Cartoon – If at first you don’t succeed
Monthly Archives: March 2017
If the AHCA can’t pass, what does @SpeakerRyan do next?
The House Republicans released the American Health Care Act (AHCA) on Monday. Aaron summarizes it here. Critics of the bill include all liberals, many conservatives, the major medical societies, and many health industry groups.
It will be challenging to pass the bill. On the one hand, Democrats will oppose it because it reduces taxes on people with high incomes while cutting Medicaid and health insurance subsidies. On the other hand, the conservative wing of the House Republicans may not support it because they view it as “Obamacare-lite“.
Nevertheless, the AHCA could pass Congress. Will House conservatives really vote against a bill that largely repeals the ACA? The House leadership is moving the AHCA forward as fast as possible, hoping they can pass it before opposition groups can mobilize. Senator McConnell can eliminate the filibuster rule so that the AHCA can be passed on a majority vote. He might then be able to hold his coalition together to get that majority.
But suppose conservatives refuse to support the AHCA and it is defeated in the House. What happens next?
Speaker Ryan will revise the bill to meet the conservatives’ demands and unite the Republican caucus. He’ll then pass the revised bill in the House. Here’s why.
First, although Ryan could conceivably pass a more liberal ACA replacement with Democratic votes, he won’t. Ryan believes what the conservatives believe. The current AHCA is his attempt to win just enough moderate Republican Senate votes to get the bill passed. The current AHCA was his move to the left, and he won’t make another one if it fails. Second, although Ryan’s in trouble if he can’t pass something, he’s finished as Speaker if he compromises with the Democrats on ACA repeal.
Ryan’s problem if he moves right is that a more conservative AHCA would probably lose moderate Senate Republican votes and be defeated in the Senate. However, that defeat would not cost Ryan his job and his credibility with the Republican base, and with them his prospects for enacting his legislative program. Moreover, the 2018 election has many Democratic seats at risk. If the Republicans take those seats and expand their Senate majority, the chances for a hard-right ACA repeal and replace bill get much better.
If I’m correct, the Democrats might think they are winning based on the critical reception of the AHCA, but they are actually in peril. They have to defeat the AHCA now and then win seats in 2018. The way to defeat the AHCA is to sustain and build the opposition to ACA repeal shown during the Congressional ‘town hall’ demonstrations this winter. They have to convince Republicans representing Blue districts and states that they are at risk if they vote for the AHCA.
Federalism and the End of American Healthcare Act
http://www.yalelawjournal.org/forum/federalism-and-the-end-of-obamacare
Republicans may talk the talk of devolving health care policy to the states, but that’s not what the American Health Care Act does. Instead, it starves health reform of the funding upon which it depends.
Most significantly, Republicans intend to phase out the Medicaid expansion and to impose a hard cap on federal contributions. If a recession forces a state to exceed its cap in a given year, any overruns will come out of its Medicaid payments the following year. With that kind of shortfall, the states will have to make savage Medicaid cuts to make ends meet.
Republicans also want to slash the subsidies that make insurance affordable in the private market. Under the ACA, no one making less than four times the poverty level has to devote more than 10 percent of her income toward private coverage; most pay much less. The American Health Care Act would erase that affordability guarantee and, instead, extend age-based subsidies that would be much too meager for most people to afford coverage.
If federal money is withdrawn, states will be stuck. Because of the countercyclical trap and ERISA, they won’t be able to enact and sustain coverage expansions on their own. The end result will not be the diversity that federalism celebrates. It will be a uniformly crappy system that leaves millions of the sick and poor without coverage.
It doesn’t have to be this way. A group of Republican senators led by Bill Cassidy (R-LA) and Susan Collins (R-ME) has floated an alternative, the Patient Freedom Act of 2017, that retains the ACA’s funding streams while giving the states more room to choose how to use that money. That’s a model that deserves serious attention from both Republicans and Democrats. It might enable partisans on both sides move past the rancorous debate over the ACA.
For now, however, the Republicans seem intent on dismantling coverage gains across the entire United States. Their proposals trade on the rhetoric of states’ rights, but they would have the perverse effect of inhibiting state power. That’s bad for federalism — and bad for the country.
Traditional Medicare is cheaper
http://www.academyhealth.org/blog/2017-03/traditional-medicare-cheaper
OK, you knew that already. But what are the implications for access to care?
t probably won’t come as a surprise to you that traditional Medicare (TM) pays lower health care prices than commercial market insurers. We’ve known this for quite some time. A significant issue, however, is whether lower TM rates lead (or could lead) to reduced access to care for Medicare beneficiaries.
Jacob Wallace and Zirui Song took up the issue in a Health Affairs paper published last year. They examined health care price and utilization of outpatient imaging and outpatient surgical procedures across the 65-year divide — when most people become eligible for Medicare. Their data included just over 200,000 individuals captured in Truven Health Analytics’ 2007–2013 Medicare and Commercial Claims and Encounters database with broad-network, commercial market insurance before age 65 and TM from age 65 onward.
As shown in the chart just below, unadjusted, per beneficiary, quarterly spending trends for outpatient imaging and procedures are about the same before and after Medicare eligibility, but there is a large discontinuity when Medicare eligibility begins. In the last quarter before age 65, spending for a privately insured patient is about $119. At age 65, on Medicare, that drops 25% to about $89. After adjusting for age, quarter, year, and individual fixed effects, the relative change upon Medicare eligibility is even larger: 32%.
Healthcare Triage – The American Health Care Act: A Republican Response to The Affordable Care Act
Healthcare Triage – The American Health Care Act: A Republican Response to The Affordable Care Act
After so many, many years, it’s finally here. The Republican bill for repeal and replace. Kudos to Mark and Stan for getting this up so fast.
Welcome to a very special episode of Healthcare Triage.
The AHCA’s mandate replacement doesn’t make sense to me
I’m having a really hard time with this. I’m going to try and walk through my dilemma in the hope that someone will be able to make me understand.
The Republicans hate the individual mandate. I get that. I don’t necessarily understand their rationale, but I accept it. They also, however, understand the need for some sort of carrot/stick to get healthy people to buy insurance so that we don’t get adverse selection and see the private insurance market enter a death spiral. So they need to replace it.
We have discussed this before. There are many ways to solve this adverse selection problem without a mandate. Open enrollment periods, penalties for not signing up, loss of protections, inducements for keeping coverage, etc. We have written about this again and again and again and again and again and again. So I’m not saying that you can’t replace the individual mandate.
Many wonks believe that too few healthy people are joining the exchanges. This is leaving the risk pool too expensive and leading to higher premiums. To fix that, we could increase the size of the mandate penalty (stick), increase the size of the subsidies to make insurance cheaper (carrot), or both (carrot and stick).
The AHCA plan, though, goes at this sideways. It eliminates the stick. It reduces the carrot. And it then puts in a new plan – the 30% insurance markup if people lose continuous coverage.
In theory, making people pay a lot more if they don’t buy insurance as soon as they need to will make healthy people join the market. If they know it will cost a lot more if they wait until they are sick, or if they know it will mean they won’t have community ratings if they don’t purchase plans early, they should buy in – reducing adverse selection.
But this plan doesn’t really do that. It’s a one-time, one year, 30% markup on insurance. That’s a tiny, tiny penalty in the scheme of things.
Cartoon – Will this make me feel happy
Cartoon – The Side Effects
Cartoon – Our Bankruptcy Insurance is good
Cartoon – I wouldn’t call us Morally Bankrupt
HENRY KOTULA 