Tag Archives: ACA Repeal

With Coverage in Peril and Obama Gone, Health Law’s Critics Go Quiet

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For seven years, few issues have animated conservative voters as much as the repeal of the Affordable Care Act. But with President Barack Obama out of office, the debate over “Obamacare” is becoming less about “Obama” and more about “care” — greatly complicating the issue for Republican lawmakers.

Polling indicates that more Republicans want to make fixes to the law rather than do away with it. President Trump, who remains popular on the right, has mused about a replacement plan that is even more expansive than the original. The conservative news media are focused more on Mr. Trump’s near-daily skirmishes with Democrats and reporters, among others, than on policy issues like health care. And the congressional debate, as well as the paid advertisements on both sides, is centered on the substance of the law rather than its namesake, draining some of its toxicity on the right.

As liberals overwhelm congressional town hall-style meetings and deluge the Capitol phone system with pleas to protect the health law, there is no similar clamor for dismantling it, Mr. Obama’s signature legislative accomplishment. From deeply conservative districts in the South and the West to the more moderate parts of the Northeast, Republicans in Congress say there is significantly less intensity among opponents of the law than when Mr. Obama was in office.

“I hear more concerns than before about ‘You’re going to repeal it, and we’re all going to lose insurance’ because they don’t think we’re going to replace it,” said Representative Mike Simpson, a Republican who represents a conservative district in Idaho.

But it was not until now, with the Republicans taking control of the federal government, that the debate fully shifted from the theoretical to the tangible. It was easy for conservatives to rally against a law identified with a president they despised when he was capable of vetoing any repeal. Now that he is gone and the law’s benefits appear to be on the chopping block, the people who stand to lose the most are the most vocal.

“I’ve heard from constituents who have been harmed by the Affordable Care Act over the course of its being in existence,” said Representative Leonard Lance, Republican of New Jersey, whose affluent district Mr. Trump narrowly lost last year. “More recently, because of our discussions on repairing it, I’ve heard from those who do not wish to have the act amended. More recently, that is the preponderance of those who have contacted me.”

It is a longstanding rule of politics that rallying opposition to a proposal is usually easier than galvanizing support. And never is this more the case than when a widely distributed benefit is at risk of being taken away.

GOP anxiety rises as conservatives and moderates split on ACA repeal

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http://www.modernhealthcare.com/article/20170218/MAGAZINE/302189962

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Divisions sharpened last week between hard-right and more pragmatic Republicans over both policy and strategy for repealing and replacing the Affordable Care Act.

Those differences—along with the apparently slow progress in drafting actual legislation that could be scored by the Congressional Budget Office on cost and coverage impact—underscore the tough struggle Republicans face in dismantling Obamacare and establishing an alternative system.

One of their biggest disagreements is over the future of the ACA’s expansion of Medicaid coverage to more than 10 million low-income adults. Conservatives want to eliminate it while a number of GOP senators and governors want to keep that coverage.

Congressional Republicans are feeling growing pressure to show progress on healthcare. Many are going back to their districts this week and holding town hall events, where they may face constituents who are upset about the potential loss of their ACA coverage. In addition, insurers are signaling they may pull out of the individual market in 2018, as Humana announced it would do last week.

House Speaker Paul Ryan promised Thursday to introduce repeal-and-replace legislation when the House returns from recess on Feb. 27, though he’s presented no legislative language so far. He said he’s waiting for the CBO and the Joint Committee on Taxation to score his proposed bill on costs and coverage levels before it’s unveiled.

Ryan has promised the House will repeal most of the ACA via an expedited budget reconciliation bill passed on a party-line vote by early April. He’s indicated it will include some replacement features, such as expanded health savings accounts and age-based premium tax credits.

GOP leaders want to erase most of the ACA taxes that fund the law’s coverage expansions and replace them with a cap on the tax exclusion employees receive for employer-provided health benefits.

Two people familiar with Ryan’s proposal told the Associated Press that employees would pay taxes on the value of coverage above $12,000 for individuals and $30,000 for families. Republicans would not confirm those amounts. But House Ways and Means Committee Chairman Kevin Brady told reporters that the “vast majority of Americans” would be unaffected. That suggests it wouldn’t raise much revenue.

That proposal is likely to trigger strong opposition from business and labor groups and from many conservative congressional Republicans, who may see it as a new tax.

McConnell intends to replace ‘Obamacare’ without Democrats

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http://www.pbs.org/newshour/rundown/mcconnell-intends-replace-obamacare-without-democrats/

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Republicans will repeal and replace the health care law and overhaul the tax code without Democratic help or votes, Senate Majority Leader Mitch McConnell said Friday.

“It’s clear that in the early months it’s going to be a Republicans-only exercise,” the Kentucky senator said at a news conference before lawmakers left for a weeklong President’s Day recess. “We don’t expect any Democratic cooperation on the replacement of Obamacare, we don’t expect any Democratic cooperation on tax reform.”

McConnell has condemned Democrats for passing Obamacare in the first place, in 2010, without any Republican votes, claiming the partisan exercise set the law up to fail. “The mess to come was inevitable,” McConnell wrote in his memoir last year.

But now he’s promising the same approach himself, in a sign that the partisanship and polarization dividing the country and Congress under President Donald Trump will not end anytime soon.

“Clearly this is not one of those bipartisan ‘Kumbaya’ moments, and so we, as Republicans, expect that both of those issues will be — which are very big issues — will have to be tackled Republican-only,” McConnell said.

A strictly partisan approach on major legislation is a departure in the Senate, where most significant bills require involvement by both parties. Republicans plan to use a parliamentary maneuver to get health care and tax legislation through the narrowly divided Senate as part of a budget bill that requires only a simple majority to pass and can’t be blocked by Democrats.

But McConnell said the polarization in Congress is Democrats’ fault because they haven’t come to terms with the fact that Trump won the election.

“I’m hopeful that, as I said earlier, when the fever breaks, that maybe we’ll be able to move on,” said McConnell, in a turn of phrase that former President Barack Obama sometimes used to express hope that opposition from the tea party right might recede, which it never did.

 

State fears Trump will topple health care gains under Obamacare

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http://www.sfchronicle.com/business/article/California-fears-Trump-will-overturn-health-gains-10944890.php

Member services representative Nancy Chen helps a customer with their coverage at the Asian Health Services offices on the final day of open enrollment for Covered California, the state's health insurance marketplace created by the Affordable Care Act, in Oakland, CA on Tuesday, January 31, 2017. Photo: Michael Short, Special To The Chronicle

The confused future of health care

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The confused future of health care

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With a new administration in Washington, it’s widely accepted that the Affordable Care Act (ACA), otherwise known as Obamacare, isn’t likely to survive in its current form. But nobody seems to know whether it will be replaced or repealed, or what shape health care coverage will take in the future. The experts who met for a Kennedy Schoolpanel on the subject Monday evening didn’t presume to answer those questions, but they did pinpoint the crucial issues for the transition.

While they disagreed on possible replacements, they agreed that any solution will take time to create, agree upon, and roll out.

The panel on “Alternatives to the Affordable Care Act” began with a look at the benefits and drawbacks of Medicaid. According to Katherine Baicker, the C. Boyden Gray Professor of Health Economics at the Harvard T.H. Chan School of Public Health, expansion of Medicaid under Obamacare led to a decline in certain chronic diseases — but that also cost money, because the newly insured used more care. “This forced policymakers to think about how much they cared about the benefits to the insured, versus the costs of that care. That brought politics into it, and economists aren’t so good at politics.”

Two panelists represented opposite philosophies. Jonathan Gruber, the Ford Professor of Economics at Massachusetts Institute of Technology and a former Obama administration consultant on the health act, and Avik Roy, co-founder and president of the Foundation for Research on Equal Opportunity, argued respectively that government oversight of health care is the only sure way to leave fewer citizens behind, and that the free market, aided by block grants and tax credits, could do a better job.

Roy, speaking via Skype, said that Medicaid has failed the poor by directing too much funding to higher-income groups that don’t need it. Further, Roy said, doctors in many states avoid treating Medicaid patients because they can make more money on wealthier private patients. “Our argument is to say let’s take the money that we are sending to the Medicaid program and send it directly to the patients, so they can choose the program that serves their needs.” Tax credits and health savings accounts, he said, would give the poor more choices than Medicaid does.

“Poor people can’t do anything with health savings accounts,” Gruber replied. “If you have a $10,000 income, you can’t put $3,000 into a savings account.” He said that if you take away the individual mandate, one of the cornerstones of Obamacare, you lose the funding to insure the poor unless another mechanism is put in place. “We can’t escape the mathematics of insurance: 80 percent of the pool is paid by 20 percent of the people. Any alternative to Medicaid has to address affordability, it has to address adverse selection (i.e., people who opt out), and it has to address the architecture of the plan. But there is no alternative to the right of the ACA that does not increase un-insurance. It cannot be done.”

Gail R. Wilensky, senior fellow at Project HOPE and former director of Medicare and Medicaid, added that other countries have adopted strategies that probably would not be accepted here. Also speaking via Skype, she said, “There are alternative strategies to delivering health care, such as putting tight limits on technology. The light tech centers and digital imaging could be put under government control. You could theoretically lower costs that way. But if people were uncomfortable with the mandate, with government telling them what to buy, imagine what the reaction would be to that.”

Another question is whether patients would make the smartest decisions in an open health care market. Gruber said that under President George W. Bush, many elders simply chose the cheapest available plan, often with unfortunate results. Roy countered that low-income patients are often the shrewdest health care shoppers. “It is unreasonable to expect patients to be doctors,” Baicker said. Wilensky concurred, saying “I’ve talked to many patients with health savings accounts, and they found it incredibly difficult to know what they were buying.”

Everyone agreed, however, that the ACA is not near being definitively repealed or replaced. Chandra asked all four panelists when they expected a new plan to be in place. Estimates ranged from next winter to 2019. “One big difference is that Democrats were all united behind Obamacare, but there is no Republican consensus,” Roy said. “They’re against Obamacare, but they’re not sure what they’re for. There is literally nobody in Washington who knows what the new plans will look like, and I give it a 50-50 chance that they even come to agreement.”

One possible solution, Wilensky said, is to bring together all the affected parties — policymakers, physicians, and at-risk patients — in town-hall-type meetings that look into new solutions. “There are a lot of things that don’t make sense,” she said, “and in this country we’ve tried most of them.”

A Deep Dive Into 4 GOP Talking Points On Health Care

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http://khn.org/news/a-deep-dive-into-4-gop-talking-points-on-health-care/

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Republican leaders have a lengthy list of talking points about the shortcomings of the health law. Shortly before his inauguration last month, President Donald Trump said that it “is a complete and total disaster. It’s imploding as we sit.” And they can point to a host of issues, including premium increases averaging more than 20 percent this year, a drop in the number of insurers competing on the Affordable Care Act marketplaces and rising consumer discontent with high deductibles and limited doctor networks.

Yet a careful analysis of some of the GOP’s talking points show a much more nuanced situation and suggest that the political fights over the law may have contributed to some of its problems. Here is an annotated guide to four of the most common talking points Republicans have been using. 

 

GOP Medicaid Block Grants Cut Costs … and Care

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http://www.realclearhealth.com/articles/2017/02/20/gop_medicaid_block_grants_cut_costs__and_care_110453.html?utm_source=RealClearHealth+Morning+Scan&utm_campaign=43886a5bc1-EMAIL_CAMPAIGN_2017_02_20&utm_medium=email&utm_term=0_b4baf6b587-43886a5bc1-84752421

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Most people have heard the aphorism, “if it sounds too good to be true, it probably is.” Referring to the GOP’s cure for Medicaid, “If it sounds too good to be true, it might be true; but guaranteed, it won’t be good.”

A Feb. 6, 2017 report on Medicaid makes this point perfectly. The GOP commissioned a study by Avalere Health, a health care consulting group, to assess the fiscal impact of federal block grants to state Medicaid programs. They evaluated two funding approaches: a lump sum to be negotiated and a per capita, i.e., per enrollee, formula.

Their study showed that block grants could save Washington between $110 billion and $150 billion over five years depending on which formula was used. Roughly half the states would get a small increase in their federal contribution and half would get less, sometimes a lot less. The biggest loser, Arizona Medicaid, would receive 62 percent less than it is currently receiving from Washington.

With the present Medicaid state-federal matching scheme, the more a state spends, the more money it gets from Washington. This produces a classic perverse incentive: rewarding the outcome you don’t want. We want states to reduce spending, yet Washington rewards them—with federal dollars—when they spend more! With a block grant, this perverse incentive goes away. This is a good thing.

Medicaid block grants could save $110-150 billion and would eliminate the perverse incentive. Sounds like a great idea. It makes wonderful sound bytes, and the GOP seems to want to run with it.

There is just one teeny, tiny problem with block grants as proposed: no health care.

http://thehill.com/policy/healthcare/320286-kasich-house-gop-medicaid-plan-very-bad-idea

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Kasich: House GOP Medicaid plan ‘very bad idea’

Kasich: House GOP Medicaid plan 'very bad idea'

Republican Ohio Gov. John Kasich on Sunday criticized the House Republicans’ plan to phase out ObamaCare’s expansion of Medicaid.

“I’m in Munich, but I understand that there was an initial effort by House Republicans to, for example, phase out Medicaid expansion, which means phasing out coverage,” Kasich said on CNN’s “State of the Union.” “That is a very, very bad idea, because we cannot turn our back on the most vulnerable. We can give them the coverage, reform the program, save some money and make sure that we live in a country where people are going to say, ‘At least somebody is looking out for me.’”

An outline of an ObamaCare replacement plan put forward by House Republicans on Thursday called for phasing out the Medicaid expansion by lowering the federal share of the cost back down to its traditional level, meaning that states would have to pour more of their own money into the program if they wanted to keep the expansion, a tall order.

 

Medicaid’s Role for Medicare Beneficiaries

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Medicaid’s Role for Medicare Beneficiaries

Figure 2: Health and functioning of Medicare beneficiaries who receive Medicaid compared to other Medicare beneficiaries

Key Takeaways
 This brief describes the role that Medicaid plays for 10 million Medicare beneficiaries to help inform upcoming debates about proposals to restructure Medicaid financing in ways that could reduce federal funding.What is Medicaid’s Role for Medicare Beneficiaries?

  • Medicaid covers needed services that Medicare does not, such as long-term care in nursing homes and the community.  Medicaid also helps make Medicare affordable by covering Medicare premiums and/or cost-sharing, which can be high for people with low incomes.

Who are the Medicare Beneficiaries Who Receive Medicaid?

  • Nearly three in four Medicare beneficiaries who receive Medicaid have three or more chronic conditions, such as diabetes or heart disease, which can require regular doctor appointments, medication, and/or medical tests.
  • Over 60% of Medicare beneficiaries who receive Medicaid need help with daily self-care activities, such as eating, bathing, or dressing, which are important for independent living.
  • Nearly six in 10 Medicare beneficiaries who receive Medicaid have a cognitive or mental impairment, such as dementia, which can create the need for supports to live safely at home.

How Much Does Medicaid Spend on Medicare Beneficiaries? 

  • Medicare beneficiaries account for 14% of Medicaid enrollment but 36% of Medicaid spending, as a result of their more intensive health needs and service use compared to other Medicaid beneficiaries.
  • Nearly three-quarters of states devote more than 30% of their total Medicaid spending to Medicare beneficiaries, and spending for Medicare beneficiaries comprises more than 45% of Medicaid budgets in six states.

Looking Ahead

Because Medicaid spending for Medicare beneficiaries is disproportionate to their enrollment, policy changes that lead states to limit per enrollee Medicaid spending or cut costly services could especially affect these beneficiaries.  Medicare beneficiaries who receive Medicaid are poorer than other Medicare beneficiaries, and many have intensive medical and long-term care needs as a result of old age, disability, and chronic illness.  Medicare beneficiaries rely on Medicaid to cover expensive but necessary services, especially long-term care in the community and nursing homes, that are generally not available through Medicare or private insurance.  They also depend on Medicaid to make Medicare affordable because Medicare’s out-of-pocket costs can be high for those with low incomes.  In addition, because the share of state Medicaid budgets devoted to Medicare beneficiaries varies by state, any changes that limit federal Medicaid financing will impact individual states differently. Because changes to Medicaid’s financing structure could have significant consequences for enrollees and states, the potential implications warrant careful consideration for their impact on Medicare beneficiaries.

Pre-ACA Market Practices Provide Lessons for ACA Replacement Approaches

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Pre-ACA Market Practices Provide Lessons for ACA Replacement Approaches

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Significant changes to the Affordable Care Act (ACA) are being considered by lawmakers who have been critical of its general approach to providing coverage and to some of its key provisions. An important area where changes will be considered has to do with how people with health problems would be able to gain and keep access to coverage and how much they may have to pay for it.  People’s health is dynamic. At any given time, an estimated 27% of non-elderly adults have health conditions that would make them ineligible for coverage under traditional non-group underwriting standards that existed prior to the ACA. Over their lifetimes, everyone is at risk of having these periods, some short and some that last for the rest of their lives.

One of the biggest changes that the ACA made to the non-group insurance market was to eliminate consideration by insurers of a person’s health or health history in enrollment and rating decisions.  This assured that people who had or who developed health problems would have the same plan choices and pay the same premiums as others, essentially pooling their expected costs together to determine the premiums that all would pay.

Proposals for replacing the ACA such as Rep. Tom Price’s Empowering Patients First Act and Speaker Paul Ryan’s “A Better Way” policy paper would repeal these insurance market rules, moving back towards pre-ACA standards where insurers generally had more leeway to use individual health in enrollment and rating for non-group coverage.1  Under these proposals, people without pre-existing conditions would generally be able to purchase coverage anytime from private insurers.  For people with health problems, several approaches have been proposed: (1) requiring insurers to accept people transitioning from previous coverage without a gap (“continuously covered”); (2) allowing insurers to charge higher premiums (within limits) to people with pre-existing conditions who have had a gap in coverage; and (3) establishing high-risk pools, which are public programs that provide coverage to people declined by private insurers.

The idea of assuring access to coverage for people with health problems is a popular one, but doing so is a challenge within a market framework where insurers have considerable flexibility over enrollment, rating and benefits.  People with health conditions have much higher expected health costs than people without them (Table 1 illustrates average costs of individuals with and without “deniable” health conditions). Insurers naturally will decline applicants with health issues and will adjust rates for new and existing enrollees to reflect their health when they can.  Assuring access for people with pre-existing conditions with limits on their premiums means that someone has to pay the difference between their premiums and their costs.  For people enrolling in high-risk pools, some ACA replacement proposals provide for federal grants to states, though the amounts may not be sufficient.  For people gaining access through continuous coverage provisions, these costs would likely be paid by pooling their costs with (i.e., charging more to) other enrollees.  Maintaining this pooling is difficult, however, when insurers have significant flexibility over rates and benefits.  Experience from the pre-ACA market shows how insurers were able to use a variety of strategies to charge higher premiums to people with health problems, even when those problems began after the person enrolled in their plan.  These practices can make getting or keeping coverage unaffordable.

Discussion

There were many aspects of the pre-ACA non-group market that made it difficult for people with health problems to get and keep non-group coverage.  Any proposal for replacing the ACA will have to determine which, if any, of these previous insurance practices will once again be permitted.  Medical screening was the most obvious barrier, combined with high premium costs for people who were HIPAA-eligible.  Even people who purchased coverage when they were healthy sometimes were unable to keep it because certain rating approaches could cause their premiums to spiral.  Returning to a less structured, less regulated non-group market raises questions about how people with health problems will be treated in terms of access to and cost of coverage.  Health insurance underwriting and rating is complex, and reviewing how the pre-ACA market operated provides information about the types of issues that people with health problems may confront if the ACA market structure is replaced.