Tag Archives: Individual Mandate

‘Skinny’ Obamacare repeal still lacks votes to pass

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http://www.politico.com/story/2017/07/26/obamacare-repeal-republicans-minimum-240982

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A bare-bones plan picks up some key GOP support, but centrists and conservatives are skeptical.

Even a bare-bones repeal of Obamacare is no sure thing in the Senate.

A handful of key Republican senators who had spurned earlier overtures from GOP leadership endorsed the latest plan to gut Obamacare’s individual and employer coverage mandates and its medical device tax. But several centrists said they’re undecided on the so-called skinny repeal, leaving the GOP in limbo through at least the end of the week.

Jockeying on the scaled-back approach came as the Senate rejected a straight repeal of Obamacare in a 45-55 vote Wednesday. The night before, senators turned aside a comprehensive replacement plan that had been crafted by Senate Majority Leader Mitch McConnell. The roll calls were the latest reminders that GOP leaders’ best hope at this point is just to get something — anything — through the chamber with a bare majority and into a conference with the House.

“Sure. There’s plenty we agree on,” said Senate Majority Whip John Cornyn (R-Texas) late Wednesday when asked whether he can get 50 votes. One challenge for GOP leaders is “trying to explain the concept that we need to do it this way, as opposed to solving all the problems in a Senate bill now.”

Cornyn said broader negotiations on Medicaid reforms and other divisive issues would likely re-emerge in bicameral negotiations with the House. But some Republicans are worried that those talks would revive efforts to wind down a Medicaid expansion that’s benefited their states.

Centrist GOP Sens. Rob Portman of Ohio and Shelley Moore Capito of West Virginia were undecided on the so-called skinny repeal Wednesday. Another Republican from an expansion state, Sen. Dean Heller of Nevada indicated he would back it.

“We’ll see at the end of the day what’s in it, but overall I think I’d support it,” Heller said. He said slashing Obamacare’s Medicaid expansion or its growth rate should be a nonstarter.

Conservatives could be another matter.

“I don’t like it,” Sen. David Perdue of Georgia said of the process. “Because I don’t know where we end up. This whole [health care system] holds together or falls apart in totality. We’ve got a system that is collapsing.”

South Carolina Sen. Lindsey Graham on Tuesday called the possibility of a skeletal plan a “political punt,” but it may be able to clear the narrowly divided chamber. Graham said he would vote for the slimmed-down plan only if House and Senate lawmakers use it to go to conference and come up with a fuller replacement.

Sen. Jeff Flake of Arizona also indicated that he could get on board with the skinny option.

“In Arizona, you have 200,000 people who were paying the [Obamacare insurance mandate] fine and can’t afford insurance,” Flake told reporters. “We gotta have relief to those who, one: can’t find affordable insurance so they have to pay the fine; and, two: even those that can afford to pay the premium, generally can’t afford to utilize the coverage because the deductibles are so high.”

Whether Sen. Mike Lee of Utah can back a trimmed-down proposal “depends how skinny it is,” a spokesman said. But Sen. Rand Paul of Kentucky signaled he could live with the minimalist approach.

“I’ve always said I will vote for any permutation of repeal. Obviously, I want as much as I can get, but I’ll vote for whatever the consensus can be. It’s what I’ve been saying for months: Start on what you can agree on,” Paul said in an interview Wednesday. “Starting small and getting bigger is a good strategy.”

That would leave out the divisive issues of cuts to Medicaid spending and efforts to create a new tax credit system for the individual markets. Republicans can afford to lose just two votes to pass whatever they come up with in the end.

Many Republicans are in the dark about the emerging proposal. And aides said senators were still focused on amendment votes, floor tactics and the chaotic atmosphere, making it difficult to tell what can clinch 50 votes.

“I don’t know what would be in the skinny repeal,” said Sen. Susan Collins of Maine. “Until I see what’s in it, I’m not ruling it out because I don’t know what it would be.”

The Senate also rejected on Wednesday an attempt to send their repeal effort to congressional committees for several days.

Republicans need a score on any proposal from the Congressional Budget Office to vote at a 50-vote threshold. They are aiming for a vote on Friday on their final plan after the unlimited amendment process known as vote-a-rama, which is expected to begin sometime Thursday.

In the final bill, Republicans could try to add more elements than repealing the mandates and device tax, but that could complicate efforts to get a quick CBO score.

“Look for victories where we should find them. In my opinion, the victory will always include: individual mandate repeal, employer mandate repeal and [eliminating] the medical device tax,” said South Carolina Sen. Tim Scott. “If we can add to it, we should … as much as you can repeal, let’s get it done.”

The CBO has scored those three pieces of the proposal in the past and could deliver an analysis of the “skinny repeal” more speedily than of a more wide-ranging effort, GOP senators said. Still, Republicans will have to add additional Obamacare provisions to the bill to meet minimum savings requirements required under reconciliation, the budget mechanism that allows for a bare majority instead of 60-vote threshold.

Republicans are likely to cut the Prevention and Public Health Fund, for instance. The goal would be to increase the bill’s scope enough to meet Senate savings targets without losing political support, according to Republican sources. They may be able to do so because slashing the mandates means millions would drop insurance coverage — and the subsidies that come with it.

In the end, Senate leaders would want the House to either take up their bill or go to conference and hammer out a compromise that can pass both chambers.

“I can’t imagine at the end of the process that we haven’t agreed on something,” said Sen. Roy Blunt (R-Mo.). “And all we have to do is agree on something that keeps this going.”

But conservatives are wary of a House-Senate negotiation.

“I would [be in] favor if we have a skinny repeal, just sending it over to the House and seeing if they can pass it rather than going to conference,” Paul said. “Conference committee to me means Big Government Republicans are going to start sticking in those spending proposals.”

States Have Tried Versions Of ‘Skinny Repeal.’ It Didn’t Go Well.

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States Have Tried Versions Of ‘Skinny Repeal.’ It Didn’t Go Well.

Betting that thin is in — and might be the only way forward — Senate Republicans are eyeing a “skinny repeal” that rolls back an unpopular portion of the federal health law. But experts warn that the idea has been tried before, and with little success.

Senators are reportedly considering a narrow bill that would eliminate the Affordable Care Act’s “individual mandate,” which assesses a tax on Americans who don’t have insurance, along with penalties for employers with 50 or more workers who fail to offer health coverage.

Details aren’t clear, but it appears that — at least initially — the rest of the 2010 health law would remain, including the rule that says insurers must cover people with preexisting medical problems.

“We need an outcome, and if a so-called skinny repeal is the first step, that’s a good first step,” said Sen. Thom Tillis (R-N.C.).

Based on published reports, several Republican senators, including Dean Heller of Nevada and Jeff Flake of Arizona, appear to back this approach. It is, at least for now, being viewed as a step along the way to Republican health reform.

“I think that most people would understand that what you’re really voting on is trying to keep the conversation alive,” said Sen. Bob Corker, R-Tenn. “It’s not the policy itself … it’s about trying to create a bigger discussion about repeal between the House and Senate.”

But what if, during these strange legislative times, the skinny repeal were passed by the Senate and then became law? States’ experiences with insurance market reforms and rollbacks highlight the possible trouble spots.

Considering The Parallels

By the late 1990s, states such as Washington, Kentucky and Massachusetts felt a backlash from the coverage requirement rules they previously put on the individual market. When some of the rules were repealed, “things went badly,” said Mark Hall, director of the health law and policy program at Wake Forest University.

Premiums rose and insurers fled, leaving consumers who buy their own coverage, because they don’t get it through their jobs, with fewer choices and higher prices.

That’s because — like the Senate plan — the states generally kept popular parts of their laws, including protections for people with preexisting conditions. At the same time, they didn’t include mandates that consumers carry coverage.

That goes to a basic concept about any kind insurance: People who don’t file claims in any given year subsidize those who do. Also, those healthy people are less likely to sign up, insurers said, leaving them with only the more costly policyholders.

Bottomline: Insurers end up “less willing to participate in the market,” said Hall.

It’s not an exact comparison, though, he added, because the current federal health law offers something most states did not: significant subsidies to help some people buy coverage, which could blunt the effect of not having a mandate.

During the debate that led to passage of the federal ACA, insurers flat-out said the plan would fail without an individual mandate. On Wednesday, the Blue Cross Blue Shield Association weighed in again, saying that if there is no longer a coverage requirement, there should be “strong incentives for people to obtain health insurance and keep it year-round.”

About 6.5 million Americans reported owing penalties for not having coverage in 2015.

Polls consistently show, though, that the individual mandate is unpopular with the public. Indeed, when asked about nine provisions in the ACA, registered voters in a recent Politico/Morning Consult poll said they want the Senate to keep eight, rejecting only the individual mandate.

Even though the mandate’s penalty is often criticized as not strong enough, removing it would still affect the individual market.

“Insurers would react conservatively and increase rates substantially to cover their risk,” said insurance industry consultant Robert Laszewski.

That’s what happened after Washington state lawmakers rolled back rules in 1995 legislation. Insurers requested significant rate increases, which were then rejected by the state’s insurance commissioner. By 1998, the state’s largest insurer — Premera Blue Cross — said it was losing so much money that it would stop selling new individual policies, “precipitating a sense of crisis,” according to a study published in 2000 in the Journal of Health Politics, Policy and Law.

“When one pulled out, the others followed,” said current Washington Insurance Commissioner Mike Kreidler, who was then a regional director in the federal department of Health and Human Services.

The state’s individual market was volatile and difficult for years after. Insurers did come back, but won a concession: For a time, the insurance commissioner lost the power to reject rate increases. Kreidler, first elected in 2000, won the authority back.

Predicting the effect of removing the individual mandate is difficult, although he expects the impact would be modest, at least initially. Subsidies that help people purchase insurance coverage — if they remain as they are under current law — could help blunt the impact. But if those subsidies are reduced — or other changes are made that further drive healthy people out of the market — the impact could be greater.

“Few markets can go bad on you as fast as a health insurance market,” said Kreidler.

As for employers, dropping the requirement that those with 50 or more workers offer health insurance or face a financial penalty could mean some workers would lose coverage, but their jobs might be more secure, said Joe Antos, at the American Enterprise Institute.

That’s because the requirement meant that some smaller firms didn’t hire people or give workers more than 30 hours a week — the minimum needed under the ACA to be considered a full-time worker who qualified for health insurance.

The individual mandate, he added, may not be as much of a factor in getting people to enroll in coverage as some think because the Trump administration has indicated it might not enforce it anyway — and the penalty amount is far less than most people would have to pay for health insurance.

However, the individual market could be roiled by other factors, Antos said.

“The real impact would come if feds stopped promoting enrollment and did other things to make the exchanges [— the state and federal markets through which insurance is offered —] work more poorly.”

Why There’s No Substitute for the Individual Mandate

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http://www.commonwealthfund.org/publications/blog/2017/jul/no-substitute-for-the-individual-mandate?omnicid=EALERT1248041&mid=henrykotula@yahoo.com

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Republicans seeking to replace the Affordable Care Act (ACA) are finding it difficult to eliminate its individual mandate while maintaining protections for people with preexisting conditions. The mandate has succeeded in keeping young, healthy people in the insurance market. The alternatives under consideration won’t accomplish that and would cause some people harm.

Protections for people with preexisting health conditions can destabilize health insurance markets because these protections encourage people to sign up for coverage only when they need care. The ACA addresses this by requiring those who can afford it to buy insurance even if they’re not sick and imposing a penalty on those who fail to make timely coverage purchases. The mandate has been quite effective because people may or may not believe they will need health insurance, but they can be sure they will have to pay a penalty at tax time if they don’t purchase it.

The ACA’s mandate worked. Although some have argued the law’s penalties are insufficient, the evidence indicates that they did lead young, healthy people who could afford coverage to buy insurance. In 2013, just before implementation of the ACA reforms, the uninsured rate among college-educated men ages 26 to 34—the group most likely to be able to afford coverage but not see it as a priority—was 6.9 percent. By 2015, during the first full year of the mandate, that rate had dropped to 3.8 percent, a decline of 45 percent (Exhibit 1).

Republican proposals would replace the individual mandate with provisions that penalize people who don’t maintain continuous coverage, either by forcing them to pay a premium surcharge when they do sign up for coverage (House plan), or forcing them to wait six months for coverage (Senate plan). These proposals would therefore replace the ACA’s modest but predictable assessment with larger but far-off, uncertain penalties for not buying coverage.

Studies over more than half a century consistently show that in most situations people are more responsive to immediate and certain consequences than they are to far-off, uncertain ones.1 That result is even stronger in the context of our fragmented health care system. For the Republican penalties to encourage continuous coverage, people must believe there’s a good chance they’ll face consequences if they delay purchasing insurance. But in our health care system, they know they probably won’t.

In the individual insurance market, prior to the ACA’s reforms, penalties for delaying insurance were large, far-off, and uncertain—as in the current Republican proposals. Just as in the current Republican proposals, coverage in the nongroup market before the ACA was guaranteed renewable, meaning that once in the market, people could continue to obtain coverage at prices that did not reflect changes in their health status. But before the ACA, when people first entered the nongroup market after being uninsured, insurers could lock out those with health conditions, exclude preexisting conditions, or charge any level of premiums they wanted. Those very costly consequences ought to have provided a strong inducement to avoid breaks in coverage. But the reality is that very few people actually faced those consequences. Over a seven-year period, just 15 percent of those who lost their health insurance coverage ultimately made their way to the individual market (Exhibit 2). Instead, most people who switched coverage eventually moved to employer plans (as policyholders or dependents) or to Medicaid or Medicare, which have few penalties for delaying the purchase of insurance.

This is especially true for young people. Not only are these “young invincibles” less likely to believe they need health coverage, they assume that if they do eventually want it, they will be able to get it outside of the individual market. From 2003 to 2009, about 23 percent of those ages 55 to 63 with a change in coverage eventually entered the individual market. Just 12 percent of those ages 25 to 34 did so. Most young adults who had been uninsured eventually gained coverage through an employer plan. That’s a big reason why the large, but far-off and uncertain, penalties in the pre-ACA market were never enough to encourage many young, healthy people to sign up for individual coverage—and why the ACA mandate, by contrast, prompted so many of them to sign up.

The Republican penalties are not just likely to be ineffective in encouraging people to make timely insurance purchases. As with any arbitrary penalty, their burden would disproportionately fall on some people. Before the ACA, some unlucky people who lost coverage assumed they’d regain it through a job or public program, but guessed wrong. While uninsured, they became ill or got injured. Some may then have paid exceptionally high premiums for individual coverage, many went without care, and still others paid their health care costs out of pocket. In that last group were nearly 150,000 people who became uninsured each year and incurred more than $20,000 in out-of-pocket medical expenses; 20,000 of them incurred over $50,000 in expenses. That’s a hefty price to pay for an unlucky choice.

The Republican proposals to replace the individual mandate with large but uncertain penalties would leave us in the worst of both worlds: high prices for those who do participate in the market and hefty punishments for those who are unlucky. The proposals won’t persuade young, healthy people to enter, and help to stabilize, the individual market. And they will leave some unlucky people who gambled wrong, held off buying coverage, and got sick to face exorbitant costs.

 

Republican plan to ‘repeal and delay’ will leave millions more Americans uninsured

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http://www.politico.com/interactives/2017/republican-obamacare-repeal-uninsured-double/?lo=ap_a1

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Majority Leader Mitch McConnell wants to hold a vote on a bill that would repeal major parts of Obamacare and give Republicans two years to pass a replacement. A new CBO report finds that repealing Obamacare without a replacement would result in 32 million more Americans losing health insurance over a decade — far deeper coverage losses than any of the health plans Republicans have proposed. Further, 75 percent of Americans would live in areas without any insurers selling coverage in the individual market by 2026.

The latest GOP health plan would strike:

  •  Individual mandate
  •  Insurance subsidies
  •  Medicaid expansion
  •  Planned Parenthood funding

The bill would effectively kill Obamacare’s individual and employer coverage mandates, strike health insurance subsidies, roll back Medicaid expansion and defund Planned Parenthood.

Repealing Obamacare would more than double the number of Americans without health insurance.

Under Obamacare, 10 percentof Americans would lack health insurance.

But if Republicans repeal Obamacare, the number could grow to 21 percent by 2026.

NOTE: Data includes Americans under 65 who do not have health insurance and does not include persons who are Medicare-eligible.
SOURCE: Congressional Budget Office

The uninsured rate plunged under the ACA, but would now skyrocket

ACARepeal ACA0510152025%1997201020172026Before the ACAACA passed10%21%
NOTE: Data includes Americans under 65 who do not have health insurance
SOURCE: National Center for Health Statistics and the Congressional Budget Office

In the first year alone, nearly 17 million more people would no longer have insurance — or (16 percent) of Americans. That includes 10 million fewer buying plans on the individual market, 4 million fewer people covered through Medicaid, and 2 million fewer with job-based coverage.

But once Medicaid expansion and subsidies were repealed (roughly two years after enactment), the number of uninsured Americans would increase by 27 million in 2020. By 2026, about 59 million people or 21 percent of Americans would be uninsured.

Millions of Americans Would Face a Six-Month Waiting Period to Get Health Insurance Under the Senate’s ACA Repeal Bill

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http://www.commonwealthfund.org/publications/blog/2017/jun/waiting-period-under-senate-aca-repeal-bill?omnicid=EALERT1233535&mid=henrykotula@yahoo.com

Senate Republicans this week added a provision to their bill aimed at repealing and replacing the Affordable Care Act (ACA). The new provision of “The Better Care Reconciliation Act” replaces the ACA’s individual requirement to have health insurance or face a tax penalty with a requirement to maintain continuous coverage. Anyone who applies for insurance in the individual market will be forced to wait six months for their coverage to begin if they had a gap in their insurance of more than 63 days in the prior year.  People enrolling either during an open enrollment period or in a special enrollment period are subject to the waiting period. Even newborn or adopted children could face a waiting period if they were not enrolled within 30 days of birth or adoption.

Data from the 2016 Commonwealth Fund Biennial Health Insurance Survey indicate that if such a policy had been in effect in 2016, an estimated 21 million working-age adults would have been locked out of coverage for six months had they tried to buy a health plan in the individual market.

How Many People Would Be Subject to the Waiting Period?

The Biennial Health Insurance Survey shows that in 2016, 21 percent of adults ages 19 to 64, or an estimated 40 million people, experienced a gap in their health insurance. These adults reported that they were either uninsured at the time of the survey, or that they were insured and had a gap in coverage earlier in the year.

Among this group with a gap in insurance, 75 percent, or about 30 million people, had been uninsured for more than three months, which is longer than the 63-day gap period allowed under the Senate bill.

Among the 30 million people with a coverage gap, 2 million had individual market coverage at the time of the survey and 19 million were uninsured. Had the Senate bill been in effect in 2016, 2 million people would have been forced to wait six months before their coverage kicked in. And up to 19 million people would potentially have to wait if they were to try and sign up for individual market coverage.

Those who were able to gain employer coverage or Medicaid would have been spared the six-month waiting period. Unlike the ACA individual requirement to have health insurance, the Senate bill’s requirement to maintain continuous coverage is not a universally shared responsibility. It affects those Americans whose only option for coverage is the individual market.

Policy Implications

The ACA individual mandate is reviled by the law’s opponents. Many believe that the penalties for not having coverage are too small relative to premiums to encourage those who place a low value on insurance to enroll. To encourage greater enrollment, policymakers could increase the ACA penalties and lower what people pay in premiums by increasing subsidies.

But the Senate bill’s continuous coverage requirement is a punitive substitute for the ACA mandate. People who lose their jobs and their insurance during the year and don’t find a new job with health benefits within the 63 day period could find themselves facing a half-year waiting period, even if they wait until the open enrollment period to apply for a plan. During that lengthy time without insurance, people could be diagnosed with cancer or have a serious accident that could leave them with catastrophic medical costs. Or they might avoid care entirely.

The CBO estimate projects that just next year 15 million people will become uninsured, mainly because of the repeal of the individual mandate penalty. Not only will the Senate bill provision potentially inflict suffering on millions of people, the CBO estimates it will do little to stabilize the markets.

 

The Senate health bill is out. Here’s your speed read

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https://www.axios.com/the-senate-bill-is-out-heres-your-speed-read-2446201141.html

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You can read it here, and a summary here. The highlights:

  • Ends the Affordable Care Act’s mandates and most of its taxes.
  • Phases out its Medicaid expansion over three years, ending in 2024.
  • Limits Medicaid spending with per capita caps, or block grants for states that choose them. The spending growth rate would become stricter in 2025.
  • States could apply for waivers from many of the insurance regulations.
  • The ACA’s tax credits would be kept in place, unlike the House bill — but their value would be reduced.
  • Funds the ACA’s cost-sharing subsidies through 2019, but then repeals them.

Want more? Keep reading.

  • There’s a stabilization fund to help states strengthen their individual health insurance markets.
    • $15 billion a year in 2018 and 2019, $10 billion a year in 2020 and 2021.
    • There’s also a long-term state innovation fund, $62 billion over eight years, to help high-cost and low-income people buy health insurance.
  • The ACA tax credits continue in 2018 and 2019.
  • After that, they’d only be available for people with incomes up to 350 percent of the poverty line.
  • The “actuarial value” — the amount of the medical costs that insurance would have to cover — would be lowered to 58 percent, down from 70 percent for the ACA’s benchmark plans. That’s likely to reduce the value of the tax credits.
  • All ACA taxes would be repealed except for the “Cadillac tax” for generous plans, which would be delayed.
  • Medicaid spending growth rate under per capita caps would be same as House bill until 2025. Then it switches to the general inflation rate, which is lower than House bill.
  • States would be able to impose work requirements for people on Medicaid, except for the elderly, pregnant women and people with disabilities.
  • Children with complex medical needs would be exempt from the per capita caps.

ObamaCare uncertainty driving premium hikes

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ObamaCare uncertainty driving premium hikes

ObamaCare uncertainty driving premium hikes

Uncertainty among insurers about how the Trump administration will handle the Affordable Care Act could translate into double-digit premium increases for 2018.

Insurers are beginning to file rate requests with state insurance regulators, and some states could see premium increases of 50 percent or more.

Insurers are worried about how President Trump’s plans for -ObamaCare — particularly whether the requirement for individuals to buy insurance will remain and whether insurer subsidies for covering low-income enrollees will continue.

“It’s a significant factor in pricing this year,” said Cynthia Cox, a health insurance expert with the Kaiser Family Foundation.

“I think it’s fair to say these rates are higher than we would have expected to see in the absence of uncertainty.”

Insurers also blamed rate increases on an unbalanced risk pool — which means there are too many sick, expensive patients and not enough healthy ones — higher claims for medical care and drugs, and the reinstatement of an -ObamaCare tax on health insurers.

Maryland’s largest health insurer, CareFirst BlueCross BlueShield, is proposing an average rate increase of more than 50 percent.

In a statement, CareFirst said the “lack of clarity” about whether the individual mandate would be enforced played a “significant role” in its proposed rate increases.

“Failure to enforce the Individual Mandate makes it far more likely that healthier, younger individuals will drop coverage and drive up the cost for everyone else,” CareFirst said in a statement.

The company is also requesting premium increases of 35 percent in Virginia and 29 percent in Washington, D.C.

Another Maryland insurer, Evergreen Health, is requesting rate increases of 27 percent, blaming uncertainty about -the ObamaCare insurer payments and the enforcement of the individual mandate as the “primary driver.”

In Connecticut, Anthem is requesting an average premium increase of 34 percent for plans on the -ObamaCare exchanges. The state’s other exchange insurer, CTCare, is requesting a 15 percent increase.

Rate requests must be reviewed and approved by state regulators and can often change.

Connecticut and Maryland both have earlier filing deadlines than most other states, which align more closely with the federal deadline of June.

Still, these states have been a good indicator of how insurers in other states will set their premiums, Cox said.

Because -ObamaCare subsidies are designed to increase as premiums go up, the people most affected by rate hikes would be those with higher incomes getting insurance through the exchanges and people getting insurance in the individual market.

It is difficult for insurers to price plans when they don’t know what will happen to -ObamaCare next year.

Can Obamacare Survive Another Round in the Congressional Boxing Ring?

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http://www.realclearhealth.com/articles/2017/04/25/can_obamacare_survive_another_round_in_the_congressional_boxing_ring_110564.html?utm_source=RC+Health+Morning+Scan&utm_campaign=2fcc8f4477-EMAIL_CAMPAIGN_2017_04_25&utm_medium=email&utm_term=0_b4baf6b587-2fcc8f4477-84752421

Can Obamacare Survive Another Round in the Congressional Boxing Ring?

The Affordable Care Act (ACA) has survived its biggest challenge to date with the failed attempt to repeal and replace by the GOP. But will it survive in the long run? Republican comments and President Trump’s many tweets would suggest the law is still doomed. It is hard to predict what will happen, but let’s examine some themes we are seeing so far to try to gain some insight:

One of the first things the GOP Congress wanted was to retract the cost sharing payments to insurers for low-income exchange plan members. Without these payments, insurers would lose even more money, driving many of them to not offer plans in the state exchanges. The jury is still out on whether the replacement bill’s failure will move the budget reconciliation process forward, but insurers have only two months to decide if they will provide a plan in the exchanges for 2018. If insurers do decide to stay in the exchanges, significant premium increases are very likely to help cover their costs. This will force many people who cannot afford the monthly cost to drop out of coverage. Either of these situations would push people back into the uninsured ranks where providers would lose that reimbursement revenue and drive up uncompensated care.

Loosening the individual mandate’s enforcement is another theme being discussed. New HHS Secretary Price has stated he plans to allow states to loosen the restrictions on waivers for the individual mandate. Combined with premium increases, this would allow people to opt out of coverage much more easily. The CBO report has stated 7 million people would have opted out of coverage if the American Health Care Act (AHCA) had been passed, since many people do not think they need it. Most of these people would be younger and healthier, creating higher costs for insurers, while driving up premiums and/or driving insurers to exit the exchange.

Secretary Price has also mentioned giving states the ability to set requirements to individuals to maintain Medicaid coverage, like applying for work. Studies have shown in the past this activity causes people to fall out of coverage. It is expected that this move would cause many to fall off the Medicaid roles and drive them to the uninsured ranks as well.

The federal deficit is upwards of $540 billion for 2017. And If the ACA does not change at all, then the federal government is expected to spend $1.2 trillion on Medicaid coverage alone through 2026. Previous CBO estimates indicate this would drive our yearly national deficit to over a trillion dollars in 10 years. The U.S. economy survives today because financial institutions buy treasury bonds to fund that deficit each year. But when deficits reach the heights predicted if the ACA remains entirely intact, and the national debt reaches a significant portion of our yearly GDP, bond sales could and likely will slow down. That means damage to the U.S. economy as it continues to stabilize post-recession.

A federal budget has been submitted that makes some spending cuts, but without the AHCA’s passage they pale when faced with the real problem of balancing our budget. This is not an indictment of policy to cover people with insurance, but simply a fact that our nation must find a way to balance our finances. There are many ways to cut cost, but the GOP seems fixated on cutting Medicaid spending as the key to accomplishing this.

We can only theorize what might become of the ACA, but looking at some of the themes and recent comments by the current administration, it would appear some things will change if not a complete revisit of the repeal and replace bill. Will those changes effectively kill the law since it will lack the ability to function as planned? Quite possibly, but only time will tell.

Change will happen. It will result in some sort of reimbursement cuts and very likely push more people back to the uninsured roles. Providers need to ready themselves, and start thinking about ways to improve productivity and reduce the cost to collect while increasing cash collections.

Shawn Yates serves as Director of Product Management for Ontario Systems, defining the company’s strategy for product and service offerings in the health care market. With over 20 years of experience managing self-pay receivables and collection operations for a top 20 health care system, Shawn’s background also includes working for a national outsourcing company helping clients manage their insurance and self-pay receivables, and Experian Health, the largest data and analytics company in the country.

The views above belong solely to the author.

What Trump Can Do Without Congress to Dismantle Obamacare

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House Republicans left for spring break last week, without reaching a deal to repeal and replace the Affordable Care Act. Their bill to overhaul the health care system collapsed on the House floor last month, amid divisions in the caucus.

Even without Congress, however, President Trump has the authority to modify important provisions of the health law, including many that House Republicans sought to change or repeal. Here are some examples of actions he could take (or has already taken):

A warning from the polls about letting Obamacare “explode”

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https://www.axios.com/a-warning-from-the-polls-about-letting-obamacare-explode-2347777457.html

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President Trump has said the Democrats will take the fall politically if and when Obamacare “explodes.” But new polling shows that the public will hold Trump and the GOP accountable for failing to address problems in the marketplaces, not the Democrats. That means they’ll have to think twice about some of the moves they might make that could make the Affordable Care Act’s problems worse.

What’s on the line: The polling has direct implications for some of the specific actions Republicans could take, or not take, in the months ahead:

  • Eliminating the $7 billion in federal cost sharing subsidies to insurers to compensate them for providing smaller deductibles to lower income enrollees.
  • No longer enforcing the individual mandate that helps get younger, healthier people into the insurance pools to lower premium costs.
  • No longer marketing the healthcare.gov plans to boost enrollment.

These steps would cause insurers to exit the non-group market, cause premiums to spike, and could leave millions without affordable coverage.

As the chart from our latest tracking poll shows, 62% of the public say Trump and the Republicans in Congress are in charge of the government and are responsible for problems with the ACA from now on; just 31% say President Obama and the Democrats are responsible. As is always the case with the ACA, there are party differences; 81% of Democrats and 65% of Independents said Trump and the Republicans “own it”, but just 35% of Republicans feel that way.

Trump has also said that the collapse of the ACA would bring Democrats to the table to forge a new “deal” with him on health care. That’s not impossible, but it seems unlikely: it’s hard to think of a single major element of health reform where the Democrats agree with the president and the Republicans.

As we saw when the Freedom Caucus refused to support the American Health Care Act because it wasn’t conservative enough for them, the substance and the details matter to policymakers far more than they appear to the President. He has suggested that he mostly wants a deal on health care.

Basic rules of politics seem to be holding up pretty well in the fights over the ACA. One rule, that benefits once conferred on the American people cannot be taken away, was a primary reason for the collapse of the GOP health care plan. The other: If severe problems develop in the marketplaces, or are caused by actions the administration takes to undermine the law, the party in charge gets the blame.