about-us/affordable-care-act/affordable-care-act.html
(32) https://www.ssa.gov/medicare/prescriptionhelp/
(33) http://time.com/money/4644137/obamacare-repeal-continuous-coverage-preexisting-conditions/

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