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The Myth of a Cheap Obamacare Replacement
News on the Obamacare-replacement front was dominated this past weekend by Donald Trump and Sen. Rand Paul (R-Ky.), who both touted their Obamacare replacement plans.
To be absolutely precise, they touted the claim that they had Obamacare replacement plans. They didn’t go into any great detail about what would be in those plans. (That didn’t stop CNN from captioning its interview with Paul, “Rand Paul Releases Obamacare Replacement Details.”)
The few details, or guideposts, or guidelines that they did disclose only underscored how difficult it will be for Trump, Paul and the the Republicans on Capitol Hill to fashion a replacement that meets all their stated goals. For Trump, according to an interview with the Washington Post published Sunday, this includes “insurance for everybody” that will encompass “great health care … in a much simplified form. Much less expensive and much better.” He promised “lower numbers, much lower deductibles.”
Paul, speaking on CNN’s Sunday morning “State of the Union” program, said his plan would “insure the most amount of people, give access to the most amount of people, at the least amount of cost.” That sounds like a set of concrete goals, but actually they’re ambiguous. “Most people” compared to what? “Least cost” compared to what?
Before we get into the details, such as they are, we should recognize that if one takes as the goal of healthcare policy to provide universal coverage in which everyone is “beautifully covered,” as Trump promised, then a few limitations immediately appear. Health coverage is the product of three factors: How many people are covered; the benefits provided; and the cost of those benefits. Since the 1940s, U.S. politicians and policymakers have tried to find a balance among these factors. Every effort has been confounded by the immutable facts that treating the sick costs money and treating more people costs more money. One can save money by treating fewer people, or giving the same number of people less treatment. So any politician who says he can do more for less money is almost certainly blowing smoke.
How do the Trump and Paul “details” stack up?
Rampaging goats and $10 million mansions: your guide to the weird world of Obamacare rhetoric
Rampaging goats and $10 million mansions: your guide to the weird world of Obamacare rhetoric
The Obamacare repeal effort is just getting underway and already the political wordplay is dizzying. On the GOP side, the rhetoric has gone from “repeal and replace” to “insurance for everybody” to “repair and rebuild.” Meanwhile, Democrats continually warn that the Republicans are trying to “rip apart our health care system.”
To help you keep pace with the debate, we’ve assembled this handy glossary of buzzwords and talking points. Enjoy.
From the Republicans:
Repair and rebuild
This is the GOP’s attempt to describe its legislative strategy for Obamacare, and an evolution of the phrase “repeal and replace.” As Politico reported Thursday, it is the mantra of Oregon Representative Greg Walden, who is leading the offensive against Obamacare in the House. It is meant to soften the GOP’s tone and suggest the replacement effort will be carefully staged and surgical. It also opens the door to delay tactics if things don’t quickly shape up in the GOP’s favor.
From the Democrats:
‘Make America Sick Again’
A play on Donald Trump’s campaign slogan, this phrase emerged in early January as Democrats held rallies to generate support for Obamacare. Judging by the nation’s $3.2 trillion tab for health care costs in 2015, a number expected to jump as high as $3.6 trillion this year, it seems clear a lot of us are pretty sick already. But you get the point.
Balance enrollee risk to sustain individual marketplaces, report says
Stability and sustainability in health insurance marketplaces requires a more balanced risk profile for enrollees and rules that are communicated clearly and quickly to payers, according to a new report.
The analysis (PDF), published by the American Academy of Actuaries, examined the state of insurance markets under the Affordable Care Act and noted that, while the law’s implementation did slash uninsured rates, individual marketplace enrollment was lower than anticipated and many enrollees aren’t healthy. To be most effective, the report states that more healthy people need to enroll to help offset the costs of the most ill people.
Governors voice Medicaid concerns to GOP lawmakers
A group of governors met with congressional leaders on Thursday to express their mounting concerns about the consequences of an Affordable Care Act repeal—particularly for those who have benefited from Medicaid expansion.
The closed-door meeting included several Republican state leaders, who despite generally opposing the ACA have accepted federal funds to expand Medicaid eligibility and are wary of rolling back such coverage expansions.
Michigan Gov. Rick Snyder, for example, said after the meeting that the data show his state’s Healthy Michigan program “had a lot of success, both in terms of healthier behaviors and better outcomes helping people,” according to The Hill.
Ohio Gov. John Kasich, another Republican who attended the meeting, suggested that those who gained coverage under Medicaid expansion could instead be given either premium subsidies or tax credits to help them buy private health insurance, Reuters reports.
But Synder and Kasich have been among the more vocal governors in support of Medicaid expansion, with Kasich crediting the program for helping fund the fight against opioid abuse that is ravaging his state.
Hospitals in states that have chosen to expand Medicaid eligibility have seen reductions in their uncompensated care costs, leading some in the healthcare industry to worry about what will happen under an ACA repeal. In addition, 15.7 million more people now have Medicaid coverage than before the ACA’s major coverage provisions took effect.
Trump’s executive order on Obamacare
Some misconceptions are floating around about what the executive order does and doesn’t do. Let me try to clarify.
As I explained in a post last week, “[a]uthority to implement the ACA … is vested in the Secretaries of HHS, Treasury, and Labor—not the President. In the context of the ACA, an executive order won’t be anything more than a document containing a president’s instructions to his subordinates.”
That’s all this E.O. is. It’s a set of marching orders. It has no legal force. It changes nothing on its own.
And these marching orders are pretty vague. After pruning away the bureaucratese, the executive order tells federal agencies, especially HHS, to do everything they can:
- To eliminate any “fiscal burden on any State” or any “cost, fee, tax, penalty, or regulatory burden” on individuals and providers.
- To give the states more flexibility.
- To encourage the interstate sale of health insurance.
It remains to be seen how and when these orders will be carried out. But we can make some educated guesses (most of which we could’ve made even in the absence of the executive order).
Get Health Insurance Through Your Employer? ACA Repeal Will Affect You, Too
Much of the recent attention on the future of the Affordable Care Act (ACA) has focused on the fate of the 22.5 million people likely to lose insurance through a repeal of Medicaid expansion and the loss of protections and subsidies in the individual insurance market. Overlooked in the declarations of who stands to lose under plans to “repeal and replace” the ACA are those enrolled in employer-sponsored health plans — the primary source of coverage for people under 65.
Job-based plans offered to employees and their families cover 150 million people in the United States. If the ACA is repealed, they stand to lose critical consumer protections that many have come to expect of their employer plan.
It’s easy to understand the focus on the individuals who gained access to coverage thanks to the health reform law. ACA drafters targeted most of the law’s insurance reforms at the individual and small-group markets, where consumers and employers had the greatest difficulty finding affordable, adequate coverage prior to health reform. The ACA’s market reforms made coverage available to those individuals with pre-existing conditions who couldn’t obtain coverage in the pre-ACA world, and more affordable for those low- and moderate-income families who couldn’t afford coverage on their own.
Less noticed, but no less important, the ACA also brought critical new protections to people in large employer plans. Although most large employer plans were relatively comprehensive and affordable before the ACA, some plans offered only skimpy coverage or had other barriers to accessing care, leaving individuals—particularly those with costly, chronic health conditions—with big bills and uncovered medical care. For that reason, the ACA extended several meaningful protections to employees of large businesses.
