【GLOs Academy🇺🇸：美國大選深度課程重溫】第二課：美國大選的疫情及醫保議題 (Patreon)

【老師極其認真準備，以下長長reference，真係詳細過大學課程。溫馨提示：Patreon VIP可免費上三課。】

Speaker：馮儁熙教授（美國喬治亞南方大學徐建萍公共衞生學院流行病學副教授）

背景：疫情、醫保都是今次選舉是很重要的內政議題。美國選民對拜登處理疫情的信心是上升，對特朗普政府的信心較低。

Part 1: 美國大選裡的疫情

主要論點：由於美國是一個聯邦制度的國家，防疫政策落在州政府身上，而各個州政府也各自施政，所以美國在處理疫情以及在公共衛生政策上沒有一個共識。聯邦政府只能做建議，不會介入州政府的決策。若在沒有疫苗或有效藥物控制疫情的前提下，加上地方政府沒有統一處理疫情的共識，不論是那個候選人當選總統，也難以控制疫情。

Part 2: 美國大選裡的醫保議題

主要論點：歐巴馬政府所提倡的可負擔健保法案(Affordable Care Act, ACA)為失業及自由工作者提供醫保，也能令更多從前因不同因素，而未能承擔保險費用的人士可以投保。雖說特朗普政府提倡要廢除（Repeal）及替代（Replace）ACA，但是，現時只做到廢除，卻未能成功提供另一個替代方案。

拜登的醫保方案：Public Option：任何美國市民也可以在政府所提供的醫保方案，選擇購買合適自己的保險。唯當地醫護界反對此方案，認為這方案會影響他們的薪酬。由於拜登的醫保方案失去醫護界的支持，即使拜登當選，他所提出的醫保方案也不必能夠實行。

The enclosed is the updated version of the lecture 2 US election course

PPT: https://drive.google.com/file/d/1AN5w6RKo3YK4zeUvW3IaoAzEargvEHDV/view?usp=sharing

美國大選下的疫情及醫保議題 課堂綜述及延伸閱讀

Isaac Chun-Hai Fung, PhD

Lecture delivered on October 16, 2020, 9pm EDT (October 17, 2020, 9am HKT)

on the invitation by Dr. Simon Shen

Synopsis

There are two parts in this lecture and between which there is an intermission with samples of  campaign ads run by Georgia political candidates running for the US Senate.

Part 1 provides an explanation to what appears to be a haphazard response to COVID-19 in the United  States (US). The key to understand this phenomenon is the federal polity of the US, coupled with a  polarized political climate in which a consensus to COVID-19 response cannot be reached.

Public health decision-making in the US is decentralized to over 2000 state, local and tribal  departments of public health. Four examples are given to illustrate that. Given the diversity in the  local circumstances and the opposing views of the decisionmakers, it is within our expectation that  the US domestic response to COVID-19 would appear disorganized and haphazard, regardless of  who is in the White House. The polarizing nature of the US political climate has its roots in the  urban-rural divide in the US, and the electoral system of single-member constituency (first-off-the  post) that gives politicians little incentive to reach a compromise across the political divide. Part 1  ends with a description of how the US will run its nationwide vaccine campaign and its complexity.  This is going to be a challenge whenever a safe and effective will become available.

Part 2 provides a description of the achievements of the Affordable Care Act (ACA, also known as  Obamacare), the gradual repeal of the ACA under President Trump’s term, the absence of a Trump’s  replacement plan, the potential impact of the proposed Biden’s Plan., and California v. Texas, the  forthcoming court case before the US Supreme Court that will decide the fate of the ACA.

The ACA eliminates insurance discrimination based on pre-existing conditions and gender, assists  people from 100% to 138% of poverty line in states that adopted Medicaid expansion, and provides  tax credits for buying insurance from Marketplace for individuals 100% to 400% of poverty line if  they are not qualified for affordable employer-based health insurance.

Under Trump’s administration, the ACA has been gradually repealed. The most notable was the  repeal of the individual mandate, which is the key to ensure a stable private health insurance  market that will not discriminate people based on pre-existing conditions and gender. Opinion polls  in the US suggest that even Republicans support the ACA provision of the ban on insurance  discrimination against people based on pre-existing conditions. However, the Trump administration  and the Republican party has so far failed to propose a viable replacement plan that can maintain a  stable private insurance market in which people with pre-existing conditions will not be  discriminated and that the premium will not skyrocket.

Building upon Obamacare, the Biden’s Plan proposes a “public option” (i.e., a government-run  insurance plan option alongside private insurance plans for people to choose from), bans “surprise  billing”, allows Medicare to negotiate lower drug price, increases tax credits (premium subsidies) to  low-income individuals for purchasing healthcare insurance and eliminates the “subsidy cliff”.  Nevertheless, the Biden’s Plan is very unlikely to become reality as this will require the Democrats to  control both chambers of Congress and the White House and that the Democrats can reach a  consensus between its two wings.

Finally, in Part 2, the forthcoming court case in the US Supreme Court, California v. Texas, is  described. This court case will determine if the ACA will stand in the absence of the individual  mandate. This further highlights the importance of the US Supreme Court in deciding the fate of the  healthcare reform introduced 10 years ago by President Obama.

During the intermission between the two parts of the lecture, participants watch YouTube videos that  are campaign advertisements of Georgia candidates running for the 2 US Senate seats.

In the November 2020 election, Senator David Perdue (Republican) is running for re-election. His  challenger is Jon Ossoff (Democrat). Senator Perdue is a businessman and is the senior US Senator  for Georgia. Jon Ossoff is an investigative journalist.

Meanwhile, the seat that was vacated by former Senator Johnny Isakson (Republican, US Senator,  2005-2019) and was replaced by Republican appointee Senator Kelly Loeffler is up for Special  election. As an appointee who replaced a retiring senator who did not complete his 6-year term,  Senator Loeffler must obtain her mandate from voters this November. In Georgia, there are no  primaries for both major parties in a special election. In total, 21 candidates, including Republicans,  Democrats, third party candidates and independent candidates, are running for the seat. If none of  the candidates wins 50% of the vote, the two candidates with the highest share of the votes will  stand for a run-off election in January 2021. Currently, there are 3 front-runners for this seat: the  incumbent Senator Kelly Loeffler (Republican), Congressman Doug Collins (Republican) and the Rev.  Raphael Warnock (Democrat). Senator Kelly Loeffler is a businesswoman. Doug Collins is a lawyer  and currently serves as the US representative for Georgia’s 9th congressional district. The Rev.  Raphael Warnock is the senior pastor of the Ebenezer Baptist Church in Atlanta, the very church that  the late Martin Luther King, Jr., served as the pastor decades ago.

References and Reading List

Introduction

Slide 5-6. Pew Research Center. Amid Campaign Turmoil, Biden Holds Wide Leads on Coronavirus,  Unifying the Country (Oct 9, 2020). URL: https://www.pewresearch.org/politics/2020/10/09/amid campaign-turmoil-biden-holds-wide-leads-on-coronavirus-unifying-the-country/

Part 1. US response to COVID-19

Slide 10-11. Maps for COVID-19 cumulative incidence and cumulative incidence rate by county in the  USA.Source: SharedGeo,org. URL: https://uscovid-19map.org/ (downloaded, October 13, 2020)

Federalism in Public Health

Slide 15. Gordon, Huberfeld, Jones (2020). “What Federalism Means for the US Response to  Coronavirus Disease 2019”. JAMA Health Forum. Published online May 8, 2020.  https://doi.org/10.1001/jamahealthforum.2020.0510

• This article by Gordon, Huberfeld and Jones is highly recommended as this articulates well  the main thesis of Part 1 of this lecture.

Example 1: The distinction between ‘reportable’ and ‘notifiable’ diseases in the US (Slide 16- 18)

National Notifiable Diseases Surveillance System (NNDSS). https://wwwn.cdc.gov/nndss/data collection.html

Example 2: State and local governments may not participate in a national public health  surveillance program (Slide 19-25)

National Public Radio. When Young People Get COVID-19 Infections Soon Rise Among Older Adults.  Sep 29, 2020. URL: https://www.npr.org/sections/health-shots/2020/09/29/916634414/when young-people-get-covid-19-infections-soon-rise-among-older-adults

Boehmer TK et al. Changing Age Distribution of the COVID-19 Pandemic – United States, May-August  2020. MMWR Morbid Mortal Wkly Report. 2020; 69(39):1404-1409. URL:

https://www.cdc.gov/mmwr/volumes/69/wr/mm6939e1.htm

NSSP Participation and Coverage. Map shown on Slide 23 is taken from:

https://www.cdc.gov/nssp/participation-coverage-map.html

Example 3. Facemask mandate State vs city (Slide 26-30)

Fung (2020). 美國口罩令官司背後的憲政問題. Taiwan Apple Daily. URL:

https://tw.appledaily.com/forum/20200808/JQC3KR4LISJBJTK6IS6IGNLRHI/

The quote from Georgia Code 38-3-28 is taken from:

https://law.justia.com/codes/georgia/2010/title-38/chapter-3/article-2/38-3-28/

Example 4: School districts may not comply with state public health agency’s request of  COVID-19 data (Slide 31-35)

Ty Tagami. Georgia withholds school COVID-19 counts from public. AJC. Sep 25, 2020. URL:  https://www.ajc.com/education/georgia-withholds-school-covid-19-counts-from public/MSVEFPYMIJAMDO4TRMVPR2SWUE/

So, why would there so much non-compliance and non-participation? Because there  were diverse opinions about COVID-19 issues, e.g., facemasks (Slide 36-43) National Geographic/Morning Consult October 2020 poll. URL:

https://www.nationalgeographic.com/history/2020/10/poll-increasing-bipartisan-majority-americans support-mask-wearing/

Pew Research Center. August 2020. URL: https://www.pewresearch.org/fact-tank/2020/08/27/more americans-say-they-are-regularly-wearing-masks-in-stores-and-other-businesses/ft_2020-08- 27_maskwearing_01a/

Given the growing urban-rural divide between and within states, it is difficult to return to  the consensus politics of the past, as the US society does not have a consensus on many  issues (Slide 44-51)

Sara Savot. The divide between us: Urban-rural political differences rooted in geography. Feb 18, 2020.  URL: https://source.wustl.edu/2020/02/the-divide-between-us-urban-rural-political-differences-rooted in-geography/

Gimpel, Lovin, Moy and Reeves (2020). The Urban-Rural Gulf in American Political Behavior. Political  Behavior. https://link.springer.com/article/10.1007/s11109-020-09601-w

Slide 51. Gordon, Huberfeld, Jones (2020). “What Federalism Means for the US Response to  Coronavirus Disease 2019”. JAMA Health Forum. Published online May 8, 2020.  https://doi.org/10.1001/jamahealthforum.2020.0510

Major challenge in COVID-19 response after the November election: Vaccine (Slide 52- 58)

These slides contain materials from Dr. Fung’s lecture notes on Epidemiology of Infectious Disease (EPID  7135, Georgia Southern University).

Intermission: Campaign Video Ad (Slides 59-70)

News: 11Alive. Poll shows tight races for Senate seats in Georgia. October 14, 2020. URL:  https://www.11alive.com/article/news/politics/elections/for-morning-rushpoll-shows-tight-races-for senate-seats-in-georgia/85-91e2704a-839c-4256-bd1e-e400f45ae50b

Campaign ads:

• David Perdue. Corona. URL: https://youtu.be/xriRztm0iHg

• AFP Action (Americans for Prosperity Action). David Perdue | Making Health Care a Priority |  AFP Action. URL: https://youtu.be/-b-1QHFTd5E

• Jon Ossoff. At Home — TV Ad | Jon Ossoff for Senate. URL: https://youtu.be/CXsduF1J0kA • Jon Ossoff. "Gift" | Jon Ossoff for Senate. URL: https://youtu.be/tnd4MGzsCP4 • Reverend Raphael Warnock. What Makes This Election So Special? We'll Explain - Warnock  For Georgia. URL: https://youtu.be/xunRbey_lHc

• Kelly Loeffler. Nurse. URL: https://youtu.be/QZyG6q1357M

• Kelly Loeffler. Keith. URL: https://youtu.be/2wg73KXYXAc

• Doug Collins. "Shotgun" | Doug Collins for Senate. URL: https://youtu.be/71TWG00uAyA • Doug Collins. "Away" | Doug Collins for Senate. URL: https://youtu.be/g0m4hdGfGLE • Reverend Raphael Warnock. Warnock For Georgia - Moral Health. URL:

https://youtu.be/Cv7q8isTdY4

Part 2. Health Insurance

What had Obamacare achieved from 2010 to 2020? (Slide 74-84)

Rapfogel, Gee, Calsyn (2020) 10 Ways the ACA Has Improved Health Care in the Past Decade. Center for  American Progress. 2020 Mar 23. URL:

https://www.americanprogress.org/issues/healthcare/news/2020/03/23/482012/10-ways-aca improved-health-care-past-decade/

Trump’s Record on Affordable Care Act (Slide 85-86)

Levitt (2020) Trump vs Biden on Health Care: JAMA Health Forum. Published online September 3, 2020.  https://doi.org/10.1001/jamahealthforum.2020.1110

Public Opinion on the Accordable Care Act (Slide 87-91)

Hamel et al. 5 Charts About Public Opinion on the Affordable Care Act and the Supreme Court. Kaiser  Family Foundation. Published Sep 22, 2020. URL: https://www.kff.org/health-reform/poll-finding/5- charts-about-public-opinion-on-the-affordable-care-act-and-the-supreme-court/hforum.2020.1110

Biden’s Plan (Slide 92-102)

Original source: Biden’s campaign website: https://joebiden.com/healthcare/#

Yglesias M. Joe Biden;s health care plan, explained. Jul 16, 2019. Vox:

https://www.vox.com/2019/7/16/20694598/joe-biden-health-care-plan-public-option

Cox et al. Affordability in the ACA Marketplace Under a Proposal Like Joe Biden’s Health Plan.  September 28, 2020 Kaiser Family Foundation. URL: https://www.kff.org/health-reform/issue brief/affordability-in-the-aca-marketplace-under-a-proposal-like-joe-bidens-health-plan/

California v. Texas (Slide 103-110)

Musumeci. Explaining California v. Texas: A Guide to the Case Challenging the ACA. Sep 1, 2020. Kaiser  Family Foundation. URL: https://www.kff.org/health-reform/issue-brief/explaining-california-v-texas-a guide-to-the-case-challenging-the-aca/