Looking for a really good Obamacare replacement? Here it is
by David Lazarus - LA Times
Supporters of healthcare reform may feel disheartened as President Trump and Republican lawmakers prepare to repeal the Affordable Care Act and replace it with … well, something. They can’t even agree among themselves on what the U.S. healthcare system should look like.
But there’s reason for hope, albeit a long shot.
From Our Partners: Donald Trump Promises ‘Insurance for Everybody’ With Obamacare Replaceme…
OK, a very long shot.
Rep. John Conyers Jr. (D-Mich.) has introduced a bill that would expand Medicareto “provide for comprehensive health insurance coverage for all United States residents.”
In other words, it would build on the successful single-payer insurance program that already covers more than 55 million people and bring the United States in line with almost all other developed nations in providing taxpayer-funded health coverage for everyone.
Needless to say, the legislation — HR 676 — has no chance of passage by the Republican-controlled Congress.
However, the fact that such a bill exists serves as a reminder that there are some in positions of power who understand the pitfalls of the U.S.’s private-sector-dominated health insurance system, and who are willing to place national interest ahead of corporate profits.
Also, some backers of the legislation think there’s at least one prominent Republican who might come around to their way of thinking.
“Donald Trump is a businessman, not a lifetime politician,” said Dr. Carol Paris, head of Physicians for a National Health Program, which represents 20,000 doctors who support creation of a U.S. single-payer insurance system. “HR 676 is a formula for good business. It makes good business sense.”
She’ll get no argument from me. A 2014 study by the Commonwealth Fund compared the U.S. healthcare system to those of 10 other developed countries, including Canada, Germany, France and Britain.
It found that the United States had by far the most expensive system in the world but trailed its peers in delivering bang for its healthcare bucks.
Administrative costs — paperwork, incompatible computer systems, interactions between doctors, hospitals and hundreds of insurers — eat up about 25% of U.S. healthcare spending.
Meanwhile, at an average of more than $10,000 per person, the United States pays more for healthcare annually than any other developed country without any significant improvement in outcome, such as longer life expectancy. The typical American can expect to live to 79, whereas citizens of other developed nations will live past 80, according to the Organization for Economic Cooperation and Development.
“International experience shows that single-payer financing systems, like the one described in Rep. Conyers’ bill, are the fairest and most cost-effective way to assure that everyone gets high-quality care,” Paris said.
Conyers, however, isn’t holding his breath.
He told me he doesn’t think Trump — whom he described as “erratic” — will suddenly embrace the common-sense advantages of Medicare for all. Nor does he think House Republicans will be flexible in their thinking.
“This is not something that they’re going to buy into,” Conyers said, “even though countries with universal healthcare find that it costs less and is healthier for people. We’re just too polarized right now.”
Nevertheless, he said he’s optimistic about the future. Conyers expects the Republicans’ replacement of Obamacare to be so troublesome that the public will grow increasingly receptive to new ideas. This will allow a case to be made for Medicare expansion.
“Taking 20 million people out of Obamacare is going to help our cause,” he said. “We’ve got all the arguments on our side.”
His bill already has 51 co-sponsors, including California’s Judy Chu, Mark DeSaulnier, John Garamendi, Jared Huffman, Barbara Lee, Ted Lieu, Zoe Lofgren, Grace Napolitano, Lucille Roybal-Allard and Mark Takano. No Republicans have signed on.
Under HR 676, “all individuals residing in the United States (including any territory of the United States) are covered under the Medicare For All Program, entitling them to a universal, best quality standard of care.”
The bill would cover primary care, emergency care, prescription drugs, medical equipment, long-term care, mental health services, dental services, chiropractic services, basic vision care and other healthcare needs.
And try this on for size: “No deductibles, copayments, coinsurance or other cost-sharing shall be imposed with respect to covered benefits.” Instead, funding would be made primarily through payroll taxes, as is already the case with Medicare and Social Security.
A 2013 analysis of an earlier version of Conyers’ legislation by Gerald Friedman, a healthcare economist at the University of Massachusetts Amherst, found that progressive federal tax payments “would cost less for 95% of households” than the current system of deductibles, premiums and copayments.
He also concluded that because of huge administrative savings and greater negotiating strength with hospitals, doctors and drug companies, a Medicare-for-all system “would make it possible to provide universal coverage and comprehensive benefits to future generations.”
This isn’t “socialism” and it isn’t “government-run healthcare.” Doctors would still be free to practice medicine as they see fit.
It’s simply a more effective and efficient way of managing healthcare risk for the entire population.
Private health insurers would battle ferociously to prevent such a change, but they wouldn’t be put out of business. Rather than providing total coverage, they’d simply shift to offering supplemental plans, as they already do. A more competitive market for added coverage would only benefit Americans.
It’s widely believed that Republican replacements for the Affordable Care Act will include health savings accounts coupled with high-deductible plans from private insurers, as well as high-risk pools for people with pre-existing conditions that all but guarantee limited coverage and sky-high premiums.
Think about that. Now think about the broad coverage featured in Conyers’ bill being available for less than what you pay now.
Think about having the same coverage regardless of your job (or lack thereof). Think about the number of people without insurance dropping to zero.
Think about Americans finally enjoying the same healthcare benefits as the rest of the developed world.
What’s not to like?
Grading Obamacare: Successes, Failures and ‘Incompletes’
by Margot Sanger-Katz - NYT
Did Obamacare work?
It’s worth asking as President Trump presses his promise to repeal and replace the “disaster” of Obamacare.
Ever since the Affordable Care Act was passed in 2010, it has been so contentious that it can be difficult to see beyond the partisan debate. But by looking at the many ways the law has changed health care, it’s possible to hazard some judgments.
The answer may vary with your own experience, but it ultimately depends on what you value. For those who believe the primary goal of the law should have been to bring health insurance to more Americans, the rational answer should be: Yes, Obamacare succeeded. More than 20 million Americans gained health coverage through the law.
For those who believe the primary goal of the law should have been to make health insurance affordable to all who want it, the rational answer is: No, Obamacare did not achieve uniform affordability. Health care in the United States remains the most expensive in the world, and coverage remains out of the financial reach of many Americans.
For those who believe the primary goal of the law was to make Americans healthier, the answer has to be: It is too soon to tell.
One thing is clear, though — the Affordable Care Act has shifted the nation’s baseline expectations for how health care should work. Its successes have pushed Republican politicians, like Mr. Trump, into making expansive promises to provide insurance to all Americans. Its failures have become focal points, too, leading to calls for lower insurance deductibles and for more choices in doctors and hospitals.
With the law on the precipice of repeal, public opinion has suddenly tipped in its favor. For lots of people, “Obamacare” has become synonymous with the health care system itself, with its many miracles and dysfunctions.
There are layers beneath each judgment, of course. The law was broad and complex, with many goals and provisions. This assessment touches on its largest achievements and its biggest disappointments. For many important questions, there is not yet strong evidence either way.
Successes:
Twenty million more people have health insurance.
Providing health coverage to the uninsured was Obamacare’s principal goal, and on that measure, it has succeeded. The gain of 20 million insured, based on an Obama administration estimate last year, is probably now even higher.
Not everyone shares the goal of expanded health coverage, and some of those newly insured bristle under an “individual mandate” to have insurance or pay a fine. Still, many of the newly insured could not have afforded insurance before the law passed or would have been shut out because of pre-existing health conditions.
The rapid reduction in the number of uninsured Americans has shifted the political debate about health reform. In 2009, many Republicans were comfortable with a status quo in which many Americans couldn’t get health care. Now, Mr. Trump and Republican leaders in Congress have vowed that their plans will cover as many people as the Affordable Care Act.
It has made many Americans more financially secure.
Health insurance is supposed to provide access to health care, but it is also a financial product, intended to protect people from catastrophic bills if they are sick or injured. It is still early to measure the health law’s full impact, but several studies have found that low-income Americans have become less vulnerable to health-related financial shocks. Studies have found that fewer people struggled with medical bills or avoided medical care because of cost, and that medical debt and bills in collectionshave declined.
It has reduced inequality.
In an era of growing income and wealth inequality, Obamacare was a starkly redistributive law. Not only did it subsidize health insurance for those with low and middle incomes, but it also raised taxes on high earners. This mix of policies made the law controversial, but it also furthered the Obama administration’s goals of narrowing the gap between rich and poor Americans.
It made health insurance more comprehensive.
Before Obamacare, many products could be called “health insurance.” Now, health plans are required to cover services like maternity care and treatment for drug addiction, and they can’t cap how much they will pay in a given year. Many of the law’s critics dislike its numerous coverage mandates, but the new rules have increased patients’ access to services like mental health counseling, contraceptionand cancer screenings.
It lowered the federal deficit.
Obamacare was devised with a mix of new spending and taxes, along with cuts to the federal Medicare program, so that it would save more than it cost. A recent forecast from the Congressional Budget Office estimates that, if left in place, the Affordable Care Act will continue to save federal dollars through at least 2025. (Recent legislation has made some small changes to the law’s tax provisions, but analysts at the Center for a Responsible Federal Budget ran the numbers again and found very little difference.)
Failures:
Health insurance remains very expensive.
Obamacare’s marketplaces and Medicaid expansion make health coverage a good deal for those near the poverty line, but those earning not much more still often struggle to pay health plan premiums, and face deductibles that are much higher than those seen in a typical employer health plan. In the law’s first three years, premiums were lower than expected and grew slowly. But prices shot up this year, causing financial shocks for buyers who don’t receive government help in paying their premiums. Several analysts believe the increases resulted from recent policy changes and too-low early pricing and may represent a one-time market correction. Insurers have also said that they have found the pool of Obamacare enrollees to be sicker and less predictable in their health care needs than expected. Some people who earn enough to qualify for meager or no subsidies find health care unaffordable.
The health care system remains complex and confusing.
President Obama has described the health law’s markets as being like a Kayak or an Amazon for health insurance. They’re not. Health insurance is easier to shop fornow, but it remains a complicated and opaque product, and selecting the right health plan is often frustrating or impossible for Americans unsure of their health needs — or unable to decode jargon like “out-of-pocket maximum” or “in-network provider.” After picking their insurance, patients can still struggle to use it, and can get stuck with surprise bills or long negotiations with their insurance companies.
In many parts of the country, only one insurer even offers health plans, limiting the choices available to consumers.
If you like your plan, you can’t always keep your plan. ...
The Obamacare marketplaces are set up to encourage customers to frequently switchtheir health plans to avoid steep price increases. The markets have also been turbulent, with insurers going out of business, exiting markets or shifting around their offerings each year. That has led to a large fraction of renewing customers who change health plans every year, unable to pick a plan they like and stick with it.
… Or your doctor.
Many Obamacare health plans, trying to keep prices competitive, have sharply limited the number of doctors or hospitals they will cover. Obamacare’s authors did not expect so-called narrow network plans to become so widespread. These have made it hard for some customers to find any plan that includes their favored providers, and means that switching plans often means switching doctors, too. The narrower networks, despite their inconveniences, have helped keep insurance prices lower.
Too soon to tell:
We don’t know if the law made America healthier.
Health insurance is not the same thing as health, and we still have very limited data about whether the law’s coverage expansion has lengthened lives or improved their quality in meaningful ways. There is some encouraging but very early evidence that low-income people in two states that expanded Medicaid reported improving overall health compared with their low-income neighbors in a state that did not. And there is research that more low-income Americans have visited a doctor and have received some basic preventive health services, including prescription contraceptives and treatments for diabetes.
But it will probably take many more years before it is clear whether the law has been beneficial to public health, or how large that effect may be. Even though the law allowed 20 million more people to get coverage, that’s a small fraction of the nation’s population, and it often takes years for health care services to result in measurable benefits.
It’s unclear what the law has done to national health spending.
A crucial goal for Mr. Obama was “bending the cost curve” and slowing the accelerating cost of health care in the United States. Growth in health spending has indeed slowed in the years since Obamacare’s passage, but it is hard to untangle the effects of the health law from other forces affecting health spending, including the Great Recession, rising insurance deductibles and a slowdown in the development of new medical technologies. The health law’s most ardent champions, including Mr. Obama, credit it for this change. But many economists are uncertain whether the slowdown is a result of the law or a mere coincidence.
It may have improved the quality of care in hospitals.
The health law contained many provisions intended to make medical care safer and more evidence-based. The health system is still often a dangerous place for patients, but fewer are contracting infections in the hospital, for example, or leaving the hospital only to be readmitted in a few weeks. Some trends were underway before the health law passed, so it is difficult to tease out how much change was caused by Obamacare or would have happened anyway.
Affordable Care Act Sign-Ups Dip Amid Uncertainty and Trump Attacks
by Robert Pear - NYT
WASHINGTON — The number of people who signed up for health insurance in the federal marketplace that serves most states dipped this year to 9.2 million, the Trump administration said Friday, as consumers struggled with confusion over the future of the Affordable Care Act.
That represents a decline of more than 4 percent from the total of 9.63 million people who signed up through HealthCare.gov at this time last year.
The numbers do not include activity in the 11 states that run their own online marketplaces under the Affordable Care Act, former President Barack Obama’s signature health care law. State reports suggest that they have signed up about three million people.
Veterans of the Obama administration said President Trump’s opposition to the health law and his efforts to undermine it had taken a toll. People may also have been influenced by signals from Congress that the law would soon be repealed. And some consumers may have been put off by the termination of their health plans, which was caused by an exodus of major insurers from the market in many states.
Just before leaving office, the Obama administration reported that sign-ups through HealthCare.gov were running slightly ahead of the number at the same time last year, with 8.8 million as of Jan. 14.
“Trump’s sabotage worked,” said Ben Wakana, who was a spokesman for Sylvia Mathews Burwell, the secretary of health and human services under Mr. Obama. “We were on track to exceed last year’s total. We expected a million people to sign up on the federal exchange in the final week of the open enrollment period.”
Still, the numbers present a challenge to Republicans who are struggling to repeal the law that allowed those millions to purchase insurance plans — and who have promised not to displace anyone covered by it.
he fourth annual open enrollment season began Nov. 1 and ended Tuesday, 11 days after Mr. Trump took office.
The Trump administration scaled back publicity and advertising in the final days of the open enrollment period. Mr. Trump also issued a broadly worded executive order that directed federal officials to waive or delay any provision of the Affordable Care Act that would impose “a cost, fee, tax, penalty or regulatory burden on individuals.”
The order, issued within hours of Mr. Trump’s inauguration on Jan. 20, did not specify what actions would be taken. But lawyers and health policy experts read it as an indication that the government might not enforce the federal requirement for people to have health insurance or pay a tax penalty.
Mr. Trump has described the Affordable Care Act as “a complete and total disaster” and has said he wants to replace it with better, cheaper coverage “for everybody,” but he has not offered a plan to achieve that goal.
Senator Orrin G. Hatch, Republican of Utah and chairman of the Finance Committee, who is trying to draft a replacement for the law, said that “today’s numbers failed to keep pace with last year’s.” In addition, he suggested, some people who signed up will not pay their premiums and will therefore not have coverage this year.
“Either way,” Mr. Hatch said, “enrollment numbers are down, and costs are up.”
That response was predicted by Representative Nancy Pelosi of California, the House minority leader and an architect of the law.
“Now, Republicans will cynically point to the dip in enrollment they caused, declare the Affordable Care Act broken and move to steal the affordable health coverage of every American,” she said. “Meanwhile, in states committed to delivering affordable health coverage to their residents, enrollment in the Affordable Care Act’s marketplaces has surged.”
“Democrats will continue to stand our ground to ensure that every American has access to affordable health coverage,” she added.
Enrollment reports from the Obama administration were invariably upbeat, saying the numbers showed that people needed and wanted insurance under the Affordable Care Act.
The first report from the Trump administration struck a different tone.
“Obamacare has failed the American people, with one broken promise after another,” Matt Lloyd, a spokesman for the Department of Health and Human Services, said Friday. “Premiums in the A.C.A. marketplace have increased 25 percent while the number of insurers has declined 28 percent over the past year.”
Of the 9.2 million people who signed up through HealthCare.gov, one-third were new to the federal marketplace, and two-thirds were returning customers. The individual insurance market is in constant flux. With changes in income and employment, consumers may gain or lose coverage from Medicaid, employers and other sources of insurance.
The Obama administration predicted in October that 13.8 million people would sign up for coverage in the enrollment period that ended this week. The total appears likely to fall short of that goal.
Leslie Dach, a former Obama administration official who is trying to preserve the health law as a leader of the Protect Our Care Coalition, said, “Enrollment was a success, and it would have been even higher without the Trump administration’s efforts to suppress enrollment.” Despite those efforts, he said, “Americans continued to enroll in the final weeks, proving that there is considerable demand for quality and affordable coverage.”
Several states that run their own insurance exchanges appear to have done better than the federal marketplace. In New York, 908,200 people signed up through the state marketplace for either a qualified health plan or the “basic health program” authorized by the Affordable Care Act for low-income people. That represents an increase of 39 percent.
Under the Obama administration, enrollment in marketplace insurance plans was consistently lower than the levels originally projected by the Congressional Budget Office, in part because consumers were more likely to get and keep employer-sponsored insurance.
Drop in Late Obamacare Enrollment Appears to Be a Trump Effect
by Margot Sanger-Katz - NYT
In the waning days of this year’s Affordable Care Act sign-up period, the Trump administration declared war on the health law, releasing an executive order that could weaken its requirements and yanking advertisements and outreach off the air.
Those actions appear to have made a difference. Sign-ups for health plans in the states managed by the federal government are down slightly compared with last year. About 9.2 million Americans picked an Obamacare marketplace plan for this year, according to a government report released Friday. Last year, that number was 9.6 million.
The decline by itself isn’t that meaningful, but several snapshots over previous months had shown that sign-ups were on track to overtake last year’s enrollment. It was only in the final two weeks of enrollment, when there’s typically a deadline-driven surge, that the numbers dropped. Fewer than 400,000 people signed up for Obamacare plans over the last two weeks. Last year, more than 700,000 people signed up in the last week alone.
The falloff suggests that Trump administration actions may have confused consumers, discouraged them from enrolling or simply made it easier to forget about the deadline.
So far, the numbers do not show that the markets are failing, or in the “death spiral” that Mr. Trump and House Speaker Paul Ryan have often mentioned. But they show how important signaling is, and how confused the signaling currently is.
Mr. Trump’s executive order, signed on the day of his inauguration, was widely reported as eliminating the law’s requirement to buy insurance. (I differ with that view.) And the reductions in outreach may have prevented some people who intended to sign up from getting the reminder that they needed. More broadly, promises from Mr. Trump and Republicans in Congress to quickly repeal Obamacare may have caused some people to think the law was no longer in effect at all.
My colleagues Abby Goodnough and Robert Pear spoke with sign-up counselors around the country, who said many of their customers assumed that Obamacare would be repealed soon.
Premiums were substantially higher this year than last in many places, and it’s possible that those high prices also depressed sign-ups. But most Obamacare customers do not pay full price for their plans, so they do not feel the increases.
Full national sign-up numbers won’t be released until next month. The 9.2 million sign-ups reported Friday come only from states that use the federal government’s website to select plans. Sign-ups appear to be up in a few states using their own system.
Of course, some people who signed up during the enrollment period may drop out of coverage or simply fail to pay their premiums, meaning the number of people who will be covered in Obamacare plans is likely to be lower than the current numbers. Moreover, people who signed up early for plans because they thought it was required may drop coverage if they come to believe they will face no penalty.
That’s why the future health of Obamacare’s markets will depend largely on what the Trump administration and Congress do next. That path is hard to predict. After a week of steps that appeared to undermine the Obamacare markets, the Trump administration appeared to change course. Some of the canceled outreach was restored. And a new regulation, currently under review by the Office of Management and Budget, is expected to help stabilize the health insurance markets — though it’s hard to be sure until it is published.
Yet on Friday, a spokesman for the Department of Health and Human Services — the agency still responsible for administering Obamacare — issued a statement that adopted the harshest tones of Mr. Trump. “Obamacare has failed the American people, with one broken promise after another,” said the spokesman, Matt Lloyd. “We look forward to providing relief to those who are being harmed by the status quo.”
A rapid Obamacare repeal is looking increasingly unlikely. Mr. Trump reaffirmed this morning that health care legislation is high on his priority list, but Congress’s efforts have largely stalled. The Trump administration may want to keep things calm in the interim. If so, it will probably take more steps to reassure anxious insurers and customers. Or it may decide that further chaos will help encourage congressional action.
If Mr. Trump’s preference is the former, he may learn from this week’s news that his words matter.
https://www.nytimes.com/2017/02/03/upshot/drop-in-late-obamacare-enrollment-appears-to-be-a-trump-effect.html?hpw&rref=upshot&action=click&pgtype=Homepage&module=well-region®ion=bottom-well&WT.nav=bottom-well
Commentary: Obamacare editorial ignored the ‘repeal and replace’ scenario, Maine Republican chief says
We owe it to Congress to let them work toward sustainable solutions for our health care needs.
Another View: Single-payer coverage right fix for flawed Obamacare program
Americans are hungry for universal health care they can count on in moments when they are strong and in good health as well as those moments when they are vulnerable.
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