Tag Archives: ACA Repeal

Drowning In A ‘High-Risk Insurance Pool’ — At $18,000 A Year

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http://khn.org/news/drowning-in-a-high-risk-insurance-pool-at-18000-a-year/

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Some Republicans looking to scrap the Affordable Care Act say monthly health insurance premiums need to be lower for the individuals who have to buy insurance on their own. One way to do that, GOP leaders say, would be to return to the use of what are called high-risk insurance pools, for people who have health problems.

But critics say even some of the most successful high-risk pools that operated before the advent of Obamacare were very expensive for patients enrolled in the plans, and for the people who subsidized them — which included state taxpayers and people with employer-based health insurance.

Craig Britton of Plymouth, Minn., once had a plan through Minnesota’s high-risk pool. It cost him $18,000 a year in premiums.

Britton was forced to buy the expensive coverage because of a pancreatitis diagnosis. He called the idea that high-risk pools are good for consumers “a lot of baloney.”

“That is catastrophic cost,” Britton said. “You have to have a good living just to pay for insurance.”

Vermont Tests The Waters On GOP Health Care Overhaul

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http://www.healthleadersmedia.com/health-plans/vermont-tests-waters-gop-health-care-overhaul?spMailingID=10548476&spUserID=MTY3ODg4NTg1MzQ4S0&spJobID=1120254532&spReportId=MTEyMDI1NDUzMgS2#

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A statewide experiment aims to test new payment systems, prevent unnecessary treatments, and constrain overall growth in the cost.

Tiny — and very blue — Vermont could be at the leading edge of the health reforms envisioned by the Trump administration and a Republican Congress.

The Green Mountain State, population around 626,000, got a broad waiver last October from the federal government to redesign how its health care is delivered and paid for. The statewide experiment aims to test new payment systems, prevent unnecessary treatments, constrain overall growth in the cost of services and drugs, and address public health problems such as opioid abuse.

The six-year initiative — an outgrowth of a failed attempt by Vermont a few years ago to adopt a single-payer plan for all residents — could eventually encompass almost all of its 16 hospitals, 1,933 doctors and 70 percent of its population, including workers insured through their jobs and people covered under Medicare and Medicaid.

The Obama administration approved the experiment, but it fits the Republican mold for one way the Affordable Care Act could be replaced or significantly modified. The Trump administration and lawmakers in Congress have signaled that they want to allow states more flexibility to test ways to do what Vermont is doing — possibly even in the short-term before Republicans come to an agreement about the future of the ACA.

The Financial Consequences of Terminating the ACA’s Cost-Sharing Reduction Payments

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http://www.commonwealthfund.org/publications/blog/2017/mar/terminating-aca-financial-consequences?omnicid=EALERT1173966&mid=henrykotula@yahoo.com

To make health care truly affordable, the Affordable Care Act (ACA) reduces both the cost of insurance premiums, and the out-of-pocket costs that lower-income enrollees pay for health care. People who purchase their own health plans through the marketplaces benefit not just from tax credits that lower the cost of their plans, they also benefit from reduced out-of-pocket costs (in the form of lower deductibles and copayments) if they earn 250 percent or less of the federal poverty level, or $29,700 for a single person. The cost reductions increase the closer people get to the poverty level, resulting in the lowest-income enrollees receiving what is essentially “platinum-plus” coverage for the same cost as a silver-level plan (see box). Over half of marketplace enrollees receive these cost-sharing reductions, and in some states the proportion is considerably higher.

Cost Exposure in Marketplace Plans

Insurance companies that sell plans inside or outside the marketplaces must offer them at four different levels of cost exposure, also known as actuarial values:

  • Bronze, covering an average 60% of medical costs
  • Silver, covering 70%
  • Gold, covering 80%
  • Platinum, covering 90%.

Insurers also are required to provide silver-level marketplace plans with reduced cost-sharing for people who have incomes between 100 percent and 250 percent of the federal poverty level. The lower one’s income, the higher the proportion of health care costs covered:

  • 100%–<150% of poverty: eligible for plans with 94% actuarial value
  • 150%–<200% of poverty: eligible for plans with 87% actuarial value
  • 200%–<250% of poverty: eligible for plans with 73% actuarial value.

Thus, as Congress considers whether to repeal, replace, or repair the ACA, one of the looming issues is whether to continue funding this critical component. The ACA authorizes the federal government to reimburse insurers for these reductions in patient cost-sharing. However, a Republican-led Congress has never appropriated the funds needed to make these cost-sharing reduction (CSR) payments to insurers.

In order to keep insurers from leaving the marketplaces, the federal government has used other, nonearmarked funding sources for the past three years to make these CSR payments. Some members of Congress, however, believe that it is unlawful to make these payments without an official appropriation, and so have sued to stop the payments. A federal district court initially ruled in their favor, but has stayed the ruling, pending a decision by the Court of Appeals. So far, the Trump Administration and current congressional leaders have not declared whether they favor continuing or discontinuing these payments, so both sides have asked the court to pause the court case while they determine what they want to do.

If the current administration wanted to discontinue CSR payments immediately, it could simply stop defending the prior administration’s position in the pending lawsuit, essentially admitting defeat and allowing the district court’s decision to take effect. But Congress would then need to decide whether to appropriate the necessary funds. Therefore, it is critical to understand what the consequences would be if CSR payments were discontinued.

To do so, we analyzed federal rate filings by the 217 health insurers selling coverage through the ACA’s marketplaces in 2017 who projected their expected CSR payments.1  For the current year, insurers set their rates with the expectation that they would receive $7.35 billion in CSR payments from the federal government, a figure similar to what the Congressional Budget Office has estimated for 2016.2  This expected payment amounts to $64.79 per member per month, which is 14 percent of insurers’ total premium amount. Insurers set their premiums for 2017 with the expectation that they would earn a 7 percent profit overall (weighted by enrollment) (Exhibit 1). Thus, if the CSR payments cease and insurers are not allowed to adjust their premiums, they project a loss of 7 percent overall.

If Obamacare Exits, Some May Need to Rethink Early Retirement

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Here’s another possible consequence of repealing the Affordable Care Act: It would be harder for many people to retire early.

Americans reaching 65 become eligible for Medicare. Before reaching that age, some can get retiree coverage from their former employers. But not very many companies, especially small ones, offer medical insurance to retirees. If early retirees are poor enough, they could turn to Medicaid. To retire early, everybody else would need to turn to the individual health insurance market. Without the subsidies and protections the A.C.A. put in place, health care coverage would be more difficult to obtain, cost consumers more where available, and provide fewer benefits than it does today.

That means that if the A.C.A. is repealed, retiring early would become less feasible for many Americans.

This consequence is called job lock — the need to maintain a job to get health insurance. One of the arguments in favor of the A.C.A. was that it would reduce or eliminate job lock. With repeal of the law on the agenda of Congress and President Trump, there is renewed concern about how health insurance could affect employment and retirement decisions.

 

 

Where is the Democratic ACA replacement bill?

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Where is the Democratic ACA replacement bill?

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David Leonhardt says that the Republicans are “unable to agree on a [health care] policy” and “don’t have the votes to pass [an ACA replacement] plan.” OK, but what I want to know is, what is the Democratic alternative?

On the face of things, this is a strange question, because the Democrats cannot pass a bill in this Congress. Nevertheless, the Democrats should think about what they want to see in a replacement. There is a chance that the Republicans will fail to pass a bill that replaces the ACA without harming lots of Americans, including Republican voters. Here’s why:

  • As Nicholas points out, the Republican’s draft bill that recently leaked showed that they are not close to coming up with a coherent plan. Their current draft could lead to higher costs for insurance, or loss of insurance, for many people currently covered under the ACA. This isn’t playing well.
  • The far-right House Freedom Caucus has announced that it will oppose any bill that does not fully repeal the ACA. If all 32 HFC members took this view, the remaining House Republicans would not hold a majority. The leader of the larger but less conservative House Republican Study Group has also said that he “couldn’t support the party’s existing Obamacare replacement strategy.”
  • There are only 52 Republicans in the Senate and a few of them are moderates on the ACA. So it’s not clear that a bill acceptable to the radical right in the House can pass the Senate.
  • Let’s put this gently: President Trump lacks well-formed views about health care policy. He may not be willing or even able to coordinate the Republican factions.

We don’t know what will happen if no bill is passed or if the ACA is repealed without a replacement. But the Women’s March, the flash protests in response to the Travel Ban, and the uptick in support for the ACA suggest that the Republicans will face well-mobilized opposition if they screw up. If so, the GOP could be looking at the 2018 election with a deeply unpopular president and chaos in the health care system for less affluent Americans. If there is a prospect of losing their majorities, the Congressional Republican leadership might be willing to work with Democrats to pass a bipartisan ACA replacement.

As I described here, there is a left argument that Democrats should refuse any compromise and let the Republicans reap the consequences of their policies. A centrist counter-argument is that a lasting change in health care institutions requires bipartisan legislation, and the best time to get a deal is when Republicans are desperate.

Do I think that it’s likely that the Republicans will be willing to negotiate with Democrats about an ACA replacement? No. The lesson of 2016, however, is that anything is possible. So if the opportunity to negotiate arrives, the Democrats will need to have thought through what compromises they would be willing to accept.

In speech to Congress, Trump backs GOP leaders’ healthcare tax credits idea

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http://www.fiercehealthcare.com/aca/speech-to-congress-trump-backs-gop-leaders-healthcare-tax-credits-idea?mkt_tok=eyJpIjoiWkRjeU1tTTFPVEUyTjJaaCIsInQiOiJBNGU4aWlDQkpcL3l6eURqQUMyR2w3aVFtNStxVzBraUpQcTVOamQ4SVNEVUNDeXFQQ1RDWG5qdmptMjI4VWpiVTdHUDltN0ZTMG5ObWlHOWl0cXRmVEpjQ0h2bFU1NXJKM2YzaHBrcnc2VlVJVkoyTHJrQjBndGI5b3BGWmdJV1oifQ%3D%3D&mrkid=959610&utm_medium=nl&utm_source=internal

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In his address to Congress Tuesday night, President Donald Trump called for an end to the Affordable Care Act while voicing support for a key tenet of GOP leaders’ replacement plan that has met resistance from some within the party.

“Obamacare is collapsing, and we must act decisively to protect all Americans,” Trump said. “Action is not a choice—it is a necessity.”

He outlined five principles that he said should guide Congress as it works to create a better healthcare system:

  • Ensure that Americans with preexisting conditions have access to coverage, and that there is a stable transition for those currently enrolled in plans available on the ACA exchanges
  • Help Americans purchase their own coverage, through the use of tax credits and expanded health savings accounts. In a dig at the ACA’s essential health benefits requirements, Trump added that “it must be the plan they want, not the plan forced on them by the government”
  • Give governors the resources and flexibility they need with Medicaid “to make sure no one is left out.”
  • Give consumers the freedom to purchase health insurance across state lines, “creating a truly competitive national marketplace that will bring cost way down and provide far better care”

Trump’s support of tax credits to help people afford coverage is in line with a recently leaked draft bill from the House, which would give consumers age-based tax credits to purchase individual market plans. That provision received pushback from two prominent conservative House members, who characterized the tax credits as a “new entitlement program.”

Beshear’s response cites Kentucky’s embrace of ACA

In the Democratic response to Trump’s speech Tuesday, former Kentucky Gov. Steve Beshear pushed back against the GOP’s plans to scrap the ACA, saying his state reaped the benefits of embracing the law despite its conservative leanings.

Under Beshear’s administration, Kentucky expanded Medicaid eligibility and set up its own state exchange, Kynect. Thanks to those efforts, Beshear said in his speech, half a million Kentucky residents gained coverage—people who are “not aliens from some distant planet,” but “our friends and neighbors.”

While he acknowledged the ACA does need “some repairs,” Beshear said Trump and his fellow Republicans “seem determined to rip affordable health insurance away from millions of Americans who most need it.”

In Beshear’s own state, his GOP successor Gov. Matt Bevin has moved to shut down Kynect and roll back Medicaid expansion. In that effort, he’s had help from Trump’s pick for to lead the Centers for Medicare & Medicaid Services, Seema Verma.

The leaked Republican replacement

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The leaked Republican replacement

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The text of a draft bill to repeal and replace Obamacare leaked on Friday. Because the draft hews to principles that Republicans have outlined before, its basic contours aren’t that surprising. As I explained to Greg Sargent at the Washington Post:

The emerging GOP replacement would repeal tax hikes on the very rich and, instead, impose a tax [on employer coverage] that would hit many more people, including lots of public employees like schoolteachers and police officers. At the same time, it would slash Medicaid for the poorest Americans, as well as subsidies that the near-poor rely on to buy private coverage.

Drilling down to details, I had some observations. Take these with a big grain of salt: the leaked draft is dated February 10, so we don’t know how closely it resembles what’s currently under discussion in the House.

Five takeaways from the leaked Republican bill to repeal Obamacare

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http://www.pbs.org/newshour/rundown/5-takeaways-leaked-republican-bill-repeal-obamacare/

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A formal draft of the House Republican plan to repeal and replace the Affordable Care Act leaked out on Friday.

The final version is likely to be different — how much different, it’s hard to say. The draft obtained by Politico is dated two weeks ago, and rumors have been swirling here that Republicans received an unfavorable analysis from the Congressional Budget Office, the official scorekeepers on the cost and coverage implications of legislation.

But this is nonetheless an important milestone — real legislative text, prepared with an eye toward the complex parliamentary procedures needed to pass ACA repeal with only Republican votes, and presumably with the endorsement of House leadership.

Much attention will be paid to the proposed tax credits offered for people to buy health insurance and the changes to the tax treatment of employer-based insurance. Here are five provisions with big implications for health and medicine.

 

Medicaid’s Role: What’s at Stake Under a Block Grant or Per Capita Cap?

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Medicaid’s Role: What’s at Stake Under a Block Grant or Per Capita Cap?

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A new video slideshow from the Kaiser Family Foundation explains how Medicaid works now and what is at stake as policymakers in Washington consider converting program financing to a block grant or per capita cap.

The 3-minute video describes how Medicaid is financed under current law, whom it covers and how spending is distributed across various groups of enrollees, including children, adults, seniors, and people with disabilities. It shows, for instance, that although seniors and people with disabilities comprise about a quarter of Medicaid enrollees, they account for nearly two-thirds of Medicaid spending because they have more complex health needs and therefore higher per person costs.

Proposals to convert Medicaid to a block grant or per capita cap financing could reduce federal Medicaid spending over time and be tied to increased flexibility for states in how they run their Medicaid programs. However, the video slideshow also explains how such proposals may shift costs to states, beneficiaries and providers, as well as limit states’ ability to respond to changes in medical costs and/or demand for Medicaid.

PD Editorial: 20 million reasons to retain and repair Obamacare

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http://www.pressdemocrat.com/opinion/6701027-181/pd-editorial-20-million-reasons

For six years, and over the course of five dozen high-profile, low-probability votes, Republicans in Congress vowed to do away with Obamacare.

Republicans denounced the Affordable Care Act as “a crime against democracy” and labeled it “the most dangerous piece of legislation ever passed.” Oklahoma Sen. Tom Coburn went so far as to warn seniors, “You’re gonna die sooner.”

The election of Donald Trump removed the specter of a presidential veto, yet the Affordable Care Act hasn’t been repealed.

Large and boisterous crowds supporting Obamacare at town hall meetings probably are making some lawmakers nervous about the fallout from killing a program that provides insurance for 20 million Americans. Here’s another possible explanation: Despite its shortcomings, Obamacare has delivered on its basic promise — expanding access to health care by reducing the cost of insurance, especially in states such as California that fully embraced the program.

California has reduced its uninsured rate to a record low of 7.1 percent, according to a report issued this month by the Centers for Disease Control and Prevention.

That’s a decline of 9.9 percentage points since the Affordable Care Act took full effect in 2013.

The CDC figures, based on data for the first three quarters of 2016, also showed a marked improvement on a national scale, with 8.8 percent of Americans lacking health insurance. In 2013, the uninsured rate was 14.4 percent.

Let those be benchmarks.

Trump and congressional Republicans still say they’re going to repeal and replace the Affordable Care Act. But any plan that results in fewer people having coverage isn’t a replacement. It’s retrenchment. And that isn’t acceptable.

Despite their harsh criticism of Obamacare, Republicans are far from agreeing on any replacement. They have promised to keep the most popular provisions of Obamacare, including protection for people with pre-existing conditions and coverage of dependents up to age 26. There also is GOP support for retaining requirements that insurers cover treatment of mental illness and substance abuse. Targeted for elimination are the financing mechanisms needed for the program to remain viable — individual and employer mandates and subsidies to help low- and middle-income families pay insurance premiums. A proposal to convert Medicaid to a block grant program almost certainly will result in some states raising the threshold for eligibility.

The numbers simply don’t add up.

Hospitals justifiably fear a return to the days of writing off millions of dollars from providing emergency care to uninsured patients, and insurers will have little choice but to drop out of the exchanges — 11 participate in California — if people can wait until they’re sick before buying coverage.

That’s the death spiral Republicans have been predicting since the Affordable Care Act passed in 2010. It could become a self-fulfilling prophesy if insurers conclude that the risk pool that undergirds the insurance market has been, or will soon be, undermined.

No big program is perfect. Republicans have pointed out Obamacare’s shortcomings for years while refusing to work with Democrats on improvements. If it collapses now, some Republicans will point fingers at Obama and claim the program was fatally flawed. But if millions of people who gained access to health insurance suddenly find themselves without coverage once again, many of them are going to blame the people who wrote the cancellation notice.