Health Care in America – The Experience of People with Serious Illness

http://features.commonwealthfund.org/health-care-in-america?_ga=2.69920404.568922675.1539785477-833267550.1532293701

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Listening to People with Serious Illness

These are just a few of the many voices of people with serious illness. They express the bewilderment and the loss of control. They convey fear that the system is indifferent to their needs and that the cost of care is beyond their reach. They reflect the joy of feeling well enough to get back to the familiar parts of life.

Most Americans expect the health care system will deliver effective treatment and support them through trying times when they get sick. But in reality, health care in America sometimes hurts even as it helps. Appointments can be difficult to get. Clinics and emergency rooms are often overcrowded. Doctors’ recommendations can be confusing and difficult to follow. And when the bills arrive, the costs can be unexpected and devastating. More than 40 million adults in the United States experienced serious illness in the past three years. More than 41 million provided unpaid care to elderly adults during the past year.

Health Care in America: The Experience of People with Serious Illness, a project of the Harvard T.H. Chan School of Public Health, the New York Times, and the Commonwealth Fund, is examining the experiences of Americans with serious illness — the sickest of the sick — and those who help care for them. Our goal is to understand whether our health care system is doing all it can do not just to treat illness but to help people cope with illness. Where is the system failing to meet people’s needs? How is it adding to already heavy burdens? Can the most seriously ill Americans afford the care our health system delivers?

To help answer these and other questions, we surveyed nearly 1,500 Americans with serious illness and the friends or family members caring for them. We considered someone to have serious illness if, within the past three years, they had two or more hospital stays and visits with three or more doctors. Below we discuss what we found. We then point to opportunities to help ensure that American health care not only saves people but also supports them in their time of need.

Serious Illness: A Life-Altering Journey

People going through serious illness often experience profound loss: loss of control, loss of independence, loss of time, and the loss of capabilities that most of us take for granted. The physical, emotional, and financial toll can be life-altering. It can mean an end to the activities that give life pleasure; growing isolation from friends, family, and familiar places; and an inability to work or support others. And there is the worry of being a burden on family and friends.

People with serious illness experience distress over and above the physical symptoms of their specific condition. And our new survey reveals that many are distressed. Sixty-two percent feel anxious, confused, or helpless at some point. Nearly half have emotional or psychological problems. Social isolation, a known risk factor for worse health outcomes, is common, with one-third of respondents reporting feeling left out, lacking in companionship, or isolated from others.

Many people with serious illness want to continue working or continue to provide care for family and friends who need their help, but they face high hurdles. Nearly three of four have had problems related to work or their ability to care for others (Appendix 1). Half reported being unable to do their job as well as they could before. Twenty-nine percent lost a job or had to change jobs. Half reported wanting to work but being unable to do so.

Our Health Care System Often Adds to the Burden of Illness

It’s fair to say that several consequences of serious illness — the distress, isolation, confusion, and lost earnings — are simply part of being sick. In some cases, they are probably inevitable. But being sick in America also means carrying some burdens that our health care system foists upon us.

Americans have high expectations for their health care. Most believe that when serious illness strikes, their health professionals will be fully prepared to make a diagnosis and provide appropriate treatment. This belief is not wholly unwarranted, of course. News stories brim with pioneering medical advances. For people with what were once fatal and untreatable diseases, there are now cures. Once harrowing chemotherapy regimens have been replaced by pills taken once a day. New technologies are improving the quality of life for many people with serious disabilities.

A health care system that promises so much would seem capable of minimizing the burdens of illness and care, of helping people cope. But for too many, American health care does the opposite: it places unexpected and unnecessary burdens on the sick. People struggle to obtain effective treatments and services. Pervasive fragmentation and lack of coordination across the health system make obtaining services heavy labor for people with advanced illnesses or frailty.

How common are such problems for this vulnerable group? In our survey, six of 10 people with serious illness reported at least one problem receiving care (Appendix 2). The difficulties people reported are symptomatic of the confusing patchwork that is health care in the United States. Nearly a third of those with serious illness spoke of trouble understanding what their health insurance covered. Twenty-nine percent reported being sent for duplicate tests or diagnostic procedures by different doctors, nurses, or other health care workers. Twenty-three percent of respondents said they experienced a problem with conflicting recommendations from the health professionals that saw them. One of five had difficulty understanding a doctor’s bill — a confusion not just about the costs of care but about what services were provided.

Unnecessary tests and procedures are not only redundant and costly. They carry their own risks to health. Safety in health care is, in fact, an ongoing challenge, especially for patients requiring complex care plans. Nearly one of four adults in our survey reported a serious medical error in their care. We know from other studies that people with serious illness are especially prone to diagnostic errors, prescribing errors, and communication mishaps. Every doctor and many patients can recall missed abnormal lab results, failure to account for allergies, and lost information that led to terrible side effects, or even death.

Paying for Care: Teetering on the Edge of Financial Ruin

Health care can be extraordinarily expensive for anyone, but especially so for people with serious illness. Millions of Americans are ruined financially by the costs of their treatment. Although most survey respondents reported having insurance coverage, nearly one in 10 were uninsured. Even with coverage, many are not adequately protected from health care costs. More than half of people with serious illness in our survey (representing more than 21 million people) experienced one or more dire financial consequences related to their care (Appendix 3).

Apart from its sometimes lasting health consequences, serious illness also appears to cause long-term financial problems for many. More than one-third of survey respondents used up most or all of their savings. Nearly one-quarter were unable to pay for basic necessities like food, heat, or housing. Nearly a third were contacted by a collection agency for unpaid bills. And the financial consequences are not felt by patients alone. More than one in four survey respondents reported that the costs of care placed a major burden on their family.

What Can Be Done to Improve the Experience of the Seriously Ill?

The burdens described above are not an inevitable companion to serious illness. They are a consequence — at times inadvertent, but no less real — of how our health system operates today. But things could be different. It is fully within our means as a nation to improve the experience of the millions of Americans living with serious illness and the millions more who help care for them.

In fact, strategies for delivering a better health care experience — one that ensures comprehensive, holistic care while always respecting the dignity of the individual — already exist. They just need to be adopted on a much wider scale.

  1. Build the capacity to identify and manage the behavioral health needs of patients and their caregivers. Integrating behavioral health services into medical care requires more than simply improving communication among siloed professionals. Multidisciplinary care teams that include behaviorists, social workers, and patients working together can ease the sense of helplessness, the loss, and the social isolation that seriously ill people commonly experience.
  2. Assess and address social service needs. Our findings illustrate that the impact of serious illness extends well beyond the medical realm. Many people cannot work while dealing with a life-threatening condition. This means fewer resources at a time when expenses can increase dramatically. Access to and support for reliable transportation, supportive housing, nutritious meals, and other services are critical to helping the seriously ill maintain a level of well-being.

  3. Make it easier for patients, caregivers, and professionals to work in close coordination with one another. Patients want their clinicians and other providers to talk to each other — and they want in on the conversation, too. Providers can improve communication with each other, with patients, and with caregiving family members and friends by taking full advantage of advances in consumer-friendly digital tools like secure texting, email, telehealth, and social media platforms. Coordination could be further enhanced by care managers or community health workers who check in on patients and caregivers between appointments and connect them to needed services.
  4. Make care more affordable. Universal health insurance coverage is a fundamental protection against the cost of unexpected illness. It not only guards against the threat of financial ruin but minimizes the costs incurred by everyone else when sick people who are uninsured (or underinsured) show up in emergency rooms or hospitals, which by law must treat everyone in need of care. Guaranteed coverage of preexisting conditions is especially important to those who have experienced serious illness and would otherwise be denied coverage by insurers. Keeping out-of-pocket costs like copayments and coinsurance reasonable not only prevents bills from going unpaid but makes it easier for patients to stick with their preventive care regimen, avoid repeated emergency room visits and hospitalizations, and maintain progress in their treatment.

Conclusion

Americans have high expectations for their health system. They spend more than the citizens of any other country with the hope that the right care will be there for them when serious illness strikes. But along with the treatments and services that can improve life for the seriously ill come an unwanted and unnecessary set of physical, emotional, and financial burdens. These burdens result from the choices made by policymakers, practitioners, payers, and others. Listening to the voices of people with serious illness, reckoning with the human costs of our current system, and lifting the burdens that health care places on us when we become sick may be the most important work health care can undertake.

 

Test for the ACA

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The politics and substantive rules of the road for the Affordable Care Act are more stable now than they have been in years. But chaos is never far away.

What to watch: The upcoming ACA enrollment season, which starts Nov. 1, will be the first one with the Trump administration’s agenda fully in place, and it will test just how effective that agenda is.

  • For the first time, the ACA’s individual mandate won’t be in effect, and consumers will actually be able to the buy cheaper, skimpier insurance plans the Trump administration has been positioning as an alternative to ACA coverage.
  • Insurers don’t like some of these changes on the merits. But they’ve known all this was coming, and generally feel they have a pretty good handle on how badly these policies will affect the market for ACA coverage. The next enrollment window will tell them whether they guessed correctly.

This period of relative certainty could come undone in court.

  • The very early tea leaves suggest that the latest legal challenge to the ACA might have more legs than legal experts initially thought.
  • The red states leading that lawsuit want the courts to strike down the entire law; the Trump administration wants them to only strike down protections for pre-existing conditions. Either outcome would plunge health care back into policy and political chaos.

The bottom line: We’re either adjusting to the new normal, or in the calm before the storm. A federal judge in Texas and a six-week enrollment period will tell us which. — Sam Baker

Sign up for Sam’s daily Vitals newsletter here.

GOP defeats bid to cancel expansion of Obamacare-evading plans

https://www.washingtontimes.com/news/2018/oct/10/gop-defeats-bid-cancel-expansion-obamacare-evading/

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Senate Republicans turned back a Democratic bid Wednesday to kill President Trump’s plan to expand the sale of health plans that fall short of Obamacare’s rules, saying Americans who buy insurance on their own need more options, not fewer.

Sen. Susan Collins, Maine Republican, sided with Democrats in the 50-50 vote, though the resolution needed a majority to advance.

Its defeat was never in doubt, really, though the vote allowed Democrats to paint Republicans as “junk plan” peddlers who don’t care about people with preexisting conditions who might pay more for robust coverage, as healthier people who cross-subsidize their costs ditch Obamacare for skimpier options.

This administration wants to let these junk insurance plans run rampant and let people be duped into thinking they’re having insurance when it covers almost nothing,” Senate Minority Leader Charles E. Schumer said. “They are a massive risk to any family who purchases them, and worse, they cause rates to go up for everyone else.”

Democrats are elevating their defense of health coverage for sicker Americans this mid-term season, citing polling that shows GOP threats to undo Obamacare’s protections for preexisting conditions are unpopular.

Sen. Tammy Baldwin, Wisconsin Democrat facing re-election, pushed Wednesday’s resolution under the Congressional Review Act, which gives Capitol Hill a chance to veto new rules and regulations.

She targeted a Trump rule, finalized in August, that would allow companies to sell “short-term” health plans that fall short of Obamacare’s full coverage menu, and to allow Americans to hold the plans for up to a year.

President Barack Obama himself allowed consumers to hold short-term insurance for a full year until 2016, when he capped short-term plans at three months.

Republicans were quick to point that out, although Mr. Trump’s regulation would let consumers renew for an additional two years.

The administration and its GOP allies say Americans have been priced out of Obamacare’s market, so invalidating Mr. Trump’s attempt to extend a lifeline would be cruel.

“Surely, they must have a better answer than snatching away one of the remaining options that some Americans still prefer,” Senate Majority Leader Mitch McConnell said.

“Our constituents deserve more options, not fewer,” he said. “The last thing we should do is destroy one of the options that still is actually working for American families.”

 

The Health 202: Preexisting Conditions

https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2018/10/12/the-health-202-republicans-play-defense-on-preexisting-conditions/5bbf91061b326b7c8a8d194b/?utm_term=.1a2bca86b60d

THE PROGNOSIS

With less than a month before the midterm elections, endangered Republican lawmakers are mounting a defense against attacks they’re trying to dismantle a core element of the health-care law they fought to eliminate.

Democratic candidates on the campaign trail now regularly accuse Republicans of wanting to take away health-care protections for people with preexisting conditions. They’ve pointed to a lawsuit brought by 20 attorneys general in Republican-led states aiming to overturn the Affordable Care Act as proof the GOP wants to let such protections go down with the health-care law. That’s after Republicans whiffed in their effort to repeal and replace the ACA  last summer.

Vulnerable Republican contenders are responding to the slams by airing campaign ads saying they embrace this portion of the ACA. They’re also introducing a wave of bills in Congress they say would protect those with prior illnesses from losing access to affordable health care. But experts question the efficacy of those measures, saying they seem more designed as protection against Democratic attacks than significant policy solutions, as I helped report in a story with Colby Itkowitz this week.

In August, 10 Senate Republicans, including Sen. Dean Heller of Nevada, one of the most vulnerable GOP senators facing reelection in November, sponsored a bill to guarantee protections for patients with preexisting conditions regardless of whether the ACA is struck down in court.

The bill, spearheaded by Sen. Thom Tillis (R-N.C.), would guarantee that insurers sold plans to individuals regardless of whether they have preexisting conditions. But critics and health-policy experts contend the bill leaves a loophole that would exclude coverage for certain services associated with those conditions. For example, a person with cancer wouldn’t be denied coverage, but the insurer wouldn’t be required to cover that patient’s cancer treatments.

Larry Levitt, senior vice president for health reform at the Kaiser Family Foundation, explained the Justice Department’s argument in the Texas lawsuit that certain provisions of the ACA should be thrown out, including a “preexisting condition exclusion prohibition.”

Levitt said that such exclusions were common before Obamacare. While Tillis’s bill would restore some parts of the ACA if the Texas lawsuit is successful, it wouldn’t change rules that prohibit insurers from excluding coverage for those with prior illnesses.

“The thing about insurance regulation is it’s kind of like plumbing: A small leak becomes a big leak,” Levitt said. “Insurers would take advantage of that loophole.”

Tillis spokesman Daniel Keylin pushed back on those criticisms and said they are based on an assumed outcome of the Texas lawsuit.

Keylin said there have been “misleading and inaccurate claims made about this bill, claims that assume the courts will strike down the entirety of the Affordable Care Act in Texas versus United States.”

Keylin said the Tillis bill wasn’t meant to be “comprehensive health-care legislation,” or the “totality of Congress’s answer to the Affordable Care Act falling.”

“There is obviously no ironclad way to precisely predict how the court will rule. However, this legislation is an important preemptive step toward getting feedback, hashing out ideas, and underscoring the importance of protecting Americans with preexisting conditions,” Keylin said

He said Tillis would consider “modifications or amendments” to the measure if the court ruling goes beyond what the bill addresses.

On the House side, Rep. Steve Knight (R-Calif.), locked in a tight race in California’s 25th district, introduced a bill last month similar to Tillis’s proposal. Two other vulnerable Republican congressmen also introduced nonbinding resolutions affirming their support for protecting those with preexisting conditions, though neither contains substantive policy solutions.

Iowa Republican Rep. David Young’s resolution says regardless of what happens to the ACA, Congress should retain protections for preexisting condition. Texas Republican Rep. Pete Sessions’s resolution says states should be allowed the authority to restructure their individual health-care marketplaces, but should ensure people with preexisting conditions can access affordable coverage.

“It seems not to be politically acceptable anymore to be against protecting people with preexisting conditions,” Levitt said, pointing to all the Republican proposals. “If you look at an example, like Sen. Tillis’s bill, it shows how wide a gap there can be between a state of desire to protect people and the reality of what an actual piece of legislation does.”

For their parts, spokespeople for Young and Sessions said the congressmen’s views on protecting patients with certain conditions are not new. In a statement, Knight said he has “always advocated” for such coverage.

“He’s always been supportive of protecting preexisting conditions going back to the [American Health Care Act]. This is just another step,” Young spokesman Cole Staudt said.  “This is not a new position for him.”

Sessions, Young and Knight voted to repeal the ACA, though Young co-sponsored an amendment to the Republican bill that would have buffered the impact of the repeal on people with preexisting conditions. Staudt added  that Young would consider introducing  legislation in the future depending on the outcome of the Texas lawsuit.

Yet Joel Ario, managing director of Manatt Health and former director of the Health and Human Service’s Office of Health Insurance Exchanges, said any proposal that “deviates from what was originally in the ACA as a single risk pool concept is going to disadvantage people with preexisting conditions.”

He pointed to Republicans’ record opposing individual pieces of Obamacare, pointing to the elimination of the individual mandate in the GOP tax overhaul:  “Anybody who voted for the mandate repeal voted against people with preexisting conditions,” he said.

Ario called GOP messaging ahead of the midterms a response to public polling that shows how important preexisting condition coverage is to voters.

“Republicans are trying to play into public support for protecting preexisting conditions,” he said, adding they’re “ignoring the fact that their previous action disadvantaged people with preexisting conditions.”

 

Coverage for pre-existing conditions lives on, even though the Affordable Care Act seemed doomed

https://www.statnews.com/2018/10/10/coverage-preexisting-conditions-lives-on-aca/

The most enduring legacy of the Affordable Care Act may be emerging now in midterm races across the country, and our health care system may never be the same.

For the first time in our history, Americans are agreeing that even if you are sick you should be able to find private health insurance coverage you can afford. Not only do 81 percent of voters now think it should be illegal for insurance companies to deny coverage to people with pre-existing conditions, but both political parties have embraced this central tenet of Obamacare.

Responding to Democratic attacks and polling data, Republicans are backpedaling from opposition to the Affordable Care Act’s guarantees that the more than 50 million Americans with pre-existing conditions should be able to find coverageWriting last month in the Wall Street Journal, Republican strategist Karl Rove urged candidates to embrace the pre-existing condition guarantee, but to find new conservative strategies for securing it.

This development is historic. Before the passage of the Affordable Care Act, Americans broadly embraced a national obligation to insure the elderly, the poor, and the disabled. We’ve now added the sick to this list. If the past is prelude, there will be no retreating from this commitment. Once acknowledged, commitments like Medicare and Medicaid are virtually impossible to claw back.

As policymakers look to respond to this newfound promise to the sick, they will be confronted with the harsh reality of private health insurance markets: The only way insurers can offer affordable coverage to the sick is if they have a substantial number of healthy enrollees.

Many of the ACA’s most controversial provisions are aimed at providing private insurers a steady supply of good risks. This includes the much-vilified individual mandate, as well as restrictions on the sale of skimpier, cheaper policies, such as short-term health plans, that appeal to healthy purchasers and siphon them away from the risk pools that cover less-healthy consumers. The ACA also provided temporary reinsurance that protected private plans against unpredictable, catastrophic losses likely to occur when they cover very sick clients. That provision, however, has expired.

The challenge facing policymakers going forward will be how to execute this new guarantee that the sick have access to private insurance. A wide variety of options spanning the political spectrum exist, but virtually all require some form of government involvement.

The left proposes that, if private companies don’t step up, the federal government should fill in by allowing consumers with pre-existing conditions (or even those without them) to buy into Medicare or Medicaid. As Medicare and Medicaid are among our nation’s most cost-effective insurers, this could be a way of expanding coverage while keeping costs in check.

Another alternative would be to build on the Affordable Care Act’s current provisions that require insurers to cover pre-existing conditions, prevent insurers from charging more for those conditions, and provide strong financial incentives for healthy individuals to purchase private marketplace plans. Despite the repeal of the individual mandate and other attempts to undermine the ACA, private insurance markets created by the ACA have shown considerable resilience, with premiums actually declining this year for the first time since the ACA was enacted.

Republicans have released legislation that would amend the Health Insurance Portability and Accountability Act to require insurance companies to sell plans to people with pre-existing conditions and not charge them more because they have been, or are, sick. Insurers, however, would be able to deny coverage for specific illnesses. In other words, insurers would have to sell coverage plans to people with pre-existing conditions, say diabetes, but would not have to cover their diabetes. Insurance companies could also increase premiums based on age, gender, or occupation.

Another Republican approach, discussed during the “repeal and replace” debate, would make available subsidized plans, such as the ACA, but increase premiums over time if individuals failed to purchase them at the outset. In theory, healthy individuals would jump into the pool to avoid paying a penalty at a later date. This is an approach used under Medicare Part B, a voluntary program that covers outpatient services, that has been fairly effective and politically acceptable.

Whether it would work outside of Medicare and avoid the need for more intrusive government intervention remains to be seen. The elderly are much more likely to feel that they need insurance and to respond to incentives to get it earlier rather than later, while younger, healthier people may be more reluctant to buy and then end up priced out of the insurance market.

These and other routes toward coverage for sick Americans will be fiercely debated in the coming years. As we do so, we shouldn’t lose track of the profound change in attitude and expectations around health insurance for the sick that will animate this debate.

Elected officials should expect to be held accountable this November, and for many Novembers to come.

 

 

 

The Health 202: The rate of people without health insurance is creeping upward

https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2018/09/13/the-health-202-the-rate-of-people-without-health-insurance-is-creeping-upward/5b99569b1b326b47ec95958c/?utm_term=.ae9e8af79dd2

 

THE PROGNOSIS

New Census Bureau data on the number of uninsured Americans is either a testament to the resiliency of the Affordable Care Act or a sign that President Trump’s anti-ACA rhetoric and policies are starting to work.

As our colleague Jeff Stein reported Wednesday, there was a slight uptick in the number of Americans without health insurance in 2017 compared to 2016, even though that number essentially remained statistically flat. Still, the fact that uninsured rate went up at all, by about 400,000 people, marks the first time since the ACA’s implementation that the uninsured rate didn’t drop. 

Supporters of the ACA worry the news marks the beginning of a trend, especially when some of Trump administration policies intended to circumvent the ACA go into effect next year.

Ahead of open enrollment last year, the Trump administration dramatically decreased funding for any Obamacare outreach or advertising, limited resources for “navigators” who help people find an insurance plan, and shortened the window for people to sign up for insurance from three months to six weeks in states that use a federally run marketplace.

“Even with all of that, health coverage stayed steady. But at the same time, we’d like to see further progress in the rate of the uninsured,” said Judith Solomon of the Center on Budget and Policy Priorities.

It’s part of a pattern to weaken the 2010 health-care law known as Obamacare. After the GOP Congress failed to repeal and replace the ACA last summer, the Trump administration moved to dilute the law in other ways: including signing off on a plan to eliminate the individual mandate penalty next year; allowing individuals to buy skimpier, short-term health plans without certain coverage requirements under Obamacare; and seeking to allow states to put conditions on Medicaid coverage.

Some of the most prominent health care organizations in the country came together this morning to voice their disapproval of those short-term plans — including the American Cancer Society Cancer Action Network, the American Heart Association, Planned Parenthood Federation of America, the National Women’s Law Center, the , American Academy of Family Physicians, the American Academy of Pediatrics and Families USA.

“The Administration’s decision to expand short-term health plans will leave cancer patients and survivors with higher premiums and fewer insurance options,” said Dr. Gwen Nichols, chief medical officer of the Leukemia & Lymphoma Society.

The groups’ statements, compiled and released by Sen. Tammy Baldwin (D-Wis.), are in support of the senator’s effort to have Congress rescind the White House regulation. Nearly every Democratic senator has signed a resolution of disapproval to overturn it.

The census data reflects trends that started last year, when the administration’s policies had yet to be implemented. Fourteen states saw their uninsured populations rise in 2017. The only three states that didn’t see a spike in that number were New York, California and Louisiana. The first two aren’t surprising given those states’ robust efforts to enroll their own residents, while Louisiana expanded Medicaid in June 2016 so its decrease represents those low-income individuals who now have government coverage.

Medicaid expansion in most of the 33 states and D.C. that have done so under the ACA has predictably decreased the number of people without coverage. The uninsured rate last year in states with an expanded Medicaid program was 6.6 percent compared to 12.2 percent in non-expansion states — a gap that has only continued to grow since 2013.

To be fair, as Larry Levitt, senior vice president at the Kaiser Family Foundation, pointed out on Twitter: the uninsured rate started leveling off before the Trump administration started its work. But Levitt suggested the uninsured rate may really rise in 2019 when elimination of the individual mandate penalty takes effect. Moreover, states are increasingly taking the White House up on its suggestion to add work requirements to their Medicaid programs — in just the first three months of it being implemented in Arkansas, more than 4,000 people were jettisoned from the rolls for failure to comply.

Matthew Fiedler, a health-policy expert at the Brookings Institution, agreed with Levitt’s assessment, noting that the bulk of the people who were uninsured pre-ACA have already been enrolled  in the program. He contended that if policy had remained static, there would likely have been a modest decline instead of similar increase in the uninsured rate — though not a dramatic one. The real effects, he said, of the Trump administration’s efforts to chip away at the ACA are still to come. 

“I don’t think the right takeaway is that none of the policy changes will have a negative effect. I think they will going forward, we just haven’t seen that yet,” he said. “I think if your goal is to evaluate the ACA, I think the right takeaway is that there was a lot of progress, but more policy progress to be made.”

Of course, Democrats and Republicans have disparate views on how to get there. Democrats are now pushing for a public option or a universal health care system in which the government would foot the bill for many health-care costs. A lot of them feel  the ACA “got us roughly 40 percent there and established a framework for lawmakers to make that progress going forward,” Fiedler said. That’s why we’re now seeing so many Democratic candidates and lawmakers embracing some iteration of a “Medicare for all” program.  

Republicans still criticize the ACA as vast government overreach and are vowing they will take another stab at repealing it should they maintain the congressional majorities after the November midterms.

“We made an effort to fully repeal and replace ObamaCare and we’ll continue,” Vice President Pence said while campaigning for Baldwin’s opponent, Leah Vukmir, if the GOP performs well in the midterms.

One additional interesting data point from the census is ages at which there was the greatest increases or decreases in the uninsured rate. As highlighted in the chart above, rates of those without insurance rose at ages 18 and 19 — when children are no longer eligible for the Children’s Health Insurance Program; and for those between ages 25 and 26 — when children no longer qualify for their parents’ insurance. The uninsured rate dropped, however, for those aged 64 and 65 — when adults are eligible for Medicare.

The greatest spike in those without insurance was documented for 26 year olds. That’s likely because young adults are typically healthier and feel less urgency to pay for insurance when they lose coverage under their family’s plan.

As noted by the New York Times’ Margot Sanger Katz on Twitter, these stats show just how crucial government programs and laws have been in providing health coverage to Americans:

Is Obamacare Constitutional? The Battle Begins Again

http://www.thefiscaltimes.com/2018/09/05/Obamacare-Constitutional-Battle-Begins-Again

 

The debate over the Affordable Care Act entered a new phase Wednesday as a federal court in Texas began hearing oral arguments in a lawsuit brought by 20 Republican-led states challenging the constitutionality of the 2010 law.

Eighteen Republican state attorneys general and two GOP governors bringing the suit argue that the law’s individual mandate was rendered unconstitutional when Congress lowered the penalty for individuals who don’t buy coverage to zero.

The Supreme Court, in upholding the law in 2012, deemed that penalty a tax and thus a valid and legal exercise of Congress’ power of the purse. The lawsuit claims that the law is no longer constitutional because the zeroed-out penalty can no longer raise revenue. “It’s nothing but a hollow shell because its core has been invalidated,” said Misha Tseytlin, Wisconsin’s solicitor general.

The plaintiffs also claim that this means the entire ACA — and, in particular, its protections for patients with pre-existing conditions looking to buy insurance — must be struck down because the mandate can’t be severed from the rest of the law. The Trump Justice Department decided not to defend the ACA in the case.

What a Kavanaugh Confirmation Might Mean

The case, which legal experts see as a long shot, may still wind up before the Supreme Court — which is why Democrats have brought up Obamacare and its protections for patients with pre-existing conditions in this week’s confirmation hearing for Brett Kavanaugh, President Trump’s nominee to replace Justice Anthony Kennedy.

“Kavanaugh has signaled in private meetings with Senate Democrats that he is skeptical of some of the legal claims being asserted in the latest GOP-led effort to overturn the Affordable Care Act,” the Los Angeles Times’ Jennifer Haberkorn reported last week. Three Democrats in the meetings told the Times that Kavanaugh suggested that if one piece of the law is struck down, the rest of the law doesn’t necessarily have to fall with it.

But that may not be enough to assuage Democratic fears that Kavanaugh could be the deciding Supreme Court vote against Obamacare. “Democrats are more concerned about Kavanaugh’s past writings on expansive presidential powers, which they say could lead to his supporting efforts by the Trump administration to dismantle the health-care law without Congress,” The Washington Post’s Colby Itkowitz notes.

Where Public Opinion Stands

The political debate over Obamacare has shifted as public perception of the law has improved. The latest Kaiser Family Foundation tracking poll, released Wednesday, finds that 50 percent now view the law favorably while 40 percent see it unfavorably, with the divide still falling along partisan lines. Just under 80 percent of Democrats support the law, while a similar percentage of Republicans oppose it.

That may be why Republicans still view repealing the law as a potent issue with their base. Vice President Mike Pence, in Wisconsin last week to campaign for Senate candidate Leah Vukmir, said the GOP push to repeal and replace the health care law was still alive: “We made an effort to fully repeal and replace Obamacare and we’ll continue, with Leah Vukmir in the Senate, we’ll continue to go back to that,” he told reporters. With Sen. Jon Kyl (R-AZ) replacing John McCain, a critical vote against the GOP’s 2017 Obamacare repeal bill, there has been chatter about another potential repeal effort — though Senate Majority Leader Mitch McConnell effectively shot that down on Wednesday.

In the meantime, open enrollment on the ACA exchanges is set to begin on November 1, with the Trump administration once again providing reduced funding for outreach groups that help people enroll. A recent report by the nonpartisan Government Accountability Office criticized the administration’s management of Obamacare signup periods.