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Republican Health Proposal Would Redirect Money From Poor to Rich
Republicans in Congress have been saying for months that they are working on a plan to repeal and replace Obamacare in the Trump era. Now we have the outline of that plan, and it looks as if it would redirect federal support away from poorer Americans and toward people who are wealthier.
A white paper drafted by House leadership and the staff of the House and Senate committees that oversee health policy details a structure that could replace large sections of the Affordable Care Act. Crucially, the proposal largely contains provisions that could be passed through a special budget process that requires only 50 Senate votes, and fulfills President Trump’s promise that the repeal and replacement of the law would take place “simultaneously.”
The plan would make major changes in how health care is financed for Americans who don’t get coverage from work. It would greatly expand the number of Americans who could benefit from federal help in buying health insurance, but it would change who benefits most from that support.
Obamacare, as the A.C.A. is known, extended health coverage to 20 million Americans through two main mechanisms. It expanded Medicaid coverage to Americans below or just above the poverty line in states that participated, and it offered income-based tax credits for middle-income people to buy their own insurance. Obamacare was a redistributive law, transferring money from rich to poor.
The Republican plan would alter both of those programs, changing the winners and losers. It would substantially cut funding for states in providing free insurance to low-income adults through Medicaid. And it would change how tax credits are distributed by giving all Americans not covered through work a flat credit by age, regardless of income.
That means that the biggest financial benefits would go to older Americans, like, say, Secretary of State Rex Tillerson. If he didn’t have a job in the Trump cabinet and access to government coverage, a 64-year-old multimillionaire like him would get the same amount of financial assistance as someone his age, living in poverty, and he would get substantially more money than a poor, young person.
Trump tries to save Obamacare exchanges while undermining them
http://www.latimes.com/opinion/la-ol-trump-obamacare-exchanges-20170215-story.html
With the drive to “repeal and replace” Obamacare losing steam, the Trump administration quietly moved to shore up a key feature of the healthcare law this week: the state exchanges where people shop for non-group coverage. And to its credit, Trump’s Department of Health and Human Services zeroed in on some of the factors that have led a handful of major insurers to leave the exchanges.
But before you praise (or condemn) Trump for coming to Obamacare’s rescue, consider this: Another arm of the new administration has taken a step that could undo much of the work the department is trying to do, and leave the exchanges no better off — and possibly in worse shape — than they are today.
The real threat to the exchanges’ health remains the specter of Congress enacting a law that repeals all or part of Obamacare in two or three years. Planting such a legislative time bomb would have an immediate impact, sending the market for non-group insurance policies quickly into chaos, according to analysts from both sides of the political spectrum. As John Rother of the pro-Obamacare National Coalition on Health Care put it, “[N]o market stabilization effort can succeed if policymakers disrupt existing coverage arrangements rather than improving on them.”
A core problem for the exchanges, which serve people not covered by a large employer’s group health plan, is that the people shopping there are running up larger healthcare bills than insurers expected. That’s resulted in losses for many insurers, persuading some to withdraw from the market and others to jack up premiums sharply.
Some critics argue that these trends are signs of Obamacare’s impending doom; the law’s supporters say they’re just growing pains, and there’s still plenty of evidence that the exchanges are sustainable (albeit with some adjustments). California’s experience is a case in point — its exchange, Covered California, still offers shoppers two or more options in every region, and its premium increases have been modest compared to the rest of the country’s.
California provides model to replace the Affordable Care Act
http://www.sacbee.com/opinion/op-ed/soapbox/article132714019.html
The new administration and Congress are under intense pressure to craft a market-based alternative to the Affordable Care Act. It won’t be easy. To achieve the financial stability required to make the market work, reformers should heed some important lessons from California.
Health plans and risk-taking medical groups essentially made a “deal” with Congress to participate in the ACA. They agreed to cover applicants with pre-existing conditions without charging higher premiums in return for: an expanded individual market driven by a federal mandate that everyone buy insurance; premium and cost-sharing subsidies financed by insurers and the government; and three federal risk-mitigation programs to help stabilize the new marketplaces.
It didn’t work out. Many health plans were priced incorrectly because more sick people enrolled and fewer healthy people signed up than expected. To compound the problem, Congress held up billions of dollars in promised payments from the federal risk corridor program to partially offset losses.
Most health plans responded by raising premiums. This year, premiums on the federally run exchanges rose about 25 percent, raising the annual benchmark premium to $5,586 for single coverage. Even then, about two-thirds of insurers are losing money in the individual market, several in the hundreds of millions of dollars.
For a model of how government and health insurers can work together to sustainably expand coverage and ensure stable markets, Congress should examine what happened in California.
Covered California, the state-run marketplace, took several steps to ensure long-term health plan involvement. The result has been a robust, competitive exchange that covered 1.5 million people in 2016 across 12 insurers. Premium increases were half the national average.
Here are the California approaches that any federal replacement plan should encourage other states to adopt:
Has the ACA Been a Job Killer? 2016 Update
http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2017/rwjf435131
The Affordable Care Act (ACA) has had little to no adverse effects on employment through 2016.
The Issue
The ACA contains several provisions that could impact jobs, including: the employer mandate, the expansion of Medicaid benefits to low-income adults, and the provision of tax credit subsidies to individuals enrolling in the health insurance marketplaces.
Key Findings
- In 2016, actual and expected employment rates were both 71.8 percent, indicating no ACA-associated effect on overall employment, based on the Census Bureau’s monthly Current Population Survey from January 2000 through December 2016.
- Despite a downtrend in part-time work since 2013, part-time work did not fall as much as expected, with the 2016 part-time employment rate 6 percent higher than expected, based on pre-ACA patterns.
Based on an analysis of employment, number of hours worked per week among workers, and part-time employment, researchers find that the Affordable Care Act has had little to no adverse effects on employment through 2016, while increasing health insurance coverage for 20 million Americans.
THE SHAMEFUL REPUBLICAN ASSAULT ON MEDICAID
In terms of political theatre, Donald Trump’s press conference on Thursday was the event of the week, or maybe the year. Strictly in policy terms, though, it was less important than the media briefing that Paul Ryan, the House Speaker, and other House Republican leaders held, also on Thursday, about their plans to abolish Obamacare and replace it with some version of what we might call Trumpcare, or maybe Trump/Ryancare.
There are still huge questions about what this new system will look like, and when it might be enacted. In a new seventeen-page paper, “Obamacare Repeal and Replace,” the G.O.P. lawmakers outlined proposals that are familiar from a plan that Ryan put out last year. They included expanded health savings accounts, financial aid for the establishment of high-risk pools at the state level, and the replacement of income-based subsidies to purchase individual insurance with universal tax credits.
But the paper also contained some huge gaps. It didn’t say how large the new tax credits would be, or how they and other elements of the reform would be paid for. To pay for its provisions, the 2010 Affordable Care Act levied more than a trillion dollars in tax increases over a decade. The Republican replacement will, in all likelihood, cover millions fewer people than Obamacare, but it will still have to be paid for. Ryan and his colleagues were largely silent on where the tax burden would fall.
For all this deliberate obfuscation, though, House Republicans are now being very clear about one thing: whatever legislation emerges after the Senate and the White House have weighed in, it will almost certainly roll back the Obama Administration’s expansion of Medicaid, the federal health-insurance program for poverty-stricken and low-income households. Under the outline released on Thursday, the current Medicaid system would be replaced by block grants to the states, and the extra federal money that went to Medicaid as part of the A.C.A. would gradually be removed. In effect, the Medicaid expansion would be slowly suffocated.
Bringing Moneyball to Medicine
http://www.chcf.org/articles/2017/02/bringing-moneyball-medicine
For most of the last year I had the privilege of serving as director of the US Agency for Healthcare Research and Quality (AHRQ), the lead federal agency charged with improving the safety and quality of America’s health care system. AHRQ is not a payer or regulator. It develops the knowledge, tools, and data needed to improve the health care system and help Americans, health care professionals, and policymakers make informed health decisions.
Change is a reality of our political process. When the new administration took over last month, I reluctantly departed to return to my work as a primary care physician and a health services researcher at the University of California, San Francisco (UCSF). The completion of my work at AHRQ did nothing to dampen my excitement about AHRQ’s future and its readiness to support transformation to an improved health care system.
In meetings with staff at AHRQ, I described our challenge as bringing Moneyball to medicine. It was my way of pointing out how major league sports have integrated data analytics into their workflow to improve team performance. There is a parallel opportunity for us in health care.
Moneyball is a movie based on the true story of Billy Beane, the general manager of Major League Baseball’s Oakland A’s. The film tells the story of a ballplayer-turned-executive, played by Brad Pitt, who finds himself stuck with an underperforming team that makes roster choices based largely on the opinions of “expert” scouts. While these scouts know a lot more than the average person does about the star potential of young players, they also have a remarkable number of misfires, leading the team to spend money on players who don’t pan out.
Cartoon – The Comfort of Small Hands
Cartoon – Things sure have changed
