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Outside Of Washington, There Is A New Vital Center In Health Care Reform

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http://healthaffairs.org/blog/2017/07/31/outside-of-washington-there-is-a-new-vital-center-in-health-care-reform/

Larissa Pisney of Denver joins others during a protest outside the office of U.S. Rep. Mike Coffman, R-Colo., over the health care overhaul bill up for a vote in the U.S. House Thursday, May 4, 2017, in Aurora, Colo. (AP Photo/David Zalubowski)

Republicans in Congress are mired in political quicksand. Following passage of the Affordable Care Act (ACA) in 2010, they locked themselves into a promise to repeal and replace it at the behest of ultra-conservative donors and party activists who control the GOP’s nomination process. Since 2010, however, Americans and rank-and-file Republicans increasingly came to expect help meeting the rising costs of medical care and insurance and to accept the ACA’s tangible programs to address these concrete challenges.

The Democrats created their own political trap. They passed the ACA on the promise of making health care affordable but deductibles and rising premiums continued to present a burden to many Americans.

Both parties are missing, however, the vital center on health reform that has formed since 2010. Americans are frustrated with Democrats for not delivering on their promise of affordability, and they are now alarmed with Republican efforts to repeal—instead of improve—the ACA’s coverage of costs.

Tracking Changes In Public Opinion

Most public opinion polls are unable to track these changes in opinion about health care because they are only snapshots, drawn from a moment in time. To remedy this, we have been gathering panel data, tracking the views of the same group of Americans every two years since the ACA’s passage in 2010. This equips us to study how individuals respond to the ACA as they experience or learn more about the law’s provisions over time. Specifically, we conducted four waves of interviews in the two-month period leading up to national elections from 2010 to 2016 when health reform received heightened attention; this avoided the risk of choosing an arbitrary month when health reform might have arbitrarily lost or gained salience.

The first wave was conducted by the Survey Research Institute (SRI) at Cornell University and consisted of a national sample of 1,200 adults. Abt SRBI (now part of Abt Associates) conducted the last three waves, returning to the same individuals. All waves asked identical questions and were administered by telephone, using only landlines in 2010 and adding mobile phones in 2012, 2014, and 2016. Forty-nine percent of the original 2010 survey (587 individuals) responded to all four waves. Survey weights were applied to each survey to match representative demographic targets and allow us to generalize from our panel to the adult population in the United States.

Why Americans Dislike Health Reform

Republicans have been eager to highlight the unpopularity of the Affordable Care Act, also known as “Obamacare.” Exhibit 1 shows that unfavorable assessments of the ACA have steadily increased since its passage. Unfavorability rose from 44 percent in 2010 to 58 percent in 2016.

Exhibit 1: Increasingly Unfavorable Views Of The Affordable Care Act (Percent)

Question: “As you may know, a major health care bill was signed into law in 2010. Given what you know about this law, do you have a generally favorable or generally unfavorable opinion of it, or do you have a neutral opinion, neither favorable nor unfavorable?” Exhibit 1 presents the “unfavorable” responses.

Why are Americans increasingly disenchanted with the ACA? The public’s displeasure emanates to a large extent from frustrations with health care costs. Democrats promised to lower the costs of medical care and insurance with the enactment of the ACA. They did succeed to slow the rate of increase in national health care spending and insulate most subsidized enrollees in its insurance Marketplace from premium increases, as the Congressional Budget Office reports (Note 1). Yet, the costs of medical care remain high, and premiums and deductibles are out of the reach of some Americans.

The source of the public’s rising frustration with health care costs is picked up in Exhibit 2. The first grouping of bars on the left shows increasing frustration with costs for medical treatments that are not covered by insurers. By 2016, 14 percent expressed dissatisfaction with the amount and number of treatments that their insurance covered, a 6-point increase from 2014. One-third of Americans also expressed dissatisfaction in 2016 with the out-of-pocket costs that they were forced to pay because of gaps in their insurance coverage, as shown in the middle cluster. This is an 8-point increase from 2014.

Exhibit 2: Rising Concerns About Affordability (Percent)

Question: Several questions asked respondents to indicate their satisfaction or dissatisfaction with individual features of the health care system—“The number and kind of treatments your health insurance will cover” and “The amount you spend out of pocket on health care costs your insurance doesn’t cover.” A separate item asked respondents to indicate their agreement or disagreement with the statement: “Public officials care about making health care more affordable for people like me.” (Exhibit 2 shows “disagreement” with the statement.)

The public’s disappointment with the persistent burden of health care costs leads it to blame lawmakers for a lack of responsiveness. The bars on the right in Exhibit 2 indicate that a growing majority of Americans disagree with the statement that, “Public officials care about making health care more affordable for people like me.” Fifty-eight percent of Americans disagreed with this statement in 2016, a 10-point increase since 2012.

In addition, the sense that the ACA has not delivered the affordability that Democrats promised may help account for the sharply stronger conclusion in recent years that the ACA’s taxes present a heavier burden. Exhibit 3 shows that the proportion of Americans who believe that their taxes have increased a lot or a little has risen from 43 percent in 2012 to 56 percent in 2016. This growing perception that the ACA has increased taxes rests on inaccurate assumptions. The ACA’s financing primarily relies on two taxes on individuals whose yearly income exceeds $200,000 or for married couples earning more than $250,000—an increase in Medicare’s tax on earnings by 0.9 percent and a new 3.8 percent tax on capital gains from investments. These taxes fall on less than 2 percent of tax filers, according to the non-partisan Tax Policy Center (Note 2).

Exhibit 3: Growing Perception That The Affordable Care Act Increased Taxes (Percent)

Question: “Do you think that the new health care law enacted in 2010 has increased the taxes that you pay, decreased the taxes that you pay, or has it had no impact on the taxes that you pay?”

Americans Oppose Repeal Because They Appreciate The Effects Of Health Reform

Considering the strong public disapproval of repeal, President Donald Trump and congressional Republicans are discovering that it is a mistake to equate the public’s frustrations with the ACA with support for repealing its programs. When respondents reported “unfavorable” views of the law, we followed up with a question asking them whether they would prefer either “repeal[ing] [the ACA] as soon as possible,” or “giving the law more time to have a chance to work, with lawmakers making necessary changes along the way.” In Exhibit 4, we combined those who favored giving it “a chance to work” with those who expressed “favorable” overall views of the law. This shows that since 2010 more Americans favored the law or wanted to give it time to be improved than backed repeal. Although support for repeal inched up since 2010, a greater percentage of Americans consistently favored the ACA and improving it over repeal by a 41-to-37 margin in 2010 and by 49-to-43 in 2016.

Exhibit 4: More Americans Prefer To Keep And Improve The Affordable Care Act Than Repeal It (Percent)

Question: This figure is based on two survey questions. The first is the following: “As you may know, a major health care bill was signed into law in 2010. Given what you know about this law, do you have a generally favorable or generally unfavorable opinion of it, or do you have a neutral opinion, neither favorable nor unfavorable?” Respondents who had an unfavorable view were asked a second question about their view about the law’s future: “The law should be given more time to have a chance to work, with lawmakers making necessary changes along the way, OR the law should be repealed as soon as possible?” The repeal bar reports responses from the second question; the other bar adds together favorable responses in the first question with the “law should be given more time” responses.

Support for keeping and improving the ACA stems from a growing appreciation for its concrete effects. Exhibit 5 shows that rising percentages pinpoint the ACA’s tangible programs as having either “a great deal” or “quite a bit” of an impact on themselves and their family (other options included “some,” “a little,” and “none”). There is greater recognition in 2016 compared to 2010 or 2012 of the impact of allowing parents with insurance to continue to cover their children until they are 26 years old. More than one in five Americans now report that the ACA expanded their access to health insurance. In addition, nearly one in four Americans, 24 percent, voiced appreciation for the impact of the ACA’s assistance to seniors to pay for prescription medications. Moreover, recognition of a personal impact resulting from the ACA’s tax credits and other subsidies to help people purchase health insurance has remained stable since 2014 and is higher than in earlier years.

Exhibit 5: Rising Appreciation Of The Impact Of The Affordable Care Act (Percent)

Question: “I’m going to read to you a list of some of the features of the health care law that was enacted in 2010. For each one, please answer this question: “How much of an impact has this feature had on you and your family: a great deal, quite a bit, some, a little, none?” Respondents are asked about the following features of health reform: coverage of adult children on their parents’ insurance plans until they are 26 years old; access to health insurance or medical care supported or provided by government; help for seniors to pay for prescription drugs; and tax credits and other subsidies to help people pay for health insurance. Exhibit 5 combines “a great deal” and “quite a bit.”

The New Vital Center On Health Reform

Overall evaluations of the ACA follow the partisan pattern that is familiar today: 68 percent of Democrats have favorable views versus 9 percent of Republicans. What stands out, however, is that the ACA’s tangible effects are starting to loosen rigid partisan dividing lines. Exhibit 6 shows the percentage of Americans reporting a personal impact from at least one of the four provisions presented in Exhibit 5. Democratic elected officials enacted the ACA, and, not surprisingly, majorities of rank-and-file Democrats have generally singled out the law’s effects from early on: 51 percent of Democrats reported an impact from at least one of the law’s features in 2010; by 2016, this recognition remained largely stable, inching up to 54 percent. Strikingly, however, the percentage of Republicans perceiving an impact on themselves or their families has increased by 8 percentage points, from 26 percent in 2010 to 34 percent in 2016 despite vociferous GOP attacks on the ACA. Among independents, the proportion soared by 23 points, from 28 percent to 51 percent. These findings indicate that appreciation for the ACA has expanded beyond the ranks of Democratic partisans who were predisposed to favor it; growing numbers of Americans across the political spectrum increasingly value the impacts of health reform in their own lives.

Exhibit 6. Widening Appreciation Of The Affordable Care Act’s Impact (Percent Reporting Impact Of A New Benefit)

Exhibit 6 presents the percentage of respondents who reported that at least one of the four provisions presented in Exhibit 5 had a “great deal” or “quite a bit” of impact on themselves or their family.

The crux of the public discontent with the ACA—and the repeal proposals by Republicans—is the amount paid for insurance coverage. Respondents to the survey appear to share the complaint of ACA critics that insurance costs are too high. After high expectations following the ACA’s enactment, satisfaction with the cost of health coverage has dropped by 10 points—from 73 percent satisfied in 2010 to 63 percent in 2016. This general assessment misses, however, a crucial condition—whether or not individuals are covered by government programs such as Medicare, Medicaid, or a subsidy financed by the ACA. We found a striking pattern among Republicans, Democrats, and independents: By a margin of 20 points or more, individuals with government coverage were consistently more satisfied with the cost of insurance than those who rely on private health plans. For instance, 79 percent of Republicans with government coverage were content with insurance costs as compared to 56 percent without this coverage. Independents outside the sway of either major party expressed the highest satisfaction when experiencing government coverage (100 percent) and exhibit the largest gap between those covered and those without coverage (41 points).

In short, Republican public officials continue to spotlight what they perceive as the disappointment of Americans with ACA coverage, but the reality is that the most dissatisfied are those who lack government insurance. In fact, most Americans (including Republicans) who benefit from government insurance are content with their coverage.

Health Reform’s New Vital Center

Public opinion toward the ACA has been poorly understood because of an apparent contradiction. On the one hand, a growing share of the public harbor unfavorable views of the ACA as a whole, and proponents of repeal have seized on this dissatisfaction to claim a popular mandate. On the other hand, the discontent of Americans stemmed from disappointment with the ACA for not satisfying their expectations of genuine protection from the burden of costs. Far from wanting to be rid of the ACA, Americans are looking to it to deliver more effective protection.

In the immediate aftermath of World War II, the historian Arthur Schlesinger, Jr., wrote of the “vital center” about the direction of America that was supported by both major political parties and most Americans. Despite today’s fractiousness in Washington over health reform, everyday Americans are converging toward a new vital center of support for health care reform.

Awareness of the ACA’s tangible impacts fits into a robust notion of collective responsibility instead of the individualist approach advocated by conservatives. Since the ACA’s passage, nearly nine out of 10 Americans have consistently embraced access to health care as a “basic right.” Not surprisingly, nearly all Democrats embrace the principle of health care as a right. What stands out is that rank-and-file Republicans overwhelming and increasingly hold the same view—rising from 64 percent in 2010 to 72 percent in 2016. Contrary to the position of Washington Republicans, establishing health care as a birthright owed to Americans is now widely shared. Republican proposals, such as those that would allow states to opt out of some of the ACA’s core consumer protections (including those guaranteeing coverage for individuals with preexisting medical conditions), may well tap into this strain of public opinion and provoke broad opposition.

Elected officials in Washington and, particularly, steadfast opponents of health reform are sliding to the margins of public opinion. The daily problems that Americans face in paying for medical care and insurance mean that pragmatism is trumping ideology. In the past, federal lawmakers responded to broad public agreement and worked across the aisle to improve the flaws in the original legislation that produced Social Security in 1935 and Medicare in 1965. The question today is whether Washington can return to that pragmatic tradition and catch up to the emerging vital center in Americans’ attitudes toward health reform.

Note 1

Congressional Budget Office. American Health Care Act: cost estimate. Washington (DC): CBO; 2017 Mar 13.

Note 2

Tax Policy Center. Tax units above and below the $250,000/$200,000 threshold, 2013–2022. Washington (DC): TPC; 2012 Nov 26

What’s the Near-Term Outlook for the Affordable Care Act?

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http://www.kff.org/health-reform/issue-brief/whats-the-near-term-outlook-for-the-affordable-care-act/?utm_campaign=KFF-2017-August-Health-Reform-Outlook-ACA&utm_medium=email&_hsenc=p2ANqtz–oP5wlywrzGCg7hZVAatEjF0shnUXWvPMPB7MBQfAJJXiDqeMCZIkw7rhXhhVQ7bv4RTl4IFWk3zbvJFTnYv730hVqBQ&_hsmi=54950542&utm_content=54950542&utm_source=hs_email&hsCtaTracking=b35f36e5-60c0-4e14-ba27-3e14c4025b79%7Cf0a0cb87-2715-4168-b499-2000076067bf

If Congress abandons efforts to repeal and replace the Affordable Care Act (ACA), President Trump has said he would “let Obamacare fail.” This Q&A examines what could happen if the Affordable Care Act, also called “Obamacare,” remains the law and what it might mean to let Obamacare fail.

Is Obamacare failing?

The Affordable Care Act was a major piece of legislation that affects virtually all payers in the U.S. health system, including Medicaid, Medicare, employer-sponsored insurance, and coverage people buy on their own. One of the biggest changes under the health reform law was the expansion of the Medicaid program, which now covers nearly 75 million people, about 14 million of whom are signed up under the expansion. Most Americans, including most Republicans, believe the Medicaid program is working well.

When people talk about the idea of the ACA failing, they are usually referring to the exchange markets, also called Marketplaces. These markets, which first opened in 2014, are part of the broader individual insurance market where just 5-7% of the U.S. population gets their insurance. People who get insurance from other sources like their work or Medicaid are not directly affected by what happens in the individual insurance market.

The exchange markets have not been without problems: There have been some notable exits by insurance companies and premium increases going into 2017, and in the early years of the exchanges, insurers were losing money. The structure of the ACA’s premium subsidies – which rise along with premiums and cap what consumers have to pay for a benchmark plans a percentage of their income – prevents the market from deteriorating into a “death spiral.” However, premiums could become unaffordable in some parts of the country for people with incomes in excess of 400% of the poverty level, who are ineligible for premium assistance.

Insurer participation in this market has received a great deal of attention, as about 1 in 3 counties – primarily rural areas – have only one insurer on exchange. Rural counties have historically had limited competition even before the ACA, but data now available because of the Affordable Care Act brings the urban/rural divide into sharper focus. On average at the state level, competition in the individual market has been relatively stable – neither improving nor worsening.

Premiums in the reformed individual market started out relatively low and remained low in the first few years – about 12% lower than the Congressional Budget Office had projected as of 2016 –before increasing more rapidly in 2017. Most (83%) of the 12 million people buying their own coverage on the exchange receive subsidies and therefore are not as affected by the premium increases, but many of the approximately 9 million people buying off-exchange may have difficulty affording coverage, despite having higher incomes. As might be expected, after taking into account financial assistance and protections for people with pre-existing conditions, some people ended up paying more and others paying less than they did before the ACA. Our early polling in this market found that people in this market were nearly evenly split between paying more and paying less. About 3 millionpeople who remain uninsured are not eligible for assistance or employer coverage and many of them may be going without coverage due to costs.

Our recent analysis of first quarter 2017 insurer financial results finds that the market is not showing signs of collapse. Rather, insurers are on track to be profitable and the market appears to be stabilizing in the country overall. In other words, those premium increases going into 2017 may have been enough to make the market stable without discouraging too many healthy people from signing up. However, there are still markets – particularly rural ones – that are fragile.

Fitch: Failed ACA replacement efforts add to healthcare sector uncertainty

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http://www.beckershospitalreview.com/finance/fitch-failed-aca-replacement-efforts-add-to-healthcare-sector-uncertainty.html

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As ACA repeal and replace efforts stall, significant uncertainty remains surrounding how federal policy will affect nonprofit healthcare organizations, leading to a negative sector outlook for healthcare, according to Fitch Ratings.

The uncertainty and negative outlook comes as the Trump administration looks for ways to weaken the ACA even if the health reform law is not repealed.

Nonprofit hospitals experienced declines in uncompensated care under the ACA because of an increase in healthcare coverage due to Medicaid expansion, rollout of healthcare exchanges and allowing children to stay on their parent’s health insurance plan until age 26.

While repeal efforts cause uncertainty for hospitals, current discussions regarding a bipartisan healthcare bill could be beneficial for nonprofit hospitals. A bipartisan effort could potentially reduce the insurance premium price hikes, according to Fitch.

Trump’s Tweets Threaten To Destabilize Insurance Markets

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http://www.npr.org/sections/health-shots/2017/08/01/540656651/trumps-tweets-threaten-to-destabilize-insurance-markets?utm_campaign=KHN%3A%20Daily%20Health%20Policy%20Report&utm_source=hs_email&utm_medium=email&utm_content=54841830&_hsenc=p2ANqtz-_BS8nGbOG01O1u0VECBzsFH5X_-bRiY3X7lsxQ8ybqJDve3xJppemqizvSfn4B0RH50L84DFNZaG18htzfxHToUJIq2g&_hsmi=54841830

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President Trump took to Twitter this week to threaten insurance companies that he may withhold crucial government payments in an effort to undermine the Affordable Care Act.

It’s not the first time the president has threatened to cut off these payments to insurers, which he refers to as “BAILOUTS.

But these payments aren’t designed to compensate insurers for business failures. Rather, they reimburse insurance companies for discounts the law requires them to give to low-income people who buy insurance through the Affordable Care Act exchanges. The federal money that goes to insurers in these payments, known as cost-sharing reductions, or CSRs, offsets the money insurers lose by lowering the deductibles and co-payments they require of these policyholders.

Trump, who is angry that the Congress failed to pass a law to repeal and replace the Affordable Care Act, or Obamacare, is wielding his threat to withhold these CSRs — which could cause chaos in the insurance markets – in hopes of forcing lawmakers back to the table to try again to get rid of the health care law.

The next cost-sharing payments are due to be paid in a few weeks and the president has said he’ll announce this week whether he’ll pay the money or keep it in the Treasury.

“In the absence of the CSR, the rate increases could be astonishing,” says Dr. Marc Harrison, CEO of Intermountain Healthcare, which operates nonprofit hospitals and clinics and insures more than 800,000 people across Utah.

“We’ll see [the number of] people who are uninsured, or functionally uninsured, go way, way up,” he adds.

Harrison says he and his company filed two sets of proposed rates for policies sold on the insurance exchange next year. If the president cuts off the cost-sharing payments, he says, the rates will be much higher.

The Congressional Budget Office estimates the payments, if they’re all made, will total $7 billion this year. Margaret Murray is CEO of the Association for Community Affiliated Plans, which represents these “safety net health plans” aimed at people with lower incomes. She says she has been in touch with the Department of Health and Human Services to urge them to fund the payments.

“Should the payments cease, insurers will be required to fund cost-sharing reductions on their own,” Murray says. If that happens, “they will either raise their rates – our plans indicate that it could be by up to 23 percent – to compensate for these losses, or they will withdraw from the markets altogether.”

If Trump does decide to stop making the payments, it may end up costing the U.S. Treasury more, while insurance companies who remain in the markets could do just fine.

That’s because insurance companies will charge more in premiums to make up for the lost payments. And that will lead the Treasury to spend more on subsidies to policyholders who qualify, according to an analysis by the consulting firm Oliver Wyman.

If those subsidies go up enough, more people could be lured into the exchange markets.

Here’s the wonky reason why:

The Obamacare exchanges require insurance policies to conform to one of four “metal” levels — bronze, silver, gold or platinum — which coincide with how much an individual is expected to pay in premiums, deductibles and other out-of-pocket expenses. A bronze plan covers about 60 percent of a customer’s health care costs, with relatively low monthly premiums, while a platinum plan will cost more each month but pay 90 percent of total health costs.

The law provides income-based tax credits to people to buy insurance, and those credits are calculated based on the price of silver plans. Last year about 85 percent of people who bought Obamacare insurance got a credit, according to the Center for Medicare and Medicaid Services.

People with the lowest incomes also get those discounted deductibles and co-payments if they buy a silver plan; and then the government reimburses insurers through CSR payments.

If Trump decides not to make those payments, insurance companies are likely to raise rates about 19 percent, according to an analysis by the Kaiser Family Foundation.

That means subsidies will have to rise for many people to meet those higher premiums. Some people may take that bigger subsidy to buy a cheaper policy — and many could even get insurance for free, according to Oliver Wyman, because premiums on bronze plans probably would not rise as much as those on silver plans.

The higher subsidies could cost the government as much as $2.3 billion in 2018, according to the Kaiser Family Foundation’s Larry Levitt. Levitt notes that Congress could end the ambiguity over the payments by appropriating the money for them.

Sen. Orrin Hatch, R-Utah, said in an interview with Reuters that he thinks Congress will do just that.

“I’m for helping the poor; always have been,” Hatch said. “And I don’t think they should be bereft of health care.”

The reason CSRs are in limbo at all is because House Republican who did not want Obamacare to succeed sued the administration, claiming the payments to insurers were illegal because they had not appropriated money for them.

A federal judge agreed, but the Obama administration appealed. When Trump took the White House he continued the appeal, to allow lawmakers time to pass a bill to repeal Obamacare and make the payments disappear altogether.

Now that that effort has failed, the lawsuit and the cost-sharing money are once again in play.

Trump on tricky legal ground with ‘Obamacare’ threat

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http://abcnews.go.com/Health/wireStory/trump-tricky-legal-ground-obamacare-threat-48962076

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President Donald Trump’s threat to stop billions of dollars in government payments to insurers and force the collapse of “Obamacare” could put the government in a legal bind.

Law experts say he’d be handing insurers a solid court case, while undermining his own leverage to compel Democrats to negotiate, especially if premiums jump by 20 percent as expected after such a move.

“Trump thinks he’s holding all the cards. But Democrats know what’s in his hand, and he’s got a pair of twos,” said University of Michigan law professor Nicholas Bagley. Democrats “aren’t about to agree to dismantle the Affordable Care Act just because Trump makes a reckless bet.”

For months, the president has been threatening to stop payments that reimburse insurers for providing required financial assistance to low-income consumers, reducing their copays and deductibles.

Administration officials say the decision could come any day.

Playing defense, some insurers are preemptively raising premiums for next year. For example, BlueCross BlueShield of Arizona this week announced a 7.2 percent average hike for 2018. But there would likely be no increase if the subsidies are guaranteed, the company said. And BlueCross BlueShield of North Carolina earlier requested a 22.9 percent average increase. With the subsidies, the company said that would have been 8.8 percent.

The “cost-sharing” subsidies are under a legal cloud because of a dispute over whether the Obama health care law properly approved the payments. Other parts of the health care law, however, clearly direct the government to reimburse insurers.

With the issue unresolved, the Trump administration has been paying insurers each month, as the Obama administration had done previously.

Trump returned to the subject last week after the GOP drive to repeal the health care law fell apart in the Senate, tweeting, “As I said from the beginning, let ObamaCare implode, then deal. Watch!”

He elaborated in another tweet, “If a new HealthCare Bill is not approved quickly, BAILOUTS for Insurance Companies…will end very soon!”

It’s not accurate to call the cost-sharing subsidies a bailout, said Tim Jost, a professor emeritus at Washington and Lee University School of Law in Virginia.

“They are no more a bailout than payments made by the government to a private company for building a bomber,” he said.

That’s at the root of the Trump administration’s potential legal problem if the president makes good on this threat.

The health law clearly requires insurers to help low-income consumers with their copays and deductibles. Nearly 3 in 5 HealthCare.gov customers qualify for the assistance, which can reduce a deductible of $3,500 to several hundred dollars. The annual cost to the government is about $7 billion.

The law also specifies that the government shall reimburse insurers for the cost-sharing assistance that they provide.

Nonetheless, the payments remain under a cloud because of a disagreement over whether they were properly approved in the health law, by providing an “appropriation.”

The Constitution says the government shall not spend money without a congressional appropriation.

Think of an appropriation as an electronic instruction to your bank to pay a recurring monthly bill. You fully intend to pay, and the money you’ve budgeted is in your account. But the payment will not go out unless you specifically direct your bank to send it.

House Republicans trying to thwart the ACA sued the Obama administration in federal court in Washington, arguing that the law lacked specific language appropriating the cost-sharing subsidies.

A district court judge agreed with House Republicans, and now the case is on hold before the U.S. appeals court in Washington. A group of state attorneys general is asking the appeals court to let them join the case, in defense of the subsidies.

Both Bagley and Jost have followed the matter closely, and disagree on whether the health law properly approved the payments to insurers. Bagley says it did not; while Jost says it did.

However, the two experts agree that insurers would have a solid lawsuit if Trump stops the payments. Insurers could sue in the U.S. Court of Federal Claims, which hears claims for money against the government.

“The ACA promised to make these payments — that could not be clearer — and Congress has done nothing to limit that promise,” said Bagley.

“I think there would very likely be litigation if the Trump administration tries to cut off the payments,” said Jost.

Another way to resolve it: Congress could appropriate the money, even if temporarily, for a couple of years. Some prominent GOP lawmakers have expressed support for that.

If the president makes good on his threat, experts estimate that premiums for a standard “silver” plan would increase by about 19 percent. Insurers could recover the cost-sharing money by raising premiums, since those are also subsidized by the ACA, and there’s no question about their appropriation.

But millions of people who buy individual health care policies without any financial assistance from the government would face prohibitive cost increases.

And more insurers might decide to leave already shaky markets.

“This is not a game,” said California Attorney General Xavier Becerra. “Millions of people would not be able to afford health insurance for their families.”

How Many People Across America Are at Risk of Losing Their Health Insurance?

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Between 2010 and 2015, more than 19 million people in the United States gained health insurance, mostly through key provisions under the Affordable Care Act, according to an analysis by the Urban Institute.

Many of the newly insured were not poor enough to qualify for Medicaid but too poor to buy their own coverage. Others were shut out because of pre-existing conditions.

These groups and others make up the millions that the Congressional Budget Office says could lose their coverage under the Republican plans to repeal and possibly replace the Affordable Care Act.

“All of the elements that enabled more people to get insurance under Obamacare — protections for pre-existing conditions, the expansion of Medicaid and subsidies to make insurance more affordable — are potentially at risk under the various options the Senate is debating,” said Larry Levitt, a policy expert at the Kaiser Family Foundation.

Under six Republican proposals that the Congressional Budget Office had analyzed, the number of uninsured in America would increase by 22 million to 32 million people in 10 years — essentially erasing much of the gains made under the Affordable Care Act. A C.B.O. analysis released Wednesday night showed that a “skinny” repeal measurebeing floated by lawmakers would increase the number by 16 million in 10 years.

“It’s a dramatic understatement to say there’s uncertainty about where this debate will end up,” Mr. Levitt said.

Healthcare groups blast skinny repeal, warn premiums will spike

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Healthcare groups blast skinny repeal, warn premiums will spike

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Healthcare groups are coming out against the Senate GOP’s plan to pass a scaled-down ObamaCare repeal bill, saying it would spike insurance premiums.

The American Medical Association, the Blue Cross Blue Shield Association and the American Cancer Society Cancer Action Network are among the range of healthcare groups blasting the bill.

The scaled-down, “skinny” repeal bill would repeal ObamaCare’s mandate for people to have insurance, which insurers and other groups warn would lead to a sicker group of enrollees and spiking premiums.

The Blue Cross Blue Shield Association warned of “steep premium increases and diminished choices that would make coverage unaffordable and inaccessible.”

“Eliminating the mandate to obtain coverage only exacerbates the affordability problem that critics say they want to address,” said Dr. David Barbe, president of the American Medical Association.

“We again urge the Senate to engage in a bipartisan process — through regular order — to address the shortcomings of the Affordable Care Act and achieve the goal of providing access to quality, affordable health care coverage to more Americans,” Barbe said.

The Congressional Budget Office previously found that repealing the individual mandate would lead to 15 million more uninsured people and cause premiums to increase by about 20 percent.

Republican senators argue the scaled-down repeal bill will never actually become law, and is just a way to set up negotiations with the House on a larger plan. But the House is making no guarantees that it won’t simply vote on the bill and send it to the president.

“The continuing effort by Senate leaders to figure out by trial and error some bill that might gain the needed 50 votes to pass is a threat to millions of Americans including cancer patients and survivors who must have comprehensive coverage in order to access prevention and medical treatment,” the American Cancer Society Cancer Action Network said in a statement.

“The legislation could cause the individual insurance market to collapse putting millions of American families at financial risk,” the cancer group said.

In addition to repealing the individual mandate, the skinny bill would also defund Planned Parenthood, cut the ObamaCare prevention and public health fund, and repeal the employer mandate.

Many healthcare groups have been strongly opposed to the GOP effort to repeal ObamaCare throughout the process, instead urging a bipartisan approach.

Medicaid cuts had been a major focus, though those are not be included in the current bill.

Regardless, America’s Essential Hospitals, which is strongly opposed to Medicaid cuts, said it is still opposed to the “skinny bill.”

“While it doesn’t directly affect Medicaid, it still would badly undermine coverage and access by destabilizing the private marketplace,” Bruce Siegel, the group’s president, said in a statement.

The AARP, a powerful senior group, also warned against it.

“The bill will leave millions uninsured, destabilize the health insurance market and lead to spikes in the cost of premiums,” it wrote in a letter to congressional leaders.

“AARP will inform our members and the public how their Senators voted,” the letter added.

CBO: 16 million more uninsured under GOP ‘skinny’ repeal

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http://thehill.com/policy/healthcare/344264-cbo-16-million-would-lose-coverage-under-gop-skinny-repeal

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The GOP’s newly released “skinny” repeal of ObamaCare would result in 16 million additional people without insurance by 2026, according to a report by the Congressional Budget Office (CBO) released Thursday night.

The bill, released just hours before its vote Thursday night, would repeal ObamaCare’s individual insurance mandate permanently and its employer mandate for eight years.

The CBO also estimated that premiums in the individual market would increase by 20 percent compared to current law in all years between 2018 and 2026.

The bill would lower the deficit by $135.6 billion in ten years, the CBO estimates. 
The Senate’s scaled-down ObamaCare repeal bill, the Health Care Freedom Act, would also defund Planned Parenthood for a year, repeal the medical device tax for three years and increase contribution limits to Health Savings Accounts for three years.

A vote on the bill is expected after midnight. Lawmakers could then offer amendments to the legislation.

‘Skinny Repeal’ of ACA Likely to Leave Everyone Wanting More

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https://www.thefiscaltimes.com/2017/07/25/Skinny-Repeal-ACA-Likely-Make-Everyone-Wanting-More

The Senate’s Republican leadership has added yet another option to the complicated menu of Affordable Care Act repeal and replacement measures that may be considered as alternatives to the House-passed American Health Care Act.

Faced with the very real possibility that they will be unable to pass any of the current versions of their own health care legislation, which ranges from a standalone repeal of the ACA to a complicated restructuring of the law, Senate leadership is now considering the possibility of a measure being referred to as a “skinny repeal” of the ACA.

This represents a sort of fall-back position if the GOP is unable to muster the votes for any of the larger repeal and replace bills. The skinny repeal bill would eliminate the employer and individual mandates, which impose penalties on some businesses that don’t offer their employees insurance and on individuals not otherwise covered who do not buy themselves insurance. It would also repeal the controversial tax on medical devices.

The skinny repeal would fall far short of the goal of complete elimination of the ACA, but it would give Republicans the ability to claim at least a small victory. However, according to the Committee for a Responsible Federal Budget, it would also result in at least 15 million fewer Americans with insurance within a year, and 20 percent increases in health insurance premiums, while saving the federal government a relatively modest $225 billion over 10 years.

The skinny repeal would likely set up Senate Republicans for brutal criticism from both sides of the aisle.

It would also be viewed by large segments of the Republican voter base as a placeholder at best, or a betrayal at worst. By leaving in place many of the ACA’s mandates on health insurance providers and its taxes, the skinny repeal would leave many GOP voters clamoring for further action against Obamacare.

On the left, critics would point out that the elimination of the coverage mandates will inject huge and perhaps fatal uncertainty into the individual insurance market, potentially causing many more people to lose insurance, either because of insurers withdrawing from the system, or premiums becoming unaffordable.

Would your plan cover John McCain’s treatment?

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https://www.healthinsurance.org/blog/2017/07/25/would-your-plan-cover-john-mccains-treatment/

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The Arizona Senator’s health plan will ensure top-notch glioblastoma treatment, but how would Americans with other health coverage fare?

Last week, we heard the sad news that Senator John McCain has been diagnosed with glioblastoma. McCain had surgery at Phoenix’s Mayo Clinic in mid-July, and it’s expected that he’ll also receive chemotherapy and radiation, along with other potential treatments. Senator McCain has proven time and again that he’s tough as nails, and appears to be facing this latest battle head-on. One thing that he likely has on his side is top-notch health insurance.

McCain is 80, which means he’s presumably been on Medicare for 15 years. Currently serving federal lawmakers are able to obtain employer-subsidized coverage in the Washington DC small-business exchange, and they can have this coverage in addition to Medicare.

How good is McCain’s coverage?

McCain hasn’t said publicly exactly what insurance he has, and his office has not responded to my inquiry. But the most likely scenario is that he has Medicare plus employer-sponsored coverage through the DC exchange – a very comprehensive benefits package.

There are certainly lots of other people who have similar coverage arrangements – either because they’re still working after turning 65, like McCain, or because they receive generous retiree health benefits that supplement their Medicare coverage. For those who don’t, there are private Medicare supplements available that cover virtually all of the out-of-pocket costs associated with Medicare.

But health coverage in the United States is a bit of a mixed bag, with some people having much better coverage than others. A serious illness tends to shine a spotlight on the flaws that exist in some health plans, so let’s take a look at how the average American facing a glioblastoma diagnosis would fare under various health plans.

Employer-sponsored health insurance

Most employer-sponsored health insurance plans provide pretty solid health coverage. According to a 2016 Kaiser Family Foundation analysis, the average deductible for covered workers was about $1,500, and that doesn’t count the 17 percent of covered workers whose plans had no deductible at all.

In addition, the average employer paid more than two-thirds of the total premiums. And the tax exclusion of employer-sponsored insurance premiums amounts to a subsidy that cost the federal government $250 billion in fiscal year 2016.

However, employer-sponsored health insurance is, by definition, linked to employment. A person going through a serious illness like glioblastoma might not be able to continue working, depending on the specifics of the treatment.

As long as the employer has at least 20 employees, the employee will be able to continue the coverage under COBRA for 18 months, even if he or she is unable to work. But COBRA is expensive, as the employer contribution to the premiums and the tax exclusion of the premiums are eliminated. (COBRA premiums are counted as a medical expense for the purpose of itemized medical deductions, but only expenses that exceed 10 percent of your income can be deducted this way.)

Although most employer-sponsored plans provide good coverage, that’s due in part to the ACA. It was not uncommon – particularly in low-wage, high turnover industries – for employers to offer “mini-meds” before the ACA, with exceedingly low benefit caps. (The ACA’s ban on lifetime and annual benefit limits means that these plans are no longer offered to employees.)

A mini-med with a $2,000 or $5,000 annual benefit maximum would not have done much in the face of glioblastoma. Vox reported that just the initial craniotomy to remove a blood clot above Senator McCain’s eye would likely have been billed at more than $76,000. And that was before the cancer diagnosis.

ACA-compliant individual market coverage

The pre-ACA individual market included plenty of solid plans. But dubious coverage also abounded, and regulations varied considerably from one state to another.

The ACA imposed a bevy of regulations on the individual health insurance market, bringing all new (as of 2014) plans up at least a basic minimum standard. Individual major medical coverage can no longer be sold without the ACA’s essential health benefits.

And for those benefits, insurers cannot limit how much they’ll pay during a year or over the course of an insured’s lifetime. (Sadly, another Arizona resident with cancer, Arijit Guha, died in 2013 at age 32. Guha’s health insurance plan had a $300,000 lifetime cap – which is no longer allowed, thanks to the ACA – and his treatment, including chemotherapy that cost $11,000 per session, quickly exceeded that limit.)

Individual-market plans also cannot discriminate against people with pre-existing conditions, either by charging them higher prices or declining their applications (both of those were standard practice in nearly every state prior to 2014). Notably, Senator McCain has a history of melanoma, which would have virtually guaranteed a declined application in the individual market pre-ACA if he had been in need of non-group coverage for some reason.

A person with ACA-compliant individual market coverage would have solid coverage for glioblastoma. The maximum out-of-pocket costs during 2017 would be $7,150, although most plans have out-of-pocket maximums below that threshold. And 57 percent of people who enrolled through the exchanges in 2017 have cost-sharing subsidies, which further reduce the out-of-pocket costs.

The American Cancer Society explains in more detail how the ACA improves access to care for people with cancer. But the short story is that a person facing glioblastoma with a 2017 individual health insurance policy has a much more secure financial safety net than someone with the same diagnosis a decade ago.

Medicaid

Medicaid provides comprehensive coverage. Although the benefits available under traditional Medicaid vary from one state to another, Medicaid expansion coverage is required to include the ACA’s essential health benefits. (The Senate’s Better Care Reconciliation Act – BCRA – would eliminate this requirement after 2019.)

Medicaid has minimal cost-sharing, limited to no more than 5 percent of a family’s annual income.

It’s true that compared with private health insurance and Medicare, fewer medical providers accept Medicaid. But the majority do work with Medicaid. (According to a Kaiser Family Foundation analysis, about 69 percent of office-based physicians accept new Medicaid patients, while about 85 percent accept new privately-insured patients.)

Short-term health insurance

The ACA implemented regulations that apply to virtually all types of health insurance. But some plans are not regulated by the law, including short-term health insurance.

As evidenced by the name, short-term plans are limited in their duration. As of 2017, a short-term plan can last no more than three months, although people who remain healthy can purchase a second short-term plan after the first one ends.

Short-term plans do not cover pre-existing conditions. So if you were to be diagnosed with glioblastoma while covered under a short-term plan, the first thing the insurer would do is go back through your medical records to make sure that you didn’t have any symptoms prior to enrolling in the plan.

Assuming you were healthy before you enrolled, your short-term plan would start to cover your treatments. But you would be facing a looming and inflexible coverage termination date, along with annual and lifetime benefit maximums. Short-term plans vary considerably in quality – some have lifetime benefit maximums of $250,000 or less, while others provide benefits well in excess of a million dollars. In the case of a glioblastoma diagnosis, coverage would end when the policy reached its predetermined end date, or when you hit your benefit maximum – whichever happened first.

Either way, you’d want to hope that you had other coverage already lined up and ready to go at that point. The cancer diagnosis would make it impossible to obtain another short-term policy.

And since a short-term plan is not considered minimum essential coverage, the termination of the short-term policy would not trigger a special enrollment period for individual or employer-sponsored insurance. You would still be able to enroll in a regular individual-market plan, or an employer plan if you’re eligible for one, during regular annual open enrollment. But you might experience a significant gap in coverage, which can be disastrous in the middle of cancer treatment.

A limited-benefit plan

Limited-benefit plans are another category of coverage that’s not regulated by the ACA (despite attempts by the Obama Administration to place some regulations on certain types of fixed indemnity coverage).

Fixed indemnity means that the plan pays a specific dollar amount if the insured has a covered claim. For example, the plan might pay $1,000 per day for hospitalization, or $50 for a doctor visit. There’s no cap on how much the patient has to pay, and these plans often have very low annual and lifetime benefit limits.

So imagine a plan that will pay $2,000 per day for hospitalization, for up to 25 days. It will also pay $2,500 for an outpatient surgical procedure and $2,500 for an inpatient surgical procedure. And it will pay $625 for anesthesia, but it does not cover prescriptions (these numbers are from a real plan currently available in the limited benefit market).

Remember that McCain’s craniotomy – before the glioblastoma was even diagnosed – likely cost $70,000. He was home very soon after the surgery, so if he was hospitalized at all, it wasn’t more than a day or two. A limited benefit plan like the one described above would have paid $2,000 for each day in the hospital (which amounts to zero dollars if the procedure didn’t result in an inpatient stay), $2,500 for the surgery, and $625 for the anesthesia. That would leave a sizeable chunk of the $70,000 bill as the patient’s responsibility.

And all of that is before the treatment for the glioblastoma even begins.

A Cruz Amendment plan

In mid-July, Senator Ted Cruz introduced an amendment to the BCRA aimed at reducing regulations on health insurance plans. The Cruz Amendment, if included in the BCRA, would allow insurers to offer non-ACA-compliant plans as long as they also offered at least one Silver plan, one Gold plan, and one plan that complies with the BCRA’s benchmark standards (58 percent actuarial value).

The non-compliant plans would likely range from decent to terrible, since they would have wide latitude in terms of the consumer protections they’d be able to waive. Essentially, it would be a return to the pre-ACA days when there was more of an “anything goes” approach to health insurance. Plans would be available without essential health benefits, would not have to cover pre-existing conditions, and could be offered with higher out-of-pocket limits than ACA compliant plans.

These plans would likely appeal to healthy people, as they would be less expensive than ACA compliant plans. But a person who seems perfectly healthy can be diagnosed with glioblastoma, at which point the holes in the coverage become glaringly apparent.

What about those who lack McCain’s coverage

In glioblastoma, Senator McCain is facing a fierce battle, and our hearts go out to him and his family. But thanks to McCain’s health coverage, he won’t have to worry about how to pay for his treatment. I’m glad he has that health coverage.

Senator McCain is not alone in his battle. There are more than 12,000 Americans who will be diagnosed with glioblastoma this year. Unfortunately, many of them do not have the level of health coverage that McCain has. Even with the best health insurance, the diagnosis plunges each family into an immensely challenging situation. With lesser – or no – coverage, the challenge becomes even more insurmountable.

Nobody deserves cancer. And nobody deserves to have to fight cancer with less-than-adequate health insurance. With our current medical know-how, we can’t keep everyone from getting cancer. But we can make sure that as many people as possible are covered by high-quality health insurance. We owe it to all the lesser-known John McCains out there to work towards that goal.

That means pushing back against any sort of “reform” that would result in fewer people with insurance. It also means rejecting proposals that would allow junk insurance plans to flood the market, lulling consumers into a false sense of security – until they’re diagnosed with brain cancer.