Saturday, October 29, 2016

Big Pharma Preps to Spend Hundreds of Millions to Keep Drug Prices High | Common Dreams | Breaking News & Views for the Progressive Community

Big Pharma Preps to Spend Hundreds of Millions to Keep Drug Prices High | Common Dreams | Breaking News & Views for the Progressive Community

The Best Way to Save Obamacare - The New York Times

The Best Way to Save Obamacare - The New York Times

Comment by Don McCanne

Jacob Hacker deeply believes in a better America for all of us. As a political scientist,
he understands the difficulties of moving the process in that direction.
During the health care reform process, he recognized the lack of
political feasibility of enacting a single payer Medicare for all
program, but, with good reason, he decided that a public option -
offering the option to purchase Medicare instead of private insurance -
was feasible. In fact, it almost happened. Since so many problems still
exist six years after enactment of the Affordable Care Act (ACA), we
should listen to Jacob Hacker to see what he has to recommend.

First, let’s go back and look at the process that led up to ACA. The
dysfunction in our system had become unbearable - runaway costs, too
many uninsured and underinsured, preventable financial hardship and
physical suffering continued - something had to be done. The policy and
political communities understood the superiority of single payer
Medicare for all, but the politics were polarized. It was decided that
the feasible approach would be for the Democrats, who were in control,
to lead by supporting the Republican proposal of building on the
existing system. Although the progressive community initially was
disappointed, they decided that the only feasible approach was to join
the (ACA) bandwagon, especially when it included the public option that
many thought would eventually transform into a single payer system once
the public realized how much better government insurance was compared to
private insurance. Although the process emasculated the public option,
one Senator was able to block it altogether.

Fast forward to today. After six years, the feasible approach has not turned
out so well. Yes, many more now are covered, but little realized how
much insurers could still innovate, for their own benefit, in a more
regulated environment. To make premiums affordable, plans had to be
offered with a lower actuarial value - accomplished by increasing the
deductibles and offering credits and subsidies for lower income
individuals (which left middle income individuals more exposed to
medical debt). But many did not realize the rapidity and intensity with
which the insurers would jack up the deductibles. And now the policy of
high deductibles is corrupting the part of the market they were trying
to protect - the employer-sponsored plans. Also they wanted to protect
the “gains” of managed care, which really is not much more than
negotiating lower rates for provider panels in exchange for granting
them exclusivity. Once again, most did not anticipate the rapid move to
ultra-narrow networks that serve the insurers so well while impairing
access for their enrollees. Higher deductibles and narrow networks can
hardly be described as successes of ACA since most people are worse off.

So now we are again facing the same political dilemma. Do we embark on a
process to establish single payer Medicare for all, or do we take the
politically feasible route of enacting a public option which would fix
our system by requiring private insurers to complete with a vastly
superior public plan, or so they would have us believe? Well, the
decision has already been made. The progressive community is already
totally on board with the public option. The tragedy is not so much that
on this path we will end up with a public plan that will be only one
more feeble player in the dysfunctional market of private plans, but
rather that we will, once again, have walked away from single payer,
perhaps for decades, because of this meme about lack of political

So let’s look more closely at what Jacob Hacker has to offer in his truly sincere effort to cure our health care system.

*  From the outset, I’ve argued that without a public option — a Medicare-like
plan that would be available to all Americans buying health insurance —
insurance competition would dwindle and premiums would skyrocket.

The insurance industry’s control of Congress would prevent a public option
that could out-compete the private plans. Our traditional Medicare
program is already being out-competed by the private Medicare Advantage
plans because Congress has continued to support policies that give the
private plans an unfair advantage while rejecting measures that would
provide the much-needed expansions in the currently deficient package of
Medicare benefits. That’s why Medicare must be improved before we
consider it as a program for all of us.

*  Critics of the public option are convinced it’s a one-way ticket to single
payer (the government alone provides coverage). History suggests the

Currently we are being inundated with threats from the conservatives that if
we enact a public option it will lead to the left’s dream of a single payer system.
Yet the progressives have jumped on board precisely because they believe a
public option will lead to their dream of a single payer system. Yet
Hacker now says that history suggests the opposite. He says that the
public option is not a threat to a system of competing private plans.
Will the progressives really be satisfied with perpetuation of the
current dysfunctional system as long as the few who buy their plans
through the exchanges will be able to choose a feeble public option?

*  We’re already heading toward single payer in sections of the nation — only
it’s a private plan doing the paying. Next year, five states will have
only one insurer in their exchanges.

Yes, so many plans have pulled out that there is only one private insurer
left in many of the exchanges. But it is sad to see Hacker characterize
these lonely private plans as single payer when the highly dysfunctional
multi-payer system remains in place. He understands the single payer
model better than most, yet his passion for the public option model
drives him to play rhetorical games that glibly dismiss the true meaning
of single payer (though he may actually be threatening the
conservatives with this bastardized form of “single payer”).

*  The diminishing number of choices doesn’t just hurt consumers; it also
makes it harder for regulators to use antitrust tools to push back
against this consolidation.

Politicians and the policy community are fixated on market competition as a means of
controlling costs, yet Nobel laureate Kenneth Arrow half a century ago
explained to us how markets do not work in health care. The United
States has relied more on markets than other nations and we have the
highest costs that has only brought us mediocrity. A publicly
administered single payer system is much more effective at controlling
costs throughout the system.

*  A public plan is attractive in part because it can offer a broader network of providers.

Can it? Since the public option is just another player in a market of
private plans, it would be funded by premiums rather than taxes. As the
provider panels are increased the premiums would have to be increased
since they can no longer offer exclusivity, making the public option
less competitive, not to mention that broader panels would be attractive
to patients with greater needs. Death spiral?

*  Medicare has pioneered innovations in reimbursement, and it has improved
hospital quality by imposing new penalties for readmissions. A public
option could build on these breakthroughs and extend them to Americans
under Medicare age.

Current Medicare innovations such as ACOs, MACRA, MIPS, and APMs have not proven to be
very effective and are causing grief amongst the health care
professionals. Besides, private insurers also adopt Medicare
innovations, but only those that have been proven to be effective.

*  The biggest advantage of the public plan, however, is its greater ability to restrain prices.

If the differential between public and private prices is too great,
providers will reject the public programs in favor of the private. Many
physicians will not accept Medicaid payments because of the low payment
rates, especially specialists. Having a ticket to a public option is not
very helpful if there is no one there to care for you.

*  Pressure from a coalition of left-leaning groups led by the Progressive Change
Campaign Committee (a group that fought for the public option in 2009)
has encouraged 33 Senate Democrats, including the party’s leadership, to
call for a public option. President Obama has started advocating for it
again, and Hillary Clinton has embraced it.

Point made on the contention that the progressives are jumping on board.

*  This year, Senate Republicans, providing another lesson, passed legislation
that repealed the Affordable Care Act through the budget process, which
isn’t subject to a filibuster. (President Obama vetoed it.) If that’s
possible under the budget rules, creating a public option should be,

If a public option can pass only by squeaking it through in the reconciliation process, that doesn’t say
much for expecting broad support in a divided Congress and a divided

*  If things keep going as they are, Americans are certain to demand greater regulation of private plans to make them operate more like public plans. Instead, we should make them
compete with a public option.

Uwe Reinhardt has frequently said that a system of competing private plans - like
they have in Switzerland - can work if they are very heavily regulated.
Yet an OECD/WHO report on the Swiss system revealed that they still have
many of the problems that we have in the United States. So keeping
private plans in the system is still a problem. Instead of making them
compete with a public option, we should get rid of them and establish
our own single public plan.

Feasible? Is it really better to just give up and perpetuate uninsurance,
underinsurance, high costs, high deductibles, narrow networks,
inequities, financial hardships, impaired access, and more physical
suffering and even deaths? What’s not feasible about trading all that in
for a system that works?

The Slowdown in Employer Insurance Cost Growth: Why Many Workers Still Feel the Pinch - The Commonwealth Fund

The Slowdown in Employer Insurance Cost Growth: Why Many Workers Still Feel the Pinch - The Commonwealth Fund

Comment by Don McCanne

With all the talk this week about double-digit percentage increases in premiums for plans
offered in the ACA exchanges, there is risk that this report my be lost
in the background, though, for most Americans, this report is of far
greater importance. For employer-sponsored health plans - where most
individuals receive their health coverage - the percentage of household
income used to pay premiums and deductibles has increased sharply in the
last decade - from 6.6% to 10.1%.

To quickly dismiss the concern about premium increases in the ACA exchanges,
although the average increase will be about 25%, of the 10.5 million
enrolled only about 1.5 million in the exchanges will see the full
increase since the others will be protected by premium subsidies. It may
also impact the 7 million who buy individual plans outside of the
exchanges. That 8.5 million combined is about 2.7% of the population,
though most will have the option to shop for lower premium plans.
Besides, these increases do not represent health care inflation but are
rather due to intrinsic defects with the business model of competing
private health plans. Healthier individuals are less inclined to enroll,
making the risk pools more expensive, but it is likely that the greater
factor was the insurers low-balling the initial premiums in an attempt
to gain greater market share (though they will never admit this).

In contrast, about 154 million people - 57% of the U.S. population under
65 - obtain their insurance through their work - a far larger group than
those who buy plans on the exchanges. But look at what is happening to
them. Their share of insurance costs are consuming an ever larger
percentage of their incomes. This financial burden on the typical
working family is great enough to prevent them from receiving some of
the essential health care services that they should have - impairing
access due to lack of affordability.

Note that this is not due to the Affordable Care Act. These individuals and
families do not buy their plans through the exchanges, and they receive
no public subsidies (except for regressive tax expenditures unfairly
benefiting primarily higher income individuals). Rather than blaming the
Affordable Care Act, we need to blame legislators and the policy
community who insisted that we keep this dysfunctional health care
financing system in place.

While rejecting single payer, some of our political leaders are suggesting that we fix
what we have - tweak the system until it works. One candidate for
president suggests enacting a refundable tax credit of up to $5000 to
help pay excessive out-of-pocket health costs, and that would help these
individuals. But the problem is that it only pours more tax funds into
our overpriced and administratively-burdened system without correcting
any of the defects that have made our financing system so dysfunctional.
And who pays those taxes? A bit of a shell game, I’d say.

We’ve had a lull in spending, but that was partly due to the recession. The
other important factor that has slowed spending is what this report is
all about. Regardless of ACA, health care costs are being shifted to
plan beneficiaries strictly to protect the markets for the insurers by
slowing the rate of premium increases. This has the deleterious effect
of slowing spending by reducing the affordability of care and thus
reducing access to the care that patients should have. Bad policy.

The solution is really simple. Fund a single universal risk pool with
equitable taxes that everyone can afford, and then use that risk pool to
pay for all necessary health care for everyone. Why didn’t those single
payer people think of that? Oh. They did.

California Today: The Drug Industry Has Spent $109 Million to Kill Prop 61. Here’s Why. - The New York Times

California Today: The Drug Industry Has Spent $109 Million to Kill Prop 61. Here’s Why. - The New York Times

Whose Fault Is It? Obamacare Rates Are Going Up... | Thom Hartmann

Whose Fault Is It? Obamacare Rates Are Going Up... | Thom Hartmann

"The most likely scenario to come out of this latest batch of Obamacare bad news is a few tweaks here and there -- but that's not going to do much in the long run.

We have two choices here:

One, we can either create a public option to inject some real competition into the market place, OR we can work towards single-payer, i.e. Medicare-for-all.

Complete repeal is not an option - not when Obamacare is already in place and so many people have benefited and continue to benefit from it.

We can - however - use it as baseline to move forward."

Wednesday, October 26, 2016

Just in case you missed it -- Here is a major cause of high premiums

A Balancing Act: Treating The Patient vs. The Healthcare System

A Balancing Act: Treating The Patient vs. The Healthcare System

"And physician compliance and paperwork burdens are being exacerbated by emerging reimbursement methods.  New value-based payment models, such as the aforementioned MACRA, require physicians to track countless “quality measures.”  Combined with EHRs, the overall effect serves to divert physician eye contact with patients – something both parties increasingly resent.


Unfortunately, as all physicians know too well, they often find that their ability to choose what is best for their patients is compromised or obstructed by bureaucratic requirements or third parties who are non-physicians and neither have the training nor the knowledge of the patient that the physician possesses. They also force physicians to be box checkers instead of maintaining important eye contact with their patients.

Speaking of all of these experiences plus new and expensive (to physicians) reporting mechanics and regulations which have the effect of turning patients into data machines, we were taken recently with what is now considered to be the favorite joke in Canada. Substitute health care regulators for NASA, and the joke unfortunately is on us.  It goes as follows:

When NASA first started sending up astronauts, they quickly discovered that ballpoint pens would not work in zero gravity.  To combat the problem, NASA scientists spent a decade and $12 billion to develop a pen that writes in zero gravity, upside down, underwater, on almost any surface including glass and at temperatures ranging from below freezing to 300 degrees Celsius.  The Russians used a pencil. "

Tuesday, October 25, 2016

Monday, October 24, 2016

Affordable Care Act: imploding and beyond repair | TheHill

Affordable Care Act: imploding and beyond repair | TheHill

"Until we recognize that the largest possible risk pool is required to implement universal coverage in the public interest, and that the private health insurance industry is on a death march, we cannot make necessary health care available to all Americans.

Can’t we get to real health care reform on a nonpartisan, win-win basis?"

What comes after fixing insurance costs? -

What comes after fixing insurance costs? -

Minnesota's health-insurance model is broken | MinnPost

Minnesota's health-insurance model is broken | MinnPost

Sunday, October 16, 2016

Friday, October 14, 2016

Attorney general: state’s health insurance market has an income inequality problem - The Boston Globe

Attorney general: state’s health insurance market has an income inequality problem - The Boston Globe

First reaction = Duh!  But, we need to remind ourselves that our U.S. poor stats on health care compared to other countries is because of our view of poverty.  It has happened with public education, with law enforcement, pollution AND with access to health care.  Many in our country, and too many in control of our country, have been brainwashed to believe poverty is caused by weakness in THOSE people.  The ones doing the brainwashing are in the 1%.

Monday, October 10, 2016

Sunday, October 9, 2016

Can fixed payments transform the health care industry?

Can fixed payments transform the health care industry?

This has the risk of "bundled payments" being the new ACO or MCO.  But, it does point out that total health care costs for individuals and the "system" involve much more than the insurance companies pay attention to.  Incentives to keep folks in nursing homes is just as bad as incentives to restrict access to care under and ACO.

Mixed results for Medicare experiment

Mixed results for Medicare experiment

ACOs are nothing more than the old, failed, Managed Care Organization model.

Thursday, October 6, 2016

Bill Clinton Is Right, For-Profit Healthcare Is the 'Craziest Thing in the World' | Common Dreams | Breaking News & Views for the Progressive Community

Bill Clinton Is Right, For-Profit Healthcare Is the 'Craziest Thing in the World' | Common Dreams | Breaking News & Views for the Progressive Community

And, another take on what Bill said:

Bill Clinton Has Lost the Plot

Is single-payer health care on America's horizon? | BenefitsPRO

Is single-payer health care on America's horizon? | BenefitsPRO

Is single-payer health care on America's horizon?

Several states — up to 20 by some estimates — have opted to explore single-payer or universal health coverage in the past few years. Illustration by Wayne Brezinka
Several states — up to 20 by some estimates — have opted to explore single-payer or universal health coverage in the past few years. Illustration by Wayne Brezinka
In recent years, experimentation with single-payer and universal health care systems has largely taken place in the nation's governmental laboratories.

Most of us call them states.

Some states — most notably Vermont — have investigated building a single-payer system for health care consumers within their borders. However, the hurdles were too great to overcome in the Green Mountain State and Gov. Peter Shumlin had to put a halt to single payer due to a very high price tag in 2014. Fast forward to the 2016 presidential election cycle, and the issue again cropped up in the campaign of Vermont's own Bernie Sanders, who made universal health care a central plank in his socialist-minded platform.

Sanders created a lot of exposure for the idea, and several states — up to 20 by some estimates — have opted to explore single-payer or universal health coverage in the past few years.

The single-payer health care debate is heating up in Colorado, and one group, Coloradans for Coloradans, is doing everything it...

As the Sanders campaign relented to the presidential bid of Hillary Clinton, the center of the debate this election year has turned to the Rocky Mountains, where residents of Colorado will see a universal health care system proposed on their ballot in November. (It may not come as a surprise that Sanders won the state's Democratic primary handily.)


Like a few other states, Colorado has a ballot initiative process to bring questions directly to voters. Proponents of a universal system gathered 156,000 signatures—more than enough for the initiative to appear on the ballot—in support of adding what's known locally as Amendment 69 to the ballot. If passed, the measure would add a 12-page amendment to the state's constitution and create ColoradoCare.

In essence, Amendment 69 would create one large insurance group for the state that would be governed by ColoradoCare's elected board of 21 trustees. Proponents call ColoradoCare a universal plan because some payers, such as Tricare, Medicare and Medicaid, would remain in place. In these instances, ColoradoCare would act as a supplemental policy.

According to ColoradoCare's website, the system would cover primary and specialty care; hospitalization; prescription drugs and medical equipment; mental health and substance use services, including behavioral health treatment; emergency and urgent care; preventive and wellness services; chronic disease management; rehabilitative and habilitative services and devices; pediatric care including oral, vision and hearing services; laboratory services; maternity and newborn care; and palliative and end-of-life care.
Under ColoradoCare, there would be no deductibles and designated primary and preventive care services would have no co-payments. ColoradoCare would replace the state's health insurance exchange.

To pay for the program, Colorado would collect a 10 percent payroll tax — 3.33 percent from the employee and 6.7 percent from the employer. Residents who are 65 years and older would see some of their retirement and Social Security income exempted from the tax, up to $46,000 for individuals and $75,000 for joint filers. While employers would still be able to offer their own health insurance plans to employees, the ColoradoCare tax would still be collected.

ColoradoCare would also have to apply for several waivers from federal programs — such as the ACA — and have the money redirected to the system. Owen Perkins, communications director for ColoradoCare, says that Colorado is the first state in the nation to apply for an ACA waiver.

“The ACA leaves roughly 6 percent of the population uncovered and roughly a fifth of the population underinsured,” says Perkins. “You wind up with a million people without realistic access to health care. It's people who are required to get health care under the ACA, but they’re making too much for Medicaid and not enough for adequate care. They’ve got deductibles that make their health insurance inaccessible.”

The debate

ColoradoCare proponents see health care as a fundamental right, like education and fire protection. They believe the system would reduce the overall amount Coloradans spend on health care, while improving quality and providing coverage for everyone. The system's backers estimate that 80 percent of Coloradans will pay less under ColoradoCare.

According to ColoradoCare's projections, the savings would come from reduced administrative costs, while increased purchasing power would give the system the ability to more aggressively negotiate prices with drug and medical equipment makers.

However, opponents of Amendment 69 say that the measure is short on details. They also point out that passage of the amendment would mean an alteration to the state constitution — a remedy too severe for the problem.

“The promise that a simple solution like combining all buyers into one block will result in more affordable care for all — unfortunately, it isn't that simple,” says Joni Reents, president of the Colorado State Association of Health Underwriters and owner of the Reents Insurance Agency in Broomfield, Colorado. “And ColoradoCare is not the solution, but rather an experiment that will be embedded in our constitution.”

Reents also isn't convinced that ColoradoCare's savings will materialize over time. “When there isn't enough money to keep up with the demand for health care, ColoradoCare will either have to ration care, increase taxes, reduce reimbursement, or some combination of the three,” Reents says. “Rationing of care in a single-payer model is accomplished by limiting access, which results in longer wait times.”

Perkins says that the quality of health care would actually improve because networks would be eliminated. Under ColoradoCare, patients would be able to choose their primary care physician, while doctors could send patients to other doctors without restrictions.
“Everybody on ColoradoCare gets the same access and the doctors get the full reimbursement,” Perkins says. “It also eliminates an incredible amount of bureaucracy for doctors because you do away with narrow networks of choice, so the doctor can send the patient to the provider they think is the best one and provide the best care.”

Perkins also points to ColoradoCare's independence as a main benefit of the system. After attempts to push health care reform through the Colorado state legislature failed, architects of universal health care not only went with the ballot initiative process, they also proposed a system that's largely free from government and private industry. However, the state would be responsible for collecting start-up taxes and the full tax if Amendment 69 were to pass.

“It's not in the hands of the legislature, Washington politicians, or the corporate insurance industry,” Perkins says. “This takes it out of government hands, D.C. politicians’ hands and away from the groups who are focused on profits and puts it into the hands of Coloradans. It removes that interference between them and their provider.”

Impact on benefits professionals

Health care is a large piece of the benefits industry, and benefits brokers and agents in Colorado, and around the country, are keeping a close eye on Amendment 69 this election season.

John Kirke, president of benefits and total rewards for IMA Inc., in Denver, says if Amendment 69 is passed, it would have a sizable impact on the benefits industry in Colorado. However, Kirke sees his fellow benefits professionals reacting to a potential passage of Amendment 69 much the same way as the industry reacted to the ACA.

“I would think that this business is so responsive to our clients that we would pivot,” Kirke says. “Our clients come to us for strategies; I think it would be a hit at first, but just like the ACA, we pivoted. We offered our clients services that they still needed. I think that if it passed, employers would add services above what Amendment 69 offers. Employers would still want advisors to help them distinguish themselves in the marketplace when they’re recruiting new employees. Our industry is creative; we would pivot to find new solutions.”

Kirke says his company has been working to educate people around the state about Amendment 69, mainly through a series of town-hall meetings. Those meetings, he says, are open to both IMA clients and non-clients. “What's disconcerting to us in our industry is the assumption in Amendment 69 that all providers will play ball with whatever the new rules are, which are undefined at the moment,” Kirke says. “In my opinion, access would be limited as providers understand that the reimbursements to them are going to materially change.”
Kirke also points out that Amendment 69 could have a more far-reaching impact on Colorado's economy than just the benefits industry. In recent years, the state has seen exploding economic and population growth. Kirke believes that Amendment 69's passage could give business owners pause as they consider Colorado when starting or re-locating their businesses.

“Colorado is riding a wave of growth and we’ve been successful there,” Kirke says “But there's no doubt in my mind that ColoradoCare would cause a business leader to question what else would Colorado be thinking from a tax standpoint. It's a highly competitive market from Texas to Arizona to New Mexico in terms of competing for business, and we have to keep our momentum going.”

A state of complexity

Other states are also looking into single-payer or universal health care models. California, New Jersey and New York are all in various steps of the process.

Earlier this year, Oregon hired the Rand Corporation to complete a study about a single-payer system.

Colorado's experience with Amendment 69 may well serve as an example for others working to institute a universal health care or single-payer system at the state level.

“How to reduce health care costs in this country while maintaining access to high-quality providers is an entirely different conversation,” Reents says. “If it were simple, we would have accomplished it by now.

People like to talk about these issues as if it's a simple game, but the financing of health care isn't like checkers — it's more like chess, and we can't provide solutions in 10-second soundbites.”

Know your options on the ballot. There is information out there.

Know your options on the ballot. There is information out there.

"What was really important to me was deciding about other independents,Democrats and Green Party candidates. I have a “close to my heart” list that includes things like single payer health care also known as universal health care or medicare for all.

We recently visited my in- laws in Canada, great couple. My sister in law has fought tooth and nail to become a truly dynamite woman. She remarried a few years ago to a wonderful man. He went for an annual physical a while back. It revealed a serious cardiac problem that required a quadruple by pass. In the United States this is a death sentence for some without really good insurance and deep, deep pockets or it means a lot of debt. For my brother in law it meant he got the surgery he needed and didn’t have to liquidate everything the family owned and still be in deep debt." 

Why You Should Vote Yes for Amendment 69, the ColoradoCare Health Plan | Westword

Why You Should Vote Yes for Amendment 69, the ColoradoCare Health Plan | Westword

Wednesday, October 5, 2016

Drinks, junkets and jobs: How the insurance industry courts state commissioners - The Washington Post

Drinks, junkets and jobs: How the insurance industry courts state commissioners - The Washington Post

From MN Health Watch:

MN Commerce Department and Health Insurance
The Washington Post article seems applicable to Minnesota and our State Commerce Department. With the latest increases in the state’s individual health insurance market it appears the Commerce Department just goes along with the health insurance industry. See the StarTrbune article link below. It’s time the Commerce Dept. stops catering to health insurance companies and starts working for the people of Minnesota. Our state government needs to step up to the plate and solve our healthcare financing crisis.
Help spread the word that is unacceptable to let the MN health insurance industry dictate how we finance our healthcare system!
Washington Post article

Tuesday, October 4, 2016

Ailing Obama Health Care Act May Have to Change to Survive - The New York Times

Ailing Obama Health Care Act May Have to Change to Survive - The New York Times

Comments from Robert Reich:

"Obamacare faces a major test in the fourth annual open enrollment season, which starts on Nov. 1, a week before Election Day. In many counties, consumers will see higher premiums and fewer insurers -- as Aetna, Humana and UnitedHealth have backed out of the exchanges.

Make no mistake: An overhaul of Obamacare is coming, probably within the year. What will it look like? Three possibilities:
1. Trump and many other Republicans want to repeal it altogether and substitute – what? I keep hearing about a "block grant to the states," which is Republican shorthand for "kill it."
2. Some Democrats want to resuscitate a “public option” (remember that?) which would allow people to buy into a version of Medicare. Insurance lobbyists already are mobilizing to kill the public option, as they did when it was first considered as part of Obamacare.
3. The only sensible direction is a single-payer system. A public option could be a step toward it, but the single-payer must be on the table as well. It has large and growing support. Bernie's campaign helped educate the public about its importance -- and inevitability."