Top 10 states most affected by ACA repeal

http://managedhealthcareexecutive.modernmedicine.com/managed-healthcare-executive/news/top-10-states-most-affected-aca-repeal?cfcache=true&ampGUID=A13E56ED-9529-4BD1-98E9-318F5373C18F&rememberme=1&ts=15022017

Making good on one of his campaign promises in his first executive order, President Trump directed his administration to take steps that will facilitate the repeal and replacement of the Affordable Care Act (ACA).

Although the future of the ACA and what comes next is murky, what is clear is that certain states would suffer more than others from a repeal. In order to assess repeal’s impact on Americans based on where they live, personal-finance website WalletHub analyzed states across seven key metrics that range from “growth of uninsured rate by 2019 post-ACA repeal” to “potential economic impact due to repeal of premium tax credits and Medicaid expansion (2019 to 2023).”

“The most affected states by the ACA repeal have some of the highest insured rates in the country and have expanded Medicaid,” says WalletHub analyst Jill Gonzalez.

Here are the top 10 states that are most affected by repeal of the ACA, according to the report.

Federalism and the End of Obamacare

http://www.yalelawjournal.org/forum/federalism-and-the-end-of-obamacare

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Federalism has become a watchword in the acrimonious debate over a possible replacement for the Affordable Care Act (ACA). Missing from that debate, however, is a theoretically grounded and empirically informed understanding of how best to allocate power between the federal government and the states. For health reform, the conventional arguments in favor of a national solution have little resonance: federal intervention will not avoid a race to the bottom, prevent externalities, or protect minority groups from state discrimination. Instead, federal action is necessary to overcome the states’ fiscal limitations: their inability to deficit-spend and the constraints that federal law places on their taxing authority. A more refined understanding of the functional justifications for federal action enables a crisp evaluation of the ACA—and of replacements that claim to return authority to the states.

The upshot of the piece is that there’s much to be said—more than the ACA’s supporters generally acknowledge—for returning power to the states. That’s so even with respect to some of the ACA’s most sacrosanct provisions:

[C]onsider the ban on medical underwriting. The ACA reflects the judgment that it is unfair to deny coverage to the sick or to ask them to pay more for their coverage. The ACA thus embraces policies—in particular, the much-maligned individual mandate—that its drafters thought necessary to cope with the risk that people will wait until they got sick to purchase coverage. For the ACA’s supporters, the individual mandate is a reasonable price to pay to prevent discrimination against the sick. But many people don’t see it the same way. Some reject the claim that the government should be in the business of guaranteeing coverage for everyone. Others don’t think that medical underwriting, however distasteful, warrants a heavy-handed purchase obligation. Still others doubt that the individual mandate is strictly necessary to prevent adverse selection, and would prefer less-intrusive alternatives. If those who disagree with the ACA’s approach command the levers of political power within a state, why shouldn’t those states be allowed to try something different?

The argument can be generalized to most of the ACA’s insurance reforms. And I can already hear the response: Because this “something different” will not work. The ACA’s opponents are completely unrealistic about the tough tradeoffs that health-care policymaking entails. They will take federal money and squander it, leaving millions of people without coverage.

That might be right; indeed, I suspect it is right. But that’s my judgment. Lots of smart people do not share that judgment. And if federalism means anything, it is that national judgment should not supersede state judgment, absent a good reason for federal intervention. Yes, federal money might be squandered in a state that adopts stupid insurance rules. People could go bankrupt and even die as a result of the lack of coverage. But that’s an issue between the state and its voters. If other states use the money more effectively, the state with the stupid rules will come under pressure to improve them. And what if it turns out that what seemed stupid is not so stupid after all?

Democracy rests on the conceit that we all have an equal voice in determining what the good is, which is why Michigan voters don’t get to tell Ohioans how to spend their tax dollars, even if Wolverines know in their hearts that they make better decisions than Buckeyes. And while the federal government can make decisions for Ohio, it should not do so just because it doubts the wisdom, intelligence, or values of Ohio residents. “The states have bad ideas” is a poor justification for federal law (unless, again, those bad ideas turn on views about the inferiority of minority groups). Federalism thrives when we recognize the limits of what we know, appreciate that good people can hold views that many others find repugnant, and acknowledge that our own misconceptions and prejudices can blind us. Sometimes federalism means letting the states wave their crazy flags.

I’d welcome any suggestions and criticisms. And a big thank you to the Yale Law Journal, which has moved with stunning speed to get the piece up.

 

GOP Considers Medicaid Reforms for Reconciliation Bill

https://morningconsult.com/2017/02/14/gop-considers-medicaid-reforms-reconciliation-bill/

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House Republicans are weighing specific reforms to Medicaid that could be included in a reconciliation measure to overhaul the Affordable Care Act.

How to deal with the federal expansion of Medicaid under the ACA is one of the main unanswered questions as Congress works to overhaul Obamacare — one that has exposed divisions between the House’s most conservative members and GOP lawmakers from states that chose to expand the federal program for low-income Americans.

Rep. Brett Guthrie (R-Ky.), the vice chairman of the Energy and Commerce Health Subcommittee, said Tuesday that lawmakers are considering what types of reforms — specifically shifting to per capita allotments or allowing states to choose block grants — could be included in a House reconciliation bill to repeal the ACA.

“We’re going to deal with Medicaid reform in reconciliation, is kind of what was discussed. There’s no details yet,” Guthrie told reporters Tuesday after a House GOP conference meeting. Guthrie led a working group focused on Medicaid reforms in the last Congress.

Rep. Michael Burgess (R-Texas), who chairs the health subcommittee, told reporters Medicaid reform would be a discussion all week. House Majority Whip Steve Scalise’s office held a listening session Tuesday afternoon with members on Medicaid, and other committees are also gathering feedback. House Republicans are expecting to learn more information about health reform in a Thursday conference meeting focused on Obamacare.

House Speaker Paul Ryan attended the GOP senators’ policy lunch on Tuesday, and told attendees that appropriators and the authorizing committees are working out Medicaid reforms, Sen. Marco Rubio (R-Fla.) said.

In the House, proposals to transition to per capita allotment or block grants were included in the House GOP’s “Better Way” agenda, rolled out last year.

How has Obamacare impacted state health care marketplaces?

https://www.brookings.edu/research/how-has-obamacare-impacted-state-healthcare-marketplaces/?utm_campaign=Brookings+Brief&utm_source=hs_email&utm_medium=email&utm_content=42427416

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The Affordable Care Act (ACA) changed the nature of competition among health plans by creating regulated insurance exchanges, introducing new insurance industry regulations, and providing premium and cost-sharing reduction subsidies. Through these reforms, the law aimed to increase access to and the value of insurance coverage while lowering costs. To better understand the law’s implementation and its effect on competition, researchers with the ACA Implementation Research Network interviewed key marketplace stakeholders to analyze why carriers chose to enter or exit markets, how provider networks were built, and how state regulatory decisions affected the landscape.

As Congress and the new Administration deliberate on what’s next for the law, the Network presents their analyses of competition in California, Florida, Michigan, North Carolina, and Texas (PDFs). A summary report(PDF) of the general findings, authored by Texas A&M Professor Michael Morrisey, Brookings Senior Fellow Alice Rivlin, ACA Network Lead Richard P. Nathan, and Mark A. Hall, Brookings Nonresident Senior Fellow, is intended to generate hypotheses for further testing across state marketplaces and to identify individual idiosyncrasies within the states that provide context for national- and state-level reforms.

CONCLUSION

While the results of this five-state study may not be applicable across the country, the authors emphasize a few key lessons for further consideration when crafting a potential replacement plan or changes to the law:

    1. Health insurance markets are local and depend on the ability of insurers to create competitively priced plans. While this is often more difficult in rural locations, metropolitan areas also see variation in competition.
    2. Higher-than-expected claims costs caused concern for insurers initially, as they lacked information on the amount of health care service utilization to expect from exchange enrollees. It remains to be seen whether the trend will continue or if recent market adjustments reflect a “one-time correction.”
    3. Insurer networks have narrowed, which potentially provides greater opportunity for insurers to negotiate lower prices by assuring a greater volume of patients to a more limited number of providers. The number of preferred provider organization (PPO) exchange plans has also been decreasing, as these plans had disproportionate enrollment of people with pre-existing conditions and are generally less able to negotiate low prices from providers.
    4. Both hospital and provider competition are vital for competitive markets, with population and the number of physician groups and health systems playing a role in cost competition.

Why Republicans are suddenly talking about repairing not replacing Obamacare

https://www.brookings.edu/blog/fixgov/2017/02/09/the-politics-of-repairing-vs-repealing-obamacare/?utm_campaign=Brookings+Brief&utm_source=hs_email&utm_medium=email&utm_content=42427416

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In the past six years, Republican congresses voted more than 60 times to repeal Obamacare.  And repeal of Obamacare was the leading issue on the Republican side in both the 2014 and the 2016 congressional elections.  The cliché of the month is that the Republican Party is like the dog who caught the bus and doesn’t know what to do with it.  As one observer remarked, it may be even worse than this: the dog is now driving the bus.

Republicans have had six years to prepare an alternative to Obamacare, and they still don’t know what to do about health care.  Asked about this issue, Sen. Bob Corker (R-Tenn) said that he has “no idea” when Republicans would start drafting an alternative to Obamacare and reported that “There’s not any real discussion taking place right now.”

The Republicans have a lot of tough policy issues to address.  And as a recent Gallup survey shows, they also have a political problem that will make these challenges even harder.

As part of the promised replacement for Obamacare, Republicans led by Speaker Paul Ryan are determined to transform Medicaid into a block grant, strip it of most federal regulations, and send it to the states.  Over a decade, this would result in a huge cut in overall Medicaid spending, forcing the states to reduce benefits and coverage.

But here’s the political problem: the states that Donald Trump carried in 2016 disproportionately benefitted from the expansion of Medicaid that was one of the building-blocks of Obamacare, and they will suffer disproportionately from Medicaid cuts.

 

Why is it so hard for Republicans to replace Obamacare?

https://www.brookings.edu/opinions/why-is-it-so-hard-for-republicans-to-replace-obamacare/?utm_campaign=Brookings+Brief&utm_source=hs_email&utm_medium=email&utm_content=42427416

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Republicans in Congress have been attacking Obamacare and vowing to repeal it for nearly seven years, and President Trump made “repeal and replace Obamacare” a central promise of his winning campaign. Now the President and his party are in charge, but they are scrambling to craft a replacement. Why are they having such trouble?

The main problem is that Republicans are a diverse bunch who opposed Obamacare for a variety of reasons. Those most focused on shrinking the size and reach of the federal government thought Washington was already too involved in health care and should pull back, not expand its role or raise taxes to pay for new health spending. Those preoccupied with personal freedom balked at being required to buy health insurance. Others thought the widespread use of insurance to fund health care was already driving health spending too high and objected to further expanding health insurance. Still, others thought broadening health coverage was a desirable goal, but that the subsidies and regulations that Obamacare used to accomplish this goal were poorly designed and transferred too much power from the states to Washington. All of these Republicans could agree on trashing Obamacare, but they did not have a common intellectual basis for designing a replacement and they still don’t.

The 2016 Republican Platform says: “Our goal is to ensure that all Americans have improved access to affordable, high-quality healthcare…” It avoids saying that the federal government has a responsibility to provide that access, which many conservative Republicans do not accept.

If you changed the goal to “all Americans should have affordable health insurance,” you would lose even more conservative Republicans—the ones who see health insurance as an undesirable way to pay for most health expenditures. They believe generous health insurance keeps people from being cost-conscious consumers looking for the most cost-effective provider of knee replacement surgery or cardiac care. If these procedures are covered by insurance, providers don’t have to compete to offer attractive prices (or even make clear to the patient what their prices are). If most of their health care costs are paid by insurance, people tend to use more care, and health care spending goes up. Hence, many Republican health care proposals feature tax subsidies that help people fund health savings accounts (HSAs), so they can shop for health care with their own money. They typically encourage health insurance coverage only for relatively rare “catastrophic” events, although they allow people to use their HSAs to buy more generous health insurance if they want it.

Threat Of Losing Obamacare Turns Some Apolitical Californians Into Protesters

http://khn.org/news/threat-of-losing-obamacare-turns-some-formerly-apolitical-californians-into-protesters/

Vicki Hall, 70, is professor of gender studies at Sacramento State. She was able to afford her total hip replacement surgery because of Medicare. “If the ACA goes away, people on Medicare will be worse off,\" she says. (Ana B. Ibarra/California Healthline)

Until recently, Paul Smith didn’t consider himself much of an activist. But he woke up hours before sunrise on Saturday to attend his first town hall meeting.

That meeting near Sacramento, organized by his district’s Congressman Tom McClintock (R-Roseville), sparked a peaceful — if large and raucous — protest over Obamacare, the travel ban and other issues. And it drew national headlines.

“I have noticed many of my friends who never speak [about] politics are getting political,” said Smith, a 46-year-old Rocklin, Calif., resident and registered Democrat who works in marketing. He said he did not vote for McClintock.

Once on the political sidelines, Smith now finds himself one of the leading members of a group called Indivisible California-04 — named for McClintock’s 4th Congressional district. It is one of hundreds of groups forming across the country to “resist” the Trump Administration’s agenda, which includes repealing and replacing the Affordable Care Act.

Alongside veteran protesters, recently galvanized Californians like Smith are demonstrating, calling lawmakers and taking other measures to make their voices heard. For many, the issues are not partisan. They are personal.

Placer County resident Veronica Blake said her mother had purchased health coverage through Covered California, the state’s Obamacare insurance exchange, just a few months before her death in 2013. She was never able to use the insurance, however, since exchange-based health plans did not become effective until Jan. 1, 2014.

Before that, her mother had not been covered for nearly 10 years. She had been diagnosed with breast cancer in her early 30s, and although she beat it after a mastectomy, the preexisting condition made her a high-risk patient whom insurers didn’t want to take on, Blake said.

Blake wonders how much longer her mother would have lived if she’d had health insurance all those years. Could her heart problems have been detected and treated earlier?

Blake joined hundreds of others at Saturday’s rally, she said, because she has other family members with illnesses that would be considered preexisting conditions and fears that their coverage could be taken away.

Laurel Ward, who is a nurse in Placer County, said she made her way to McClintock’s town hall event because of what she sees daily in her crowded emergency room.

She also has a younger sister who was able to obtain coverage as a result of the Medi-Cal expansion made possible by the Affordable Care Act. “It’s difficult for young people to afford health insurance,” Ward said. “I know, because I went without insurance when I was a student.”

“Without the ACA,” she said. “It’s only going to get worse.”

 

Five Quick Ways HHS Secretary Tom Price Could Change The Course Of Health Policy

http://khn.org/news/five-quick-ways-a-new-hhs-secretary-could-change-the-course-of-health-policy/?utm_campaign=KFF-2017-The-Latest&utm_source=hs_email&utm_medium=email&utm_content=42404172&_hsenc=p2ANqtz–5EWkVt5sjIUe_63Pbf6RTjOO_GqSTuaRBRwH_raPCxqrbMpsVfuUSNHyZm7pv8SbHa4es7RH84q1NOLCwj0m44NZyWQ&_hsmi=42404172

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After a bruising confirmation process, the Senate confirmed Rep. Tom Price, R-Ga., to head up the Department of Health and Human Services, by a 52-to-47 vote.

As secretary, Price will have significant authority to rewrite the rules for the Affordable Care Act, some of which are reportedly nearly ready to be issued.

But there is much more now within Price’s purview, as head of an agency with a budget of more than $1 trillion for the current fiscal year. He can interpret laws in different ways than his predecessors and rewrite regulations and guidance, which is how many important policies are actually carried out.

“Virtually everything people do every day is impacted by the way the Department of Health and Human Services is run,” said Matt Myers, president of the Campaign for Tobacco-Free Kids. HHS responsibilities include food and drug safety, biomedical research, disease prevention and control, as well as oversight over everything from medical laboratories to nursing homes.

Price, a Georgia physician who opposes the Affordable Care Act, abortion and funding for Planned Parenthood, among other things, could have a rapid impact without even a presidential order or an act of Congress.

Some advocates are excited by that possibility. “With Dr. Price taking the helm of American health policy, doctors and patients alike have sound reasons to hope for a welcome and long-overdue change,” Robert Moffit, a senior fellow at the conservative Heritage Foundation, said in a statement when Price’s nomination was announced.

Others are less enthusiastic. Asked about what policies Price might enact, Topher Spiro of the liberal Center for American Progress said at that time: “I don’t know if I want to brainstorm bad ideas for him to do.”

Here are five actions the new HHS secretary might take, according to advocates on both sides, that would disrupt health policies currently in force:

The Republican health-care plan the country isn’t debating

https://www.washingtonpost.com/opinions/the-republican-health-care-plan-the-country-isnt-debating/2017/02/09/919464e2-eee8-11e6-9662-6eedf1627882_story.html?_hsenc=p2ANqtz-_zh-MmG6tEeoYRPpXGnfQ4Br6yG61Zm_BUto5iuDDy7KmrCnce1x4mfC1IJZgA7lEGZpWUtS2wTehJJCZgUSr8nli9FQ&_hsenc=p2ANqtz-_g3ACJaUm5w_DwBb7DyuzIOw5pujA6z1qZbrcFLgKCShQytC1zSXx63-Yuh-gFk2Ivyjf6z-tWrzEpQHRkhxEck_TU4w&_hsmi=42381353&_hsmi=42404172&utm_campaign=KFF-2017-Drew-WashPost-feb10-GOPplans&utm_campaign=KFF-2017-The-Latest&utm_content=42381353&utm_content=42404172&utm_medium=email&utm_medium=email&utm_source=hs_email&utm_source=hs_email&utm_term=.ce2754889c96

With the debate about the Affordable Care Act drawing so much scrutiny, a broader Republican agenda to fundamentally change the federal role in health care is flying under the radar. It’s the most important issue in health care we are not debating.

Many Republicans in Congress want to convert Medicaid to a block-grant program and transform Medicare from a plan that guarantees care into one in which seniors would receive a set amount of money to purchase coverage. Meanwhile, Republicans would replace existing subsidies for premiums under the ACA with less generous tax credits — all while eliminating the expansion of Medicaid that enables states to cover low-income childless adults.

Taken together, these changes would amount to a fundamental rewriting of the health-care role of the federal government. They would end the entitlement nature of Medicaid and Medicare, cap future increases in federal health spending for these programs and shift much more of the risk for health costs in the future to states and consumers.

If Republicans shy away from Medicare for the time being, for fear of angering senior voters, the fulcrum for this policy shift will be the debate about converting the Medicaid program to some form of a block grant, most likely one that would cap spending on a per- enrollee basis. This would be an enormous shift. Medicaid spending exceeds half a trillion dollars , and the program represents more than half of all federal funds spent by states. Medicaid has changed dramatically from its beginnings as a program largely for women and children on welfare. It now has more than 70 million beneficiaries, and its reach is so broad that almost two-thirds of Americans say that they, a family member or a friend have been covered by Medicaid at some point.

Physician: Consequences of ACA Repeal ‘Gigantic for Us’

http://www.healthleadersmedia.com/physician-leaders/physician-consequences-aca-repeal-gigantic-us?spMailingID=10400909&spUserID=MTY3ODg4NTg1MzQ4S0&spJobID=1100770334&spReportId=MTEwMDc3MDMzNAS2#

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Physician organization leaders are trying to plot business strategies for a post-ACA landscape of increased healthcare consumerism, lower reimbursement, and new partnerships.