Tag Archives: ACA

Senate GOP Has 12 Days to Repeal Obamacare and No Room for Error

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https://www.bloomberg.com/news/articles/2017-09-19/senate-gop-has-12-days-to-repeal-obamacare-and-no-room-for-error

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Senate Republicans making one last-ditch effort to repeal Obamacare have the daunting task of assembling 50 votes for an emotionally charged bill with limited details on how it would work, what it would cost and how it would affect health coverage — all in 12 days.

They need to act by Sept. 30 to use a fast-track procedure that prevents Democrats from blocking it, but the deadline doesn’t leave enough time to get a full analysis of the bill’s effects from the Congressional Budget Office. The measure would face parliamentary challenges that could force leaders to strip out provisions favored by conservatives. Several Republicans are still withholding their support or rejecting it outright.

And even if Republicans manage to get it through the Senate by Sept. 30, the House would have to accept it without changing a single comma.

Most Senate Republicans are still trying to figure out what it’s in the bill, which was authored by Republicans Lindsey Graham of South Carolina and Bill Cassidy of Louisiana. Until the past few days, most assumed that GOP leaders had no interest in reviving the Obamacare repeal effort after their high-profile failure to pass a measure this summer.

Republican Senator Steve Daines of Montana said he’s still trying to figure out how the bill will affect his state and wants to hear what GOP leaders say at a closed-door lunch Tuesday.

‘Active Discussion’

“It will be a very active discussion,” he said.

The new repeal bill would replace the Affordable Care Act’s insurance subsidies with block grants to states, which would decide how to help people get health coverage. The measure would end Obamacare’s requirements that individuals obtain health insurance and that most employers provide it to their workers, and it would give states flexibility to address the needs of people with pre-existing medical conditions.

But lawmakers won’t have much more information about the legislation by the time the Senate would have to vote. The CBO said Monday it will offer a partial assessment of the measure early next week, but that it won’t have estimates of its effects on the deficit, health-insurance coverage or premiums for at least several weeks. That could make it hard to win over several Republicans who opposed previous versions of repeal legislation.

So far, President Donald Trump has suggested he’d support the bill, but he hasn’t thrown his full weight behind it.

Majority Leader Mitch McConnell has told senators he would bring up the bill if it had 50 votes, and under fast-track rules he could do so at any time before Sept. 30. That’s the end of the government’s fiscal year, when the rules expire and the GOP would have to start over.

Several Holdouts

Republicans can only lose two votes in the 52-48 Senate and still pass the measure, with Vice President Mike Pence’s tie-breaker. There are at least four holdouts, and getting any of them to back the measure would require the senators to change their past positions. Pence, who would cast the potentially deciding vote, will return to Washington from New York Tuesday, where he’s been taking part in United Nations General Assembly events, to attend Senate GOP lunches.

Republican Rand Paul of Kentucky said Monday he’s opposed to the Graham-Cassidy bill, saying it doesn’t go far enough. John McCain of Arizona said he’s “not supportive” yet, citing the rushed legislative process.

Two other Republicans — Susan Collins of Maine and Lisa Murkowski of Alaska — have voted against every repeal bill considered this year in the Senate, citing cuts to Medicaid and Planned Parenthood as well as provisions that would erode protections for those with pre-existing conditions. The Graham-Cassidy bill contains similar provisions on those three areas.

“I’m concerned about what the effect would be on coverage, on Medicaid spending in my state, on the fundamental changes in Medicaid that would be made,” Collins told reporters Monday evening.

She said that Maine’s hospital association has calculated the state would lose $1 billion in federal health spending over a decade compared to current law.

“That’s obviously of great concern to me,” she added.

Hard Sell

Murkowski is getting a hard sell from Republican backers of the bill.

“What I’m trying to figure out is the impact to my state,” Murkowski told reporters Monday. “There are some formulas at play with different pots of money with different allocations and different percentages, so it is not clear.”

McCain, who is close friends with Graham, cast the deciding vote to sink an earlier repeal bill in late July when he made a dramatic return to the Senate after a brain cancer diagnosis. At the time, he made an eloquent plea for colleagues to work with Democrats and use regular legislative procedures instead of trying to jam it through on a partisan basis.

John Weaver, a former top adviser to McCain, said supporting Graham-Cassidy would require the Arizona senator to renege on his word.

‘Fair Process’

“I cannot imagine Senator McCain turning his back not only on his word, but also on millions of Americans who would lose health care coverage, despite intense lobbying by his best friend,” Weaver said in an email. “Graham-Cassidy, if truly attempted to pass, will bypass every standard of transparency and inclusion important to people who care about fair process.”

Despite the obstacles, the bill’s backers are putting on a good face about the prospects.

“We’re making progress on it,” said Republican Senator Ron Johnson of Wisconsin. “I’m still cautiously optimistic, but there are a lot of moving parts.” Johnson is planning a Sept. 26 hearing on the measure in the Homeland Security and Governmental Affairs Committee, which he leads. The Senate Finance Committee is planning its own hearing Sept. 25 on the measure.

“There’s a lot of interest,” Senator Pat Toomey of Pennsylvania said Monday. “Those guys have done some very good work.”

A number of Republicans are still pushing for changes to the bill, so the final version may evolve. It’s also subject to parliamentary challenges under the reconciliation process being used to circumvent the 60-vote threshold in the Senate. That could allow Democrats to strike provisions that take aim at Obamacare’s regulatory structure.

Last Chance

If it passed the Senate, the House would have to pass the bill without any changes. House Speaker Paul Ryan said Monday that the measure is Republicans’ last best chance to repeal Obamacare.

“We want them to pass this, we’re encouraging them to pass this,” Ryan told reporters at a news conference in Wisconsin. “It’s our best, last chance of getting repeal and replace done.”

But that won’t be easy either. The measure strives to equalize Medicaid funding between states, which means that some House Republicans from Medicaid expansion states could find it hard to support. That includes states like New York and California, which stand to lose federal funds under Graham-Cassidy. Those states have only Democratic senators, but have some GOP House members.

Another Run

In some ways, it’s remarkable that Republicans are mounting another run at repeal.

Two months ago, Majority Leader Mitch McConnell’s effort to pass a replacement with only Republican support suffered a spectacular defeat in the Senate. When members of the Senate health committee then began working on a bipartisan plan to shore up Obamacare, Graham and Cassidy revved up a new bid to get their GOP-only bill to the Senate floor.

Graham and Cassidy are hoping to channel the GOP’s embarrassment at failing to repeal Obamacare this summer after seven years of promising to do so. But Paul said Monday this legislation shouldn’t be treated like a “kidney stone” you pass “just to get rid of it.”

Despite all the obstacles, Democrats quickly geared up for another campaign against repeal, warning that the latest bill is a serious threat.

“This bill is worse than the last bill,” Senate Democratic leader Chuck Schumer of New York told reporters Monday. “It will slash Medicaid, get rid of pre-existing conditions. It’s very, very bad.”

Healthcare: It’s complicated

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http://www.theactuary.com/features/2017/07/its-complicated/

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It has been a little over seven years since the US began implementing healthcare reform at the national level, following the passage of the Patient Protection and Affordable Care Act (ACA), also known as Obamacare. However, the future of the law’s programmes has never seemed more uncertain now that the United States House of Representatives has passed legislation repealing and replacing many of the ACA’s key provisions.

While the ACA and the proposed replacement legislation are fundamentally different in their approaches to financing and regulating healthcare, they do have one thing in common: both are extraordinarily complicated.

Actuaries have had a front-row seat as healthcare reform has unfolded, and they are in a unique position to help address the challenges our complex system presents – whether that involves setting premium rates, calculating reserves, or just trying to explain healthcare policy to their Facebook friends. After all, actuaries were working to promote the financial stability of our complex healthcare system long before the ACA came along.

Even so, one might ask: Why is the American healthcare system so complicated? Does it have to be that way? Most stakeholders acknowledge that our current system has room for improvement, although opinions vary widely on what to do about that. In part, the complexity of our system is rooted in our history.

The healthcare system that we have today wasn’t formed in one fell swoop. Instead, it has been stitched together gradually over the past century by policymakers working to meet the challenges of their times. For example, the prevalence of employer-sponsored insurance was at least partly driven by price-wage controls implemented by the federal government in the 1940s during the Second World War, together with very favourable tax treatment. When the employer-sponsored market began to flourish, healthcare coverage became unaffordable for the non-working population – in particular, low-income workers, seniors, and disabled individuals – and the Medicare and Medicaid programmes were born. Currently, healthcare in the US is provided and funded through a variety of sources:

  • Employer-sponsored insurance – either self-funded by the employer or insured through a carrier
  • Individual major medical insurance – currently subsidised by the federal government for many individuals under the ACA
  • Medicare, Medicaid, and military health coverage – subsidised by federal and state governments and increasingly administered by privately managed care organisations
  • Other – for instance, the Indian Health Service, care provided to correctional populations, and uncompensated care provided to the uninsured.

 

It’s therefore not surprising that the policies being proposed today are an attempt to fix the problems we currently face, such as expanding access to affordable healthcare, reducing the cost of healthcare, or improving the quality of care received by patients.

However, our system has evolved in such a way that trying to implement a solution is like trying to solve a Rubik’s Cube – it is hard to make progress on one side without introducing new problems into other parts of the puzzle. For a Rubik’s Cube, successful solvers focus on both the local and global picture, and sometimes must make short-term trade-offs to achieve a longer-term solution. Unfortunately, the short-term nature of political pressures make it difficult to implement longer-term strategies for healthcare. Yet, we see many areas where actuaries can be instrumental in addressing the challenges presented by our complex healthcare system.

Complex times call for complex models

The ACA made sweeping changes that impacted almost every source of coverage listed above. The most profound changes, besides the expansion of Medicaid coverage, were the changes made to the individual and small employer health insurance markets. These already small markets were fractured into several separate pieces (grandfathered business from before the ACA became law, ‘transitional’ business issued before 2014, and ‘ACA-compliant’ business issued in 2014 and beyond). The only constant has been change, with many regulatory changes occurring each year (often after premium rates were set by insurers) and with the stabilisation programmes intended to mitigate risk during this time of change often paradoxically increasing uncertainty. This led some to question whether these markets were inherently too unpredictable to be viable, whereas others felt that the markets were finally starting to stabilise before the election changed everything.

Besides predictability problems caused by regulatory or political factors, two challenges facing health actuaries during these transitional years have been (1) the lag between when market changes are implemented and when data on policies subject to the new rules becomes available, and (2) the difficulty in predicting consumer behaviour in reaction to major changes in market rules such as guaranteed issue and community rating. How many of the uninsured would sign up? How price-sensitive would members be when they renewed their coverage each year? How will changes in other sources of coverage (such as Medicaid expansion) impact the individual market? How will potential actions by competitors affect an insurer’s risk?

Despite the daunting nature of these challenges, actuaries have, out of necessity, found ways to try to address them. For example, faced with the data lag problem, they explored ways to augment traditional claim and enrollment data with new data sources such as marketing databases or pharmacy history data available for purchase. Such sources can be used to develop estimates of the health status of new populations not previously covered by an insurer. Many actuaries also developed agent-based stochastic simulation models that attempted to model the behaviour of consumers, insurers and other stakeholders in these new markets. Such models continue to be used to evaluate the potential outcomes of future changes to the healthcare system, and will probably be essential should efforts to repeal and replace the ACA prove successful.

Information problems: what is a rational actor to do?

Most goods and services in the US have a price tag that consumers can use to ‘shop’ for the option that they feel gives them the best value for their dollar. Healthcare is different. If you ask how much a healthcare service will cost in the US, the answer is “it depends”. List prices such as billed charges for hospitals and physicians and average wholesale prices for pharmaceuticals are increasingly meaningless, given the enormous contractual discounts and rebates that typically apply. The same service may have wildly different prices depending on who is paying for it, and prices may not correlate well with either the clinical value the service provides to the patient or the actual cost to the healthcare provider who renders it. Layered on top of this complex foundation are the often arcane policy provisions that determine a member’s ultimate cost for a claim.

Moreover, even if a patient can determine the cost of treatment at different healthcare providers, making an informed choice often requires clinical knowledge the average person is unlikely to possess. Also, many of the most costly services are non-discretionary and often emergent in nature. In other words, even if a consumer wanted to shop they would be hard-pressed to do so.

All of this means that it is exceedingly hard for various stakeholders – patients, doctors, even insurers – to know the true cost of a service at the point of care, much less manage it. Yet a lot of effort has been spent in trying to better align cost incentives for providers and patients. Past efforts have often used crude methods, such as high deductibles paired with health savings accounts, to create incentives. Current efforts such as value-based insurance designs, which vary cost sharing based on a patient’s clinical profile, use more nuanced approaches to encourage patients to use high-value care. Moving from fee-for-service to value-based payment models for reimbursing healthcare providers has been a focus of both private and public payers in the US.

While such initiatives show promise, they come at the price of even more complexity – and it isn’t always clear that this price is worth paying. The proliferation of more complex benefit designs and provider contracting arrangements can exacerbate the price transparency problems that existed even in the relatively simple fee-for-service world.

Actuaries are well equipped to help insurers, providers and consumers navigate these waters. For example, repricing healthcare claims in an equitable way using actuarial techniques, such as comparing reimbursement rates with a standard fee schedule, is

an efficient way for providers and payers to evaluate cost levels consistently across contracts that may use very different reimbursement methodologies.

Actuaries also have a role to play in developing tools to support clinicians and consumers in understanding the financial dimensions of their healthcare decisions.

Technology: the cause of, and solution to, all our cost problems?

For better or worse, Americans seem determined to seek technological solutions to our health problems, even when lifestyle changes in diet and exercise habits might be just as effective.

Technological advances drive a significant portion of healthcare cost increases, and while many do result in profoundly valuable new therapies, some provide only marginal benefit over existing options at a significantly higher cost. Finding ways to leverage our love of technology to achieve health outcomes more cheaply would be a worthy goal, and one where an actuary could make a difference. Work to use machine learning (for example, in radiology), smarter medical devices, and other data-intensive methods to improve healthcare are still in their infancy, but show promise. From a policy perspective, actuaries could assist in designing novel approaches toward rethinking the incentives for clinical innovation, such as linking payment for new therapies to their clinical value relative to alternatives.

Will the US ever change its relationship status with healthcare from “it’s complicated” to something less ambiguous? In the near term, the answer seems to be “no.” But perhaps we can hope that – with a little help from actuaries – even a complicated relationship can be a good one.

Centrist Democrats Turn to Pragmatism, Seek Bipartisan ACA Fixes

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https://morningconsult.com/2017/09/15/centrist-dems-seek-bipartisan-aca-fixes-not-single-payer-plan/

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While some progressives campaigned this week for “Medicare for all,” a group of moderate House Democrats aligned themselves with a more modest push to stabilize the Affordable Care Act, arguing that it could spur broader health care reforms in the future.

Thirty-eight of the 61 members of the New Democrat Coalition sent a letterFriday urging the leaders of the Senate Health, Education, Labor and Pensions Committee to agree on a bipartisan bill to keep premiums from rising further for Obamacare enrollees next year.

The letter outlines five short-term proposals agreed to by the group — several of which are likely to be included in the Senate bill, such as the extension of key insurer payments known as cost-sharing reductions.

New Democrat Coalition Chair Rep. Jim Himes (D-Conn.) said that while some Democrats and Republicans continue to push polarizing health care plans after the July collapse of Senate Republicans’ Obamacare repeal push, some lawmakers of both parties are ready to try bipartisanship.

“There’s a pretty substantial group of Democrats and Republicans who are ready to work together and get some things done on this most politically charged of topics,” Himes said in an interview Thursday.

Only three of the 38 Democrats who signed the letter are co-sponsors of a single-payer health care bill introduced by Rep. John Conyers (D-Mich.) that has been endorsed by approximately 60 percent of the House Democratic caucus; Sen. Bernie Sanders (I-Vt.) introduced similar legislation in the Senate on Wednesday.

But the progressive single-payer legislation has almost no chance of passing the Republican-led Congress, and members of the New Democrat Coalition are taking a more pragmatic approach: While “Medicare for all” proponents support placing nearly all Americans on a government plan, the New Democrat Coalition is backing reforms to improve private health insurance coverage and reduce health care costs.

“We believe these ideas provide a framework to reduce health care costs for families and seniors, increase choices for consumers, and encourage participation by the young and healthy,” the Democrats wrote in the letter.

Some members of the New Democrat Coalition are also in the House Problem Solvers Caucus, which consists of centrist GOP and Democratic lawmakers and sent its own letter Wednesday urging the Senate HELP and Finance committees to move toward a bill as a crucial Sept. 27 deadline for insurers approaches.

HELP Committee Chairman Lamar Alexander hopes to reach an agreement on the legislation by early next week, the Tennessee Republican said at a hearing on Thursday.

 

Hospital group comes out against new ObamaCare repeal effort

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Hospital group comes out against new ObamaCare repeal effort

Hospital group comes out against new ObamaCare repeal effort

America’s Essential Hospitals announced its opposition to a new ObamaCare repeal and replace bill, warning of cuts and coverage losses.

The group, which represents hospitals that treat a high share of low-income people, said it is opposed to a last-ditch bill to repeal ObamaCare from Sens. Bill Cassidy (R-La.), Lindsey Graham (R-S.C.), Dean Heller (R-Nev.) and Ron Johnson (R-Wis.).

Dr. Bruce Siegel, the group’s president and CEO, said in a statement the bill “would shift costs to states, patients, providers, and taxpayers.”

“Further, by taking an approach so close to that of the earlier House and Senate plans, it’s reasonable to conclude it would have a similar result: millions of Americans losing coverage,” he added.

America’s Essential Hospitals is one of the first major health groups to come out in opposition to the bill. Most have not yet weighed in on the measure, which was only introduced on Wednesday.

Many are also skeptical of the bill’s chances, but it appears to be gaining at least some momentum.

Cassidy told reporters Friday that he thought the bill had the support of 48-49 senators, just shy of the needed 50. Still, the effort faces long odds and a fast-approaching procedural deadline of Sept. 30.

America’s Essential Hospitals was one of the most outspoken opponents of the earlier repeal bills, along with other hospital groups. Many doctors groups were also opposed and many insurers eventually weighed in against provisions to change ObamaCare pre-existing condition rules.

Maybe Don’t Count Out Obamacare Repeal Just Yet

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By Yuval Rosenberg and Michael Rainey

Maybe Don’t Count Out Obamacare Repeal Just Yet

Sen. Bill Cassidy (R-LA) told reporters on Friday that he’s getting close to securing enough votes to pass the last-ditch ACA repeal and replacement bill he’s put forth with Sens. Lindsey Graham (R-SC), Dean Heller (R-NV) and Ron Johnson (R-WI).

“I am pretty confident we’ll get there on the Republican side,” Cassidy said. “We’re probably at 48-49 [votes] and talking to two or three more.” And Senate Majority Leader Mitch McConnell has asked the Congressional Budget Office to estimate the effects of the Cassidy-Graham bill, which would speed up the scoring process.

Of course, those last two or three votes have been the challenge for the GOP all along, and they may not be any easier to round up this time. Sen. Rand Paul (R-KY), who voted for a prior repeal bill, said Friday that he won’t support this one. Plus, opponents are already stepping up their criticisms about the effects of the bill. And time is running out: Cassidy and his colleagues only have until September 30 to pass the bill this year under a process that would require only 50 supporters in the Senate. So while the Obamacare repeal may still have life, it remains a longshot.

How to turn healthcare’s single-payer threat into a reality

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http://www.modernhealthcare.com/article/20170913/NEWS/170919942

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What’s behind the renewed enthusiasm in the Democratic Party for Sen. Bernie Sanders’ single-payer healthcare bill? The GOP still controls both houses of Congress and the White House. The Affordable Care Act still faces an existential crisis.

Unless something is done in the next few weeks to shore up the exchanges for 2018 and reverse HHS’ mean-spirited efforts to undermine enrollment, the enormous progress made over the past four years—last week the Census Bureau announced the nation’s uninsured rate had dropped sharply over that period to 8.8%—will begin to reverse. For those desperately working to avert the immediate danger, single-payer advocacy is a distraction.

Unfortunately, the logic of contemporary politics made the current push for single-payer inevitable. President Donald Trump and the tea party set the table. They proved that in a populist moment, extreme positions that cater to a sliver of the electorate are a viable path to electoral success.

Expect left-wing challengers supporting single-payer to win numerous Democratic House and Senate primaries next spring. A wave election typical of first-term, off-year elections will lead to a single-payer caucus in the next Congress with as much power as the tea party caucus had after the wave of election of 2010.

Single-payer looms as their threat. If you destroy President Barack Obama’s grand compromise-his eponymous plan relied on private insurers and preserved the employer-based system- the fire next time will get rid of both.

Unlike the tea party, single-payer advocates have history on their side. The U.S. over the last half century has moved inexorably toward universal coverage: Medicare and Medicaid; the Children’s Health Insurance Program; the ACA. It will get there one way or another.

Sanders asked the right question in his op-ed last week in the New York Times. “Do we, as a nation, join the rest of the industrialized world and guarantee comprehensive health care to every person as a human right?”

Polls now report growing support for single-payer health insurance. When asked if the government has the responsibility to guarantee access to healthcare for all Americans, nearly 60% answer yes. In other words, a clear majority of Americans now say yes to Sanders’ question.

It’s not just a human-rights issue. Universal access through universal insurance coverage is a necessary if insufficient component of getting healthcare costs under control. It is also a building block for restoring the nation’s economic competitiveness, especially in areas of the country suffering from a prolonged decline. No region can thrive unless it has a well-educated, healthy workforce.

Industrialized countries diverged in how they achieved universal coverage. Some chose a government-funded, single-payer system. Others chose well-regulated private insurers. Still others chose a combination of the two.

The U.S., because its employers used health benefits to get around World War II’s wage-and-price controls, accidentally chose a mixed system. It was the erosion of the employer-based system that led to Obamacare.

Sanders and his 15 Senate co-sponsors propose to eliminate the employer-based system entirely. He would gradually expand Medicare to cover everyone over four years.

The legislation is silent on how to transfer the $1.1 trillion spent by employers on health insurance to government coffers, necessary to defray the cost of his plan. He doesn’t address how he would counter the tremendous opposition that disrupting the existing system would draw from employers and their workers, including those in many unions.

Sanders decries the lack of progressive think tanks to come up with answers to those and other transition questions. But the problem isn’t the absence of good ideas. It’s the absence of fertile soil in which those ideas can grow.

That will change rapidly if Republicans succeed in repealing Obamacare, or undermine it and send the uninsured rate soaring again. That, and only that, will turn the single-payer threat into the last viable path to universal coverage.

WHY RETURNING TO A PRE-ACA MARKET ISN’T AN OPTION

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http://www.managedhealthcareconnect.com/article/why-returning-pre-aca-market-isn-t-option

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After the recent failed attempts to repeal the Affordable Care Act (ACA), it is anyone’s guess as to what comes next. Tax reform and infrastructure now appear to have moved ahead of health care on the legislative agenda—leaving the ACA largely out of lawmakers’ hands, and the Department of Health and Human Services (HHS) at the helm.

The President has implied that the federal government might halt federal payments to insurance companies meant to provide financial assistance to consumers who qualify for subsidies if they purchase health insurance on the ACA exchange. So far that has not happened. In a recent appearance on ABC’s “This Week” Sunday newsmagazine, HHS Secretary Tom Price, MD, said that he and his team are combing through the specifics of the ACA law, “asking the question, ‘does this help patients or does it harm patients? Does it increase costs or does it decrease costs?’”

There are more than 1400 instances in the law where the HHS Secretary has discretion to make changes, making the HHS the most likely source for any forthcoming health reform.

Republicans generally favor pushing more decision-making down to the states, and offering more choice to consumers. Dr Price has talked up a provision drafted by Senator Ted Cruz (R-Texas) that was included in the Senate’s plan. It would have given consumers the choice to purchase insurance that does not meet the ACA’s standard of the essential health benefits, but instead meets a given State’s definition of which service it deems essential. Coupled with the ability to grant state waivers for changes to the current law, many have suggested this could lead to consumers purchasing plans that do not cover most services.

“Dusting Off” The Old Way

The so-called Consumer Freedom Option is strongly opposed by the nation’s largest health insurers, which seemed to bewilder Secretary Price.

“It’s really perplexing, especially from the insurance companies, because all they have to do is dust off how they did business before Obamacare,” he said during the This Week interview. It is “exactly the kind of process that has been utilized for decades.”

Even though the Cruz provision went down with the rest of the Senate bill in July, it is not unreasonable to wonder if Secretary Price might try to figure out how to offer low-cost “skinny plans.” Or if Congress might do that same if and when health care moves back into the limelight.

This begs two questions:

  1. Can the United States ever go back to the way health insurance worked before the ACA, dusting things off, as Secretary Price suggested?
  2. Can selling insurance inside and outside of the ACA—as the Cruz provision envisioned—work?

Most industry experts offer a resounding “no” to both questions. As we have reported previously, it is difficult to take benefits away once they are given. For that reason, there is consensus that the ACA in some form or fashion is here to stay. There is also near universal agreement that certain parts of the ACA—notably the exchanges—need work. But experts also point out that provisions like Sen Cruz’s, that propose parallel systems where different rules apply, will not improve the exchanges, and indeed will likely hasten the so-called death spiral.

AHIP Objects, Actuaries Agree

In a July letter to Senate leaders, America’s Health Insurance Plans (AHIP) pointed out that even though the Cruz provision calls for a single risk pool, such a pool would be established “in name only. In fact, it creates two systems of insurance for healthy and sick people.”

A paper published this year by the American Academy of Actuaries, reinforces this claim.

“If insurers were able to compete under different issue, rating, or benefit coverage requirements, it could be more difficult to spread risks in the single risk pool…. Changes to market rules, such as increasing flexibility in cost-sharing requirements, could require only adjustments to the risk adjustment program. Other changes, such as loosening or eliminating the essential health benefit requirements, could greatly complicate the design and effectiveness of a risk adjustment program, potentially weakening the ability of the single risk pool to provide protections for those with preexisting conditions.”

Such a system, according to the paper, would effectively create two risk pools, and premiums in the ACA plans would be much higher than in those not subject to ACA regulations, leading to a destabilized ACA market. Moreover, things would get worse if people were allowed to move between plans depending on their health status.

Making the Problems Worse

The experts we spoke with agreed, citing the potential for confusion and flawed benefit design. Additionally, it does not adequately address the ACA exchange problems, and indeed may exacerbate them.

“The Cruz amendment would not likely achieve anything other than allowing young/healthy individuals to purchase cheaper, inadequate coverage at a lower price,” David Marcus, director of employee benefits at the National Railway Labor Conference, explained. “It would generally do nothing to lower premiums for ACA-compliant coverage.”

Gary Owens, MD, president of Gary Owens Associates, a medical management and pharmaceutical consultancy firm, implied that Cruz’s plan is a half-baked solution that most would have a difficult time navigating.

“This seems to just one more attempt to cobble together a solution to address the issue of healthcare access and coverage,” he said. “It would probably create more confusion for consumers about which plan is appropriate for their needs.”

Norm Smith, president of Viewpoint Consulting, Inc, which surveys managed markets decision-makers for the pharmaceutical industry, concurred.

“Many of the people buying these plans would not be able to define what’s covered, and what’s not,” he said. “Plans would be difficult for state insurance commissions to control without standardized benefit design.” He added that ACA plans would be crippled as younger, healthier people leave in favor of non-ACA coverage.

F Randy Vogenberg, PhD, RPh, principal at the Institute for Integrated Healthcare, said that the Cruz approach is a tepid response to what he sees as failure on the ACA exchanges.

“It has no merit because it does not address the need to change from the current exchange products,” he explained.

More Choice or Inadequate Coverage?

Proponents cite the fact that skinny plans give more choice to consumers, and that free-market principles are needed, vs increased government intervention. Mr Smith reminded us that the ACA—which is based on the Romney plan that became law in Massachusetts—already contains free-market components. For that reason, he said that introducing more choice could work in theory. However, in practice, “with the level of medical insurance literacy being so low, I’m not sure most members will understand what they are buying.”

Mr Marcus added that “The marketplace is already designed to have market principals, though the insurance that is available through [it] is limited to certain types of coverage.  Offering more choice means certain people can get cheaper plans, but those cheaper plans are generally inadequate methods of protecting against health costs.”

Dr Owens explained that health reform will take much more than simply going back to the way insurance was sold in the 1990s, or tacking piecemeal amendments onto the ACA one after the other.

“Trying to glue on a piecemeal solution is not the answer,” he said. “Congress needs to drop the partisan approaches, put together a real working group that will take the needed time and use the available expertise to develop a comprehensive plan that takes the ACA to the next level.”

New Consumer Expectations

In the end, a big reason that insurers cannot simply dust off their plans from the past may be due to customer preference. Consumers often feel hamstrung when it comes to buying appropriate, affordable coverage. Yet they possess more power than many believe, as evidenced by the backlash Washington lawmakers have faced at local town hall meetings. This, in large part, led to the downfall of ACA repeal efforts.

The term “pre-existing conditions” is now a part of almost every health consumer’s lexicon, and people do not expect to be shut out of the market or forced to buy an exorbitantly expensive plan just because they have such a condition. The ACA appears to have cemented that mindset.

Dr Owens explained that insurers are more eager to work within the already established system of regulations, as opposed to wading into uncharted regulations.

“I don’t think the insurers want to increase the complexity of the marketplace,” he said.

Mr Smith agreed, adding that there would need to be “an awful lot of explaining before members knew what they were buying.”

“Going back just doesn’t make sense,” Mr Marcus noted. “Insurance carriers have spent huge sums of money developing systems to comply with the ACA. Profits at the largest carriers are the highest they have ever been. Insured individuals now have an expectation for ACA market reforms to be continued, but the concept behind the Cruz amendment would not change that.”

Additionally, the health insurance industry as a whole is probably concerned about payers who would choose to sell substandard plans outside of the ACA exchanges. Consumers would be left “in a bind when they need to access coverage,”  Dr Owens said, which would not reflect well on the industry. — Dean Celia

The Single Payer Debate

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The seismic shift in support for Sen. Bernie Sanders’ plan to transform the U.S. health care system into a single-payer program indicates the reach the Vermont independent has within the Democratic Party.

At the same time that his onetime presidential foe Hillary Clinton is reminding people of the party’s devastating loss last fall, Sanders is trying to define its future. His bill to enroll every American in Medicare drew 16 co-sponsors, 16 more than when he first introduced similar legislation in 2013.

It has garnered support from possible 2020 Democratic presidential hopefuls — Sens. Cory Booker of New Jersey, Kamala Harris of California, Elizabeth Warren of Massachusetts and Kirsten Gillibrand of New York — as well as Sen. Tammy Baldwin of Wisconsin, an incumbent up for re-election next year in a state narrowly won by President Donald Trump.

It also provided a welcome talking point for Republicans who have long railed against government-run health care. Several GOP senators used Sanders’ legislation as a tool to warn voters of what could come if Republicans are unable to overhaul the health care system.

‘A political crisis’

During a bill introduction Wednesday that felt more like a campaign rally than the standard press conference, Sanders — flanked by co-sponsors — stuck to his standard script of bashing Republicans and special interest groups for doing nothing to address rising health care costs.

“The crisis we are discussing is not really about health care,” he told a crowded room of activists and supporters. “The crisis we are discussing today is a political crisis which speaks to the incredible power of the insurance companies, the drug companies and all those who make billions of dollars off of the current system.”

The politics of “Medicare for all” are divisive. And aside from a short comment about raising taxes across the board, Sanders has yet to outline a clear way to pay for such a system.

There is a divide within the Democratic Party on how to define such a system, and many Senate Democrats have yet to voice their support for Sanders’ plan, including vulnerable incumbents up for re-election such as Sen. Joe Manchin III of West Virginia.

Despite those differences, however, the expanding coalition of Democrats who now back such a proposal is a display of just how Sanders, who gave Clinton a serious challenge for the presidential nomination, continues to influence the national party.

“Sen. Sanders’ presidential campaign was a phenomenon that very few people saw coming. It uncovered a groundswell of progressive activation that the party now rightly wants to tap into as we head into 2018 and 2020,” Connecticut Democratic Sen. Christopher S. Murphy said. “I think that Democrats now feel a little freer to imagine some even bigger and bolder ideas.”

Asked whether the growing support for his legislation is indicative of his influence, Sanders hedged.

“Right now, we are focusing on what the bill is about,” he said. “We’ll talk about the politics of it later.”

A national message?

Several other Democratic senators supported the national party embracing more bold ideas — like Medicare for all — in the fallout from the 2016 election and tied that movement directly to the success of Sanders’ campaign.

“It’s an idea whose time has come. There’s a clear recognition that universal coverage has to be the goal,” Democratic Sen. Richard Blumenthal of Connecticut said. “These principles are now in the public mind, front and center, and that is due, in part, to the prominence that Bernie Sanders gave to them during the campaign.”

A Democratic aide echoed those thoughts and said the shift is indicative of a recognition that the party needs to be bolder and sharper in its proposals.

“I think there will be a lot of support for this bill,” the aide said. “It’ll make the clear contrast between the two parties on health care even more clear.”

While the Sanders proposal has gained more support among members of the Democratic conference, skeptics remain.

“The Sanders bill requires people to give up their insurance. It’s not an option that you buy in. It requires people to give up the insurance,” Sen. Claire McCaskill of Missouri said. “I’ve been down the road of requiring people to do things the government says on insurance and it is a road paved with big rocky boulders.”

Asked whether she correlates the growing support for Medicare for all to Sanders’ popularity among liberals, McCaskill — who is up for re-election in 2018 in a state Trump won easily — said she had not analyzed it from that perspective.

“I just think we’ve got to think this through and not make this some kind of political litmus test,” she told Roll Call.

While other Democratic lawmakers also said they hoped support for the Sanders bill would not be a political benchmark for the party, several openly said endorsing the concept would be crucial for any successful candidate.

“I have trouble seeing how a viable Democratic candidate does not support the idea of single-payer,” Blumenthal said. “This bill is going to drive the national message.”

Bernie-Care barrier?

Some Senate Republicans, who this summer failed in their attempt to repeal and replace the 2010 health care law, are making a last-ditch attempt to overhaul it.

Sens. Bill Cassidy of Louisiana, Lindsey Graham of South Carolina, Ron Johnson of Wisconsin and Dean Heller of Nevada are pushing legislation that would transform the health care system to essentially a large federal block grant to the states based on the size of their individual insurance pool.

Their message to the Republican conference was clear: It’s either our plan or Sanders’ proposal.

“If you want a single-payer health care system, this is your worst nightmare,” Graham said. “Bernie, this ends your dream of a single-payer health care system for America.”

Republican leadership echoed that message.

“We see what the alternative is and hopefully that’ll focus the mind,” Senate Majority Whip John Cornyn said. “Their party is clearly lurched to the left even further, and it’s made it hard for otherwise pretty pragmatic people, like Chuck Schumer, to do deals which he ordinarily would do with Republicans.”

But for Sanders, the failed attempt by the GOP to overhaul the current health care law only bolsters his case.

“To my Republican colleagues, please don’t lecture us on health care,” he said. “You, the Republican Party, have no credibility on the issue of health care.”

GOP Sees Offensive Opening on Health Care for 2018

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Republicans plan to tie all Democrats to “Medicare for all” proposals.

As more and more Democrats come out in favor of some form of “Medicare for all” legislation, Republican campaign strategists are salivating.

In much the same way the GOP has tried to tie all Democrats to House Minority Leader Nancy Pelosi in attack ads, they’re planning to tie all Democratic incumbents and challengers to different proposals from Vermont independent Bernie Sanders in the Senate and Michigan Rep. John Conyers Jr. in the House, regardless of whether they’ve personally embraced those policies.

“I’m thrilled,” said Corry Bliss, executive director of the Congressional Leadership Fund, the leadership-backed super PAC that plans to spend $100 million to help Republicans keep their House majority in 2018.

“I love their new policy so much that I’m thinking about taking the $50 or so million I was planning on spending on attacking Nancy Pelosi and putting a small portion toward explaining how single-payer hurts the American people,” Bliss said Tuesday.

That strategy isn’t much different from the GOP strategy of the past seven years, when the party has gone after Democrats on the 2010 health care law. But after months of their own health care legislative failures, Republicans think they finally have an offensive opening on health care again.

“It’s first time we’ve been in that position in a long time,” said one GOP campaign strategist, who acknowledged that this year’s health care debate revived the 2010 law.

Attacking all Democrats

The National Republican Congressional Committee was especially vocal on Wednesday, with a digital ad and a slew of press releases trying to pin Sanders’ proposal on Democratic incumbents and challengers.

“Studies reveal that single-payer would cost taxpayers a staggering $32 trillion over the next ten years,” the releases say, all pointing to the same study from the Urban Institute from May 2016.

“Sanders and Pelosi are leading their members down a path with nowhere to turn but left,” NRCC communications director Matt Gorman said in a statement.

In reality, Pelosi has shied away from Medicare for all proposals, trying instead to keep her caucus’ focus on improving the 2010 health care law. Her reticence toward the issue is a fact Republicans sometimes highlight to underscore its unpopularity — as in, “This is such a bad idea, Nancy Pelosi doesn’t even support it.”

But when it comes to messaging against the proposals, Republicans are happy to include Pelosi — a perpetual boogeyman — to help tie the issue around the neck of all Democrats.

California Rep. Scott Peters, a member of the moderate New Democrat Coalition and chairman of the group’s PAC, brushed aside the threats of those kinds of attacks.

“That won’t be a very effective campaign technique. People understand where we are,” he said, walking down the House steps Wednesday afternoon. Peters, an NRCC target in 2018, doesn’t support the Conyers legislation.

But with a majority of House Democrats signing onto it, and many 2020 hopefuls embracing the Sanders plan in the Senate, Republicans see it as nationalized party issue they can apply down ballot to all candidates.

“This is going to help frame the choice next year,” Bliss said. “It will be a huge issue in every single district that we spend in next year.“

One Republican admitted, though, it may be harder to message against a Democratic proposal that doesn’t stand a chance of becoming law anytime soon and doesn’t have a Democratic president behind it.

“I don’t think it will get to the same level as Obamacare did in the 2010 cycle,” the GOP strategist said. “You don’t have the same boogeyman in President Obama and Pelosi.”

Still, Republicans hope the issue will help them by pushing Democratic candidates to the left and sinking nominees in red districts or states won by President Donald Trump last fall.

In Wisconsin, where Trump eked out a win, Sen. Tammy Baldwin has come out in support of Sanders’ legislation. She’s the only senator up for re-election in a state the president won to have signed onto the Sanders’ proposal.

Trump has called for “insurance for everybody,” but Republicans say it’d be very easy to message against a Medicare for all plan to his voters.

“Here’s a socialist idea where everyone gets the same thing,” the GOP strategist said. “That doesn’t play.” It doesn’t fit with what she called the “you deserve more” narrative that Trump pushed to working-class voters during the campaign.

Keeping up the heat

Democrats aren’t backing away from their own offensive attacks on health care, trying to make the GOP-controlled Congress own their repeal-and-replace efforts.

That continued on Wednesday, with the introduction of the Senate Republicans’ latest effort at repealing the 2010 health care law.

“The 2018 election will be a referendum on the toxic GOP health care plan that spikes costs and strips coverage,” said David Bergstein, spokesman for the Democratic Senatorial Campaign Committee.

And they’re skeptical that this week’s attention on the Medicare for all legislation will take away from what a GOP-controlled Congress has been able to do — or not do — on health care this year.

“To have that be their golden ticket out of the nightmare they face right now seems just insane,” one Democratic operative said.