The Economist - USA (2020-02-08)

22 United States The EconomistFebruary 8th 2020

2 the acahad to go in its entirety. In a re-

markable bit of up-is-downism, the presi-

dent claims to be keeping the popular bits

of Obamacare, such as the protections for

patients with pre-existing conditions, safe

from Democrats—at the same time as his

justice department is pushing to eliminate

those very protections.

This has put hhs in a bind—duty-

bound to implement a law that the presi-

dent desperately wishes to overturn. One

way it has circumvented the law’s spirit, if

not its letter, has been to make it possible

for organisations to offer health-insurance

plans exempt from aca rules that are cheap

but prone to break down when they are

most needed. These include faith-based

medical plans that offer “Christian health

care” with discretionary payouts. hhshas

done a few other things to undermine Oba-

macare without actually flouting it. “I

think there is a continued effort to—either

by regulation, incompetence or intention-

al effort—undermine outreach and enrol-

ment, which ultimately undermines the

market,” says Kathleen Sebelius, Barack

Obama’s first health secretary. The share of

Americans who are uninsured fell steadily

in Mr Obama’s second term. After 2016 that

improvement ceased (see chart).

Perhaps the most consequential official

at hhsnow is Seema Verma, who runs the

Centre for Medicare and Medicaid Services.

Though Mr Azar is her boss, they do not get

on. In December Mike Pence, the vice-pres-

ident, and Mick Mulvaney, the president’s

chief-of-staff, had to act as peacemakers

between them. Ms Verma has pushed

sweeping changes to Medicaid. The most

significant was to allow states to imple-

ment work requirements for the first time

in the history of the programme. Twenty

states, mostly Republican led, have since

announced plans to incorporate work re-

quirements with health care for the poor-

est Americans. The fullest implementation

to date, in Arkansas, resulted in 18,000 peo-

ple (or 25% of those affected) losing cover-

age for a few months before a judge sus-

pended the programme. Ms Verma has also

proposed giving states a fixed grant to

spend on Medicaid, which many wonks

fear may augur future spending cuts.

Unlike Mr Azar, her boss and rival, Ms

Verma has raised a few eyebrows and ethics

reviews. One was for spending $3m in tax-

payer funds on communications consul-

tants to boost her personal image. A second

was over a reimbursement claim she filed

for $47,000 for jewellery—including an

Ivanka Trump-brand pendant—and other

personal effects stolen out of a hired car

while she gave a speech. (She ended up re-

ceiving less than $3,000.) But Ms Verma,

who was previously a health-care consul-

tant in Indiana, is unlikely to go.

Most of the controversy over access to

contraception and abortion has been fo-

cused on states, many of which have been

passing laws that are almost outright bans

in an attempt to bait the Supreme Court

into taking a case and overturning Roe v

Wade. Meanwhile, edicts from hhsattract

less notice. In the name of expanding reli-

gious freedom, the administration final-

ised a regulation that would let employers

claim a conscientious objection to paying

for contraception—a requirement of the

aca. It has been held up in litigation since.

Because of the so-called Hyde Amend-

ment, the federal government does not pay

for abortions except for cases of incest,

rape or life-threatening complications to

the mother. But hhshas also issued a rule

banning any groups that take federal fund-

ing for family planning from referring pa-

tients to abortion providers.

All of these are traditional goals of past

Republican administrations. Mr Azar’s het-

erodox efforts to use that authority to re-

duce drugs prices have stalled, even though

there should be a bipartisan consensus

there. In July 2019 the administration aban-

doned a plan to end the rebates that manu-

facturers pay to middlemen in the drug dis-

tribution system, known as pharmacy

benefit managers, which critics claim in-

flate prices for consumers. Efforts to cap

drug prices according to an international

price index have been stuck in internal de-

liberations since October 2018. Plans to al-

low drugs to be imported from Canada into

two test states—Vermont and Florida—

look unlikely to materialise this year. New

transparency rules, requiring drugs com-

panies to include prices in advertisements

and hospitals to publish their closely

guarded price lists, are sensible but have

been stalled by lawsuits.

Much of the administration’s health-

care agenda has thus been delayed. These

cases will eventually be resolved, though.

Even if Republicans fail to win back Con-

gress, with another four years Mr Trump

could quietly reshape health care, without

the need for any legislation at all. 7

Elections have consequences

United States, health insurance, uninsured rates

By race/ethnicity*, %

Source:USCensusBureau *Civilian,non-institutionalised

40

30

20

10

0

2008 1816141210

Hispanic

Asian

Native

American

White

Black

N

ew hampshire is a contradictory

state. Its towns make good postcards,

with saltbox houses meandering outward

from a central green and a white clapboard

church. Yet few states have lost a larger

share of their population to opioids. Geo-

graphically, it resembles its twin, Vermont,

but whereas the Green Mountain State has

a genial, hippieish image, the Granite State

is the watchful neighbour sitting on his

porch, fingering his shotgun every time

your dog wanders too close to his property.

Its political culture is similarly unusu-

al. It has a libertarian spirit—eschewing

sales and income taxes, and printing li-

cence plates that read “Live Free or Die”. But

it also has America’s biggest state legisla-

ture. What unites the two is a time-hon-

oured commitment to participatory de-

mocracy. For 100 years it has held America’s

first presidential primary election (Iowans

caucus; New Hampshirites vote with bal-

lots). Although many grumble over its pri-

macy—some consider it too white (around

90%, compared with around 60% nation-

ally) and too small—New Hampshirites

take their politics seriously, and expect

face time with any future president.

In the week before the primary, candi-

dates planned to make more than 80 ap-

pearances around the state. The front-run-

nersweremakingupforlosttime.While

theywereinIowa,DevalPatrick,a former

governorofMassachusettscurrentlypoll-

DERRY

The oldest, leftiest candidate is

expected to win round two

New Hampshire’s turn

Waiting for Bernie

Waiting for a star to fall

1