The Fight for Health Care Has Begun
by David Leonhardt - NYT
When House Republicans abandoned their plan to gut an independent ethics office last week, it showed the power of public opinion. It also offered a playbook for Democrats in 2017.
As soon as news of the original plan broke late last Monday afternoon, social media exploded with outrage. Phone calls poured in to Capitol Hill the next morning. At 10 a.m., Donald Trump distanced himself from the plan, and by midafternoon Republicans had folded.
We’ve seen this script before, but it has recently come from the political right more often than the left. The Tea Party and its allies managed to alter President Obama’s 2009 stimulus and 2010 health care law, as well as help block climate, preschool and infrastructure bills.
Remember, some of those victories came when Republicans didn’t control the White House or Congress. But they had other advantages: a focused message, a strong organization and a whole lot of passion. They influenced policy by striking political fear into members of Congress.
Now it’s the left’s turn to use public opinion, and the stakes in the next fight are bigger than the House ethics office.
Even before Trump becomes president, Congress is taking steps to deprive millions of people of health insurance. Democrats in Congress should do everything they can to thwart the effort. And if you’re one of those people who despaired after last year’s election — who wondered whether facts still mattered and whether there was anything you could do — you should get involved, too. How? I’ll get to that in a moment.
Republican leaders have muddied the Obamacare debate with bureaucratic jargon: deductibles, premiums, the individual mandate, repeal and delay. Don’t be fooled. The actual issues are straightforward.
Obamacare extended health insurance to more than 20 million people — middle-class, poor and sick people — and paid for it with taxes on the wealthy and corporations. It was the biggest attack on economic inequality since inequality began rising four decades ago.
Sam Jawitz is one of the beneficiaries. He was born almost two years ago in mid-coast Maine with a birth defect that left his throat unconnected to his stomach. His first month of care cost about $100,000.
His parents — small-business owners — would have spent their every dime, of course. But without Obamacare insurance, they would have gone deeply into debt, and Sam would have missed out on follow-up care and therapy. “We would have had to say, ‘Let’s only do some things,’” his mother, Alyce Ornella, said.
Today, Sam is an “outrageous” toddler, as his mom says, who will climb almost anything and likes to break into dance for no reason.
And Congress is on the verge of taking health insurance away from a lot of future Sams.
Republican leaders say they will repeal Obamacare with a delayed effective date and later make sure that people don’t lose insurance, but the leaders have no credible plan for doing so. They’re making an empty promise based on magical thinking. Two conservative experts published a devastating explanation in the journal Health Affairs last week.
Democrats have gotten off to a decent start in fighting back. A rigorous poll found that only 20 percent of Americans favor a repeal without an immediate replacement, and a handful of Senate Republicans have publicly expressed anxiety about repeal-and-delay.
But Senate Democrats still aren’t doing everything they can. Most important, they have not committed to dragging out the debate as long as possible later this week, by offering a blizzard of amendments. Once again, Democrats are at risk of bringing a knife to a gunfight.
Republicans plan to act quickly, without the months of hearings that Democrats held on Obamacare, for a reason: Transparency is the enemy of repeal. The more Americans who understand repeal, the more unpopular it will become.
What can you do? By all means, post messages on Facebook and Twitter if you want. But you can also do something more effective. You can call your senator.
Congressional staff members privately admit that they ignore many of the emails and letters they get. They also admit that phone calls are different. They have to answer them. Other people in the office hear the phone ringing and see their colleagues on the line. Phone calls are a tangible sign of public opinion, which is why they have been effective before.
If your senators are Republicans, tell them you’re part of the large majority of Americans who oppose repeal-and-delay. If they’re Democrats, tell them you want them to work harder — to stay on the Senate floor all night, if need be — fighting for people’s health care.
That’s what this is really about. It’s not about Obama or Trump or Congress. It’s about making sure that every citizen of the world’s most powerful country can receive modern medical care.
The Problems With ‘Repeal And Delay’
Republican leaders in Congress and the incoming Trump administration have said that they plan to move quickly to repeal the Affordable Care Act (ACA) in the early weeks of 2017, with a delay in the date of when key aspects of the repeal would become effective until perhaps 2019 or 2020. This is the so-called “repeal and delay” option. They have also pledged to replace the law in separate legislation, or a series of bills, that would come later, although it is not clear what the replacement would look like or when it would pass.
We do not support this approach to repealing and replacing the ACA because it carries too much risk of unnecessary disruption to the existing insurance arrangements upon which many people are now relying to finance their health services, and because it is unlikely to produce a coherent reform of health care in the United States. The most likely end result of “repeal and delay” would be less secure insurance for many Americans, procrastination by political leaders who will delay taking any proactive steps as long as possible, and ultimately no discernible movement toward a real marketplace for either insurance or medical services.
Congress should instead roll back elements of the ACA in the same legislation that moves U.S. health care more deliberately toward a functioning marketplace that is less dependent on federal coercion and control. This approach provides the best chance of constructing a replacement plan that moves decisively in a better direction without unnecessarily creating chaos during the transition.
Possible Legislative Scenario
While “repeal and delay” seems to be the preferred approach of GOP leaders at the moment, there is still considerable uncertainty about what that will actually mean in practice and what specific changes will come out of it.
To begin with, “repeal” may not really mean full repeal of the ACA. Congressional leaders have mentioned using H.R. 3762 from the just-completed Congress as the blueprint for what they plan to do in the new year. H.R. 3762 was passed early in 2016 (and then vetoed by President Obama) using the budget reconciliation procedure, which allowed it to be approved in the Senate with a simple majority vote. In practical terms, that meant Republicans could pass it without needing any support from Democratic senators. The assumption is that a similar bill could pass again in 2017. (The GOP will have 52 seats in the Senate in January.)
However, the budget reconciliation process comes with strict rules about what provisions can be included in the legislation. Only provisions that directly change taxes or entitlement spending can be included in such bills, which means H.R. 3762 could not repeal large sections of the ACA that are more regulatory than budgetary in nature. A partial repeal bill passed using reconciliation could put an end date on funding for the premium credits and cost-sharing subsidies provided in the ACA, and reduce the federal government’s payments to states that have adopted the ACA’s Medicaid expansion. It could also terminate the taxes that partially financed the legislation when it was enacted in 2010. The repeal bill will almost certainly eliminate the tax penalty associated with enforcement of the individual mandate but is likely to delay repealing the tax credits and Medicaid expansion until at least 2019.
What a reconciliation bill cannot do is eliminate, or amend, the ACA’s rules regarding regulation of insurance. The law’s current requirements regarding essential health benefits, and the prohibition on the use of a person’s health status by insurers when setting premiums or benefit offerings, were not altered in H.R. 3762; they could not be altered in a reconciliation bill taken up in 2017, either. Consequently, a partial repeal of the ACA will necessarily result in an untenable situation in the marketplace: insurance rules that presume large subsidies for insurance and strong enforcement of the individual mandate, both of which would be eliminated by the repeal bill.
Congressional leaders have said that they would move forward after enactment of the partial repeal bill with a replacement effort that could involve a series of bills rather than one large reform plan. Some portion of the replacement plan, particularly those provisions affecting taxes and spending, might be included in a second reconciliation bill later in 2017. Other steps might be taken in other, non-reconciliation bills, which means they would likely need to draw some Democratic support in the Senate. These bills might be considered in 2017 or 2018. Proponents of “repeal and delay” suggest that the looming termination of key ACA provisions, such as the premium credits, would encourage Democrats to cooperate with the GOP in enacting parts of the replacement plan.
Greater Instability With ‘Repeal and Delay’
“Repeal and delay” would further destabilize an already unstable insurance marketplace. The ACA-regulated insurance markets have been suffering from an unbalanced risk pool in many parts of the country, with many enrollees who need extensive medical attention but few who don’t need much care. Collectively, the insurance industry has lost several billion dollars over the period 2014 to 2016. In response, many large carriers pulled back their participation in the exchanges for 2017, and those that remained increased their premiums by an average of 25 percent. Thirty-six percent of the national marketplace is being served by only one insurer in 2017.
Without rapid action to stabilize the exchange markets, we are likely to see more insurers dropping out and another round of sharply increasing premiums. Insurers must make initial decisions about their participation in the exchange markets by next April. This leaves very little time to take steps that might encourage insurers to offer exchange coverage in 2018. An immediate repeal of the individual mandate’s penalty will lead some younger, healthier enrollees in ACA insurance plans to stop paying premiums. Even if the number of those dropping out in 2017 is small, it will be lead to further losses for insurers, and make it even more difficult for them to justify continued participation in 2018. There is a real danger that many parts of the country would be left with no insurance plans at all offering coverage on the ACA exchanges in 2018.
If Congress delays enacting a replacement plan, uncertainty about what might be in that legislation would further destabilize the exchange market even if ending the tax penalty for non-enrollment is tied to the ending of the premium credits and cost-sharing subsidies. Some number of current exchange enrollees, as well as insurers, are likely to view the coming termination of the ACA as a reason to withdraw their participation. Consumers may think they will eventually be spared any tax penalty even if they drop out of coverage, and insurers (and their shareholders) are likely to think it is unwise to make any kind of continued investment in a program that could soon disappear.
A process focused solely on reversing the ACA and not on putting something better in its place could easily backfire on the GOP. The political firestorm that would ensue from several million people losing their insurance could be enough to force the GOP to reverse course and take steps to provide some kind of emergency insurance for this population, which could be even more costly than the ACA. The episode could also sour the public on the whole concept of repeal and replace.
Some in the GOP will argue that the exchanges would have been unstable in 2017 and 2018 even if Congress and the Trump administration had done nothing to change the status quo. But it will not be possible for the GOP to avoid being held accountable for what happens in the insurance marketplace if they move legislation to repeal key parts of the ACA while providing no clear roadmap for replacing it.
Steps to Stabilize the Exchanges Difficult to Enact
It will be even harder for the GOP to escape responsibility for the state of the exchanges if, as seems likely, the incoming Trump administration makes decisions in the early weeks of 2017 that create even more uncertainty about the financial viability of the market.
The cost-sharing subsidies are a case in point. The Obama administration has paid exchange insurers to reduce the level of cost-sharing for exchange enrollees with incomes below 250 percent of the federal poverty line. The House of Representatives sued the administration, arguing that the ACA did not provide an appropriation for this purpose and therefore these payments should be terminated immediately.
If the Trump administration agrees with that reasoning, insurers would no longer receive federal payment for these subsidies. However, the ACA requires exchange insurers to provide those subsidies to low-income enrollees regardless of the funding. The substantial losses that would result would cause many insurers to withdraw from the market before the end of 2017.
Another critical issue for insurers is reinsurance payments. Reinsurance is funded by a tax on insurers, with $20 billion in the first two years going to fund the program and $5 billion to go toward deficit reduction. Faced with a shortfall in revenue collection, the Obama administration used all of the funds for reinsurance and none for deficit reduction. Key GOP leaders in Congress have argued that this decision is contrary to the law. If the Trump administration reverses the decision of its predecessor, there would be $5 billion less to help insurers with high insurance claims and more insurers are likely to exit the market.
A third critical issue is enforcement of the individual mandate. Even without legislation to repeal the mandate’s penalties, the Trump administration might broaden the criteria used to exempt individuals from the penalty, potentially allowing many more people to escape any tax liability. Loosening enforcement of the mandate could lead healthier individuals to drop exchange coverage, further tilting the risk pool in the ACA exchanges toward those with expensive medical conditions.
Congress and the incoming administration could work together to add provisions to a partial-repeal bill to counter the destabilizing effects of the other decisions during 2017 and 2018. Such provisions could include:
- Full and clear funding of the cost-sharing subsidies. Congress could provide an appropriation to fund cost-sharing subsidies for the years before the termination of the ACA is supposed to go into effect. This would render irrelevant the current dispute over whether a proper appropriation was provided for the cost-sharing subsidies in the original ACA legislation.
- Funding and Extension of Insurance Risk Mitigation Features of the ACA. Congress could provide full funding for reinsurance payments, and could extend beyond 2016 (to perhaps 2018) the risk corridor and reinsurance programs.
- Maintain the individual mandate’s tax penalties until the replacement plan is fully operational. In addition, the Trump administration would need to announce that it was planning to enforce the individual mandate fully while it was still in effect.
There are compelling reasons to stabilize the exchanges. Until a new insurance structure is put in place, Americans without access to employer coverage have no other choice but to get coverage from ACA-regulated plans. However, years of GOP rhetoric denouncing the individual mandate, the subsidies for insurance companies, and excessive spending of the ACA will make it difficult for Republicans to pass a bill that includes the kinds of provisions that are needed to stabilize the existing market, even temporarily. Without taking such steps, a repeal-only bill could leave many areas of the country without any exchange insurers and make it even more difficult to assemble sensible and coherent legislation to replace the ACA.
Passing ‘Replace’ Becomes Much Harder Politically After Repeal
According to the Congressional Budget Office, the reconciliation bill that Congress passed earlier this year, and that President Obama vetoed, would have lowered federal spending by $1.4 trillion over 10 years, and reduced taxes by $1.1 trillion over the same period. The net effect would have been to lower the deficit by $317 billion over a decade.
The congressional budget process would allow the savings from repeal to be set aside and used to help finance a replacement bill that would be enacted later. But passing repeal separately from replace could still make it much more difficult to build a broad political coalition for the replacement plan. Once repeal is passed, the current law baseline would be adjusted to reflect both large spending and tax cuts. A replacement bill that provided assistance to low-income households, through either Medicaid or a refundable tax credit, would necessarily increase spending relative to the post-repeal baseline. For many in the GOP, it could be very difficult to vote for a bill that would increase spending by a few hundred billion dollars relative to the post-repeal baseline, even if the overall cost would be less than the ACA.
Congress could try to make up for the lost revenue from repeal of the ACA’s tax increases with additional savings from changes in Medicare and Medicaid. Deeper cuts in these programs would provide more funding to finance adequate refundable tax credits to make coverage affordable for lower-income households. But cuts in Medicare and Medicaid are controversial, even among Republicans. And reforms aimed at achieving savings from more efficient use of services will take time to produce results. It seems certain that whatever is done will leave a replacement plan with far less budgetary space to work with to provide support to households who will struggle to pay premiums on their own.
The Plan to Pass Replace in Steps Signals There Is No Plan
News stories suggest Congress is considering moving forward with a replacement plan in a series of smaller bills rather than one big bill. This is a signal that Republicans in Congress may not have a clear vision of what they want to do.
It is not necessary for Congress to address every issue in a replacement bill. But the solutions to the problems in U.S. health care, and with the ACA, are not be found in tinkering around the edges of existing policy.
Donald Trump and most Republicans in Congress campaigned in 2016 and in earlier elections on repeal and replacement of the ACA. They are now in a position to move forward with that agenda, and it would be unreasonable to expect them not to.
But a plan that is focused on repeal without a clear vision for what will come next, or how it will be enacted, could easily backfire. There are numerous political, budgetary, and procedural obstacles to moving forward with an effective program to replace ACA.
To build a functioning marketplace, and to provide a ready path for all Americans to get health insurance, it is necessary to put together a coherent series of policies across Medicaid, employer-sponsored insurance, and the non-group insurance market. A workable plan will necessarily touch on all of these areas, and will be lengthy and politically contentious. That may not be ideal from a political perspective, but the alternative is incoherence and half-measures that will lead to a system that many Americans will view as worse than the ACA status quo.
Republicans ready to dismantle Obamacare amid replacement concerns
by Lauren Gambino - The Guardian
After seven years of failed attempts to repeal Barack Obama’s healthcare law, Republicans finally have their chance.
This week, Republicans on Capitol Hill will press ahead with their plan to dismantle the Affordable Care Act as the White House sounds the alarm on their “repeal and replace later” approach.
The health and human services secretary, Sylvia Burwell, warned on Monday that abolishing the law with no replacement in place would disrupt the nation’s $3tn-a-year healthcare system and leave millions of patients without care.
“Our only chance of not going over that cliff depends on opponents of the law doing in the next two years what they haven’t done in the past six – develop a comprehensive replacement plan,” Burwell said in a farewell address at the National Press Club.
Burwell said lawmakers should ask themselves three questions when considering replacement legislation: does it cover as many people? Does it maintain the quality of coverage? And does it “keep bending the healthcare cost curve in the right direction?”
Asked about alternative proposals brought forward by Republicans, she said: “I think we haven’t seen a real proposal for replacement.”
Burwell’s speech matched remarks by President Obama over the last few days in defense of the healthcare law, in which he has admitted that it needs to be improved but made the case against its repeal.
After a clean sweep of Congress and the White House, Republicans will have no problem dismantling the 2010 law that they vehemently opposed from the outset. The much more complicated question – one Republicans have yet to agree on – is how to overhaul the system without eliminating coverage for the 20 million people who now have insurance through the Affordable Care Act.
“We’re acting quickly because Obamacare is collapsing under its own weight, and things will continue to get worse otherwise,” the Senate majority leader, Mitch McConnell, wrote in an op-ed for Fox News published on Monday.
“That doesn’t mean the law will end overnight. There will be a stable transition period, and once repeal is passed we will turn to replacement policies that cost less and work better than what we have now.”
On Sunday, McConnell said he expected the Senate to take its “first steps” toward unwinding the law by the end of the week and that Republicans would produce an alternative “soon”. The timeline between repealing and replacing the law should be short, he said.
“You have to both repeal and replace, and I think there ought not to be a great gap between the first step and the second,” McConnell said on CBS’ Face the Nation. Pressed on whether someone who is currently covered under the healthcare law would have insurance after it was repealed, McConnell demurred.
In his Fox News op-ed, McConnell called for Democratic support in the repeal process, writing: “We want their ideas to improve our healthcare system. We want to find ways to work together on this important issue.”
Last week, Obama said he would support the repeal of his biggest legislative achievement if Republicans came up with something better – though he expressed doubt that it will happen.
“I am saying to every Republican right now, if you in fact can put together a plan right now that is demonstrably better than what Obamacare is doing, I will publicly support repealing Obamacare and replacing it with your plan,” Obama said in an interview with Vox on Friday. “But I want to see it first.”
The president is using his final days in office to galvanize support, criticizing Republicans’ determination to gut his law without a clear plan.
“‘Repeal and replace’ is a deceptively catchy phrase,” Obama wrote in an essay for the New England Journal of Medicine, published on Friday. “The truth is that healthcare reform is complex, with many interlocking pieces, so that undoing some of it may undo all of it.”
Republicans do not have the votes to pass an outright repeal of the law. They are using an expedited process known as a budget reconciliation that will enable them to dismantle key provisions of the law with a simple 51-vote majority in the Senate.
Republicans have not formed a consensus around an Obamacare replacement, a debate some say could take 18 months or more. They will probably need Democrats’ help to pass a new healthcare law, but the party has so far indicated no willingness to help.
“They want to repeal it and then try to hang it on us,” the Senate minority leader, Chuck Schumer, said last week. “Not going to happen. It’s their responsibility, plain and simple.”
Only a handful of Democrats from conservative states have indicated that they could work with Republicans to replace the law.
While popular opinion is split over the merits of the healthcare law, many of its provisions continue to enjoy high levels of support from voters of both parties, according to a November tracking poll by the Kaiser Family Foundation.
Donald Trump has expressed support for certain provisions, including measures that bar insurance agencies from refusing to cover people with pre-existing conditions and allow young people to stay on their parents’ health insurance until age 26. Last week, Trump pledged in a tweet to replace the healthcare plan with something “less expensive & FAR BETTER!”
Last week, Kellyanne Conway, a top Trump adviser, said it was “correct” that people currently covered by the law would not lose their insurance.
“We don’t want anyone who currently has insurance to not have insurance,” Conway said on MSNBC. “Also, we are very aware that the public likes coverage for pre-existing conditions. There are some pieces of merit in the current plan.”
Congressional Republicans and the president-elect have yet to agree on a viable alternative to Obamacare. The Republican senator Rand Paul split with his party last week in a vote on legislation that would abolish the law.
Muted Response From Health Lobby as Affordable Care Act Faces Repeal
by Robert Pear
WASHINGTON — The speed of Republican efforts to repeal the Affordable Care Act has stunned health industry lobbyists, leaving representatives of insurance companies, hospitals, doctors and pharmaceutical makers in disarray and struggling for a response to a legislative quick strike that would upend much of the American health care system.
The Senate is expected to take the first step by Thursday morning, approving parliamentary language in a budget resolution that would fast-track a repeal bill that could not be filibustered in the Senate. House and Senate committees would have until Jan. 27 to report out repeal legislation. Health insurance and health care for millions of Americans are at risk.
But far from reflecting the magnitude of the moment, the most prominent message from lobbyists that lawmakers saw in their first week back at work was a narrowly focused advertisement from the U.S. Chamber of Commerce demanding the repeal of “Obamacare taxes,” especially an annual fee imposed on health insurance companies to help pay for the expansion of coverage under the health law.
“More than 20 million people could lose their health insurance, and states could lose billions of dollars in Medicaid money,” said Kenneth E. Raske, the president of the Greater New York Hospital Association. But, he added, many health care executives “don’t want to get on the wrong side of the new administration or the Republican majority in Congress.”
Health care professionals are not totally silent, but industries that were integral to the creation of the Affordable Care Act in 2010 are keeping their voices down as Republicans rush to dismantle it. Some Republican lawmakers are openly fretting about their leaders’ repeal strategy, saying they must develop an Affordable Care Act replacement before they repeal it. Five Republican senators proposed on Monday to extend the deadline for drafting repeal legislation by five weeks, until March 3. One of the five, Senator Bob Corker of Tennessee, said the extra time would allow Congress and the Trump administration to “get the policy right” as they try to arrange a smooth transition to a new system of health coverage.
But the naysayers are getting no cover from a major lobbying and advertisement blitz like the ones that blanketed the airwaves in 2009 and 2010.
To block the repeal effort, said Senator Richard J. Durbin of Illinois, the No. 2 Senate Democrat, “we need two or three Republicans to join us.”
Doctors are telling Congress to proceed with caution, insisting that no one should lose coverage. The American College of Physicians, representing 148,000 specialists in internal medicine, has sent letters to senators urging them to “vote no” this week on the budget resolution.
Hospitals were expecting to receive tens of billions of dollars in additional revenue for treating people who were newly insured under the health law, and they are alarmed at the prospect that it may now be repealed. But, they say, if Congress goes ahead and rolls back the expansion of coverage, it must also restore tens of billions of dollars that the health law cut from Medicare payments to hospitals.
Top executives from state hospital associations will fly to Washington this week to develop their strategy. Many also plan to visit offices on Capitol Hill, where they will warn of the potential damage if Congress repeals the health law without guaranteeing similar coverage for those who would lose it.
A coalition of consumers and liberal advocacy groups is spending more than $2 million on television advertisements urging Congress to stop its attack on the law. The ads, by the Alliance for Healthcare Security, are aimed at a handful of Republican senators, including Lisa Murkowski of Alaska, Jeff Flake and John McCain of Arizona, Susan Collins of Maine, Dean Heller of Nevada, Lamar Alexander and Mr. Corker of Tennessee, and Shelley Moore Capito of West Virginia.
But by Washington standards, that is a pittance. Pharmaceutical Research and Manufacturers of America, an industry lobbying group, set aside $150 million in 2009 to support the law’s passage.
Some lobbyists have tacitly accepted the likelihood that major provisions of the health law will be repealed, setting their sights instead on shaping its replacement. They fear that if they come out strongly in opposition to repealing the law, they will lose their seats at the table as congressional Republicans and the Trump administration negotiate a replacement.
For now, passage of the budget resolution this week looks likely. The real fight is expected to come two to three weeks from now, when two House committees and two Senate committees produce legislation to repeal the Affordable Care Act and must answer to Republicans who say a replacement measure must be ready at the same time.
At least a half-dozen Republican senators have expressed doubts about the Republican leadership strategy of using the budget resolution to fast-track legislation to repeal the law, with a delayed effective date to allow time to find a replacement in the future.
“Repeal and replacement should take place simultaneously,” Mr. Corker said last week. Senator Tom Cotton of Arkansas said on MSNBC, “It would not be the right path for us to repeal Obamacare without laying out a path forward.”
Members of the hard-right House Freedom Caucus are also pressing leaders to embrace a replacement bill before they eviscerate the existing law.
And that concern is not confined to Congress. Gov. John R. Kasich of Ohio, a Republican, has also warned Congress against repealing the law without a replacement. What, he has asked, will happen to the 700,000 people who have gained coverage under the expansion of Medicaid in Ohio?
Senator Rand Paul, Republican of Kentucky, said that he spoke on Friday with President-elect Donald J. Trump, and that Mr. Trump agreed a replacement measure must be ready.
“I think he consistently has said, and I think many people who look at this say, ‘Gosh, you’re going to repeal this huge, dramatic thing and not have a replacement on the same day?’” Mr. Paul said on Monday. “I mean, doesn’t make a lot of sense to do that.”
Many of the lobbyists who might have slowed the process appear flummoxed, in part because they were expecting Hillary Clinton to win the election.
Some companies, anxious about changes in health policy, said they were afraid to speak out because they feared that Mr. Trump would attack them on Twitter, as he has badgered Boeing, Ford, General Motors, Lockheed Martin and Toyota.
Marilyn B. Tavenner, the chief executive of the leading lobby for insurers, America’s Health Insurance Plans, is in a particularly awkward position. As an Obama administration official from 2010 to 2015, she led work on the health law, issued rules to carry it out and often defended it on Capitol Hill. In December 2015, Speaker Paul D. Ryan of Wisconsin pointed to her as an example of how federal officials passed through a revolving door to work for companies they once regulated.
“If the insurance industry does not understand how Obamacare works, why not hire the person who ran it?” Mr. Ryan said in a gibe at Ms. Tavenner that drew laughter from his audience at the Library of Congress.
Ms. Tavenner said the requirement for people to have insurance — the individual mandate — was likely to be eliminated. But, she said, to stabilize the market, Congress should maintain “subsidies for low- and moderate-income individuals to purchase insurance and financial help for plans that enroll high-cost individuals, through at least Jan. 1, 2019.” She is also asking Congress to kill the tax on insurers, which has already been suspended for 2017.
Kaiser Permanente, the managed care company that serves more than 10 million people, declined to comment specifically on Republican plans to repeal the Affordable Care Act. Instead, it offered a statement of general principles saying that people should have access to health care and that “we must continue to accommodate those who have pre-existing conditions.”
George C. Halvorson, a former chief executive of Kaiser Permanente, said insurers were guarded in their comments because the current environment was “extremely politicized.” He predicted they have more to say when Congress turns to the task of devising a replacement for the law.
“You need to make your point when it will have optimal impact,” Mr. Halvorson said.
Lobbyists for the Blue Cross and Blue Shield Association have been more active and outspoken.
They support changes to the health care law because, they say, premiums and deductibles are too high and commercial insurers have been dropping out of the public insurance marketplaces. One-third of counties in the United States have only one insurer offering coverage in the marketplace, they say, and in many cases, it is a Blue Cross plan.
But Blue Cross lobbyists expressed alarm that Congress or a federal court might eliminate the cost-sharing subsidies that the government pays insurers to reduce out-of-pocket costs for low-income people. Without these payments, Blue Cross wrote in a primer delivered to congressional offices, consumers will see “significant premium increases in 2018, making coverage even more unaffordable for millions of working Americans.”
While defenders of the Affordable Care Act try to figure out a strategy, conservative groups are pressing hard for full repeal of the law as soon as possible. Among them are Heritage Action for America, an offshoot of the Heritage Foundation, and Freedom Partners, a conservative group backed by the billionaire brothers Charles G. and David H. Koch.
Democrats and their allies are planning a huge fight to save Obamacare
by Noam Levey and Michael Mamoli - LA Times
Energized by Republican moves to roll back the Affordable Care Act, leading patient advocates, consumer groups, labor unions and Democratic officials are mobilizing a nationwide campaign to defend the law and protect millions of Americans who depend on the law and other government health programs.
The campaign, which is quickly ramping up ahead of President-elect Donald Trump’s inauguration next week, aims to reshape the debate over the law after years in which the public conversation has been dominated by its critics.
But Obamacare supporters believe that as Republicans push to gut the 6-year-old law, Americans, including many who voted for Trump, will come to appreciate its protections and fight to keep them.
“This is about one of the most important things in every person’s life: the basics of your health,” outgoing Health and Human Services Secretary Sylvia M. Burwell said in a speech Monday.
“This is real, and it affects everyone’s lives. … That is what’s different, when the conversation shifts from the rhetoric to reality.”
Already, there are signs of this new dynamic, as a growing number of Republicans voice concerns about rushing to repeal Obamacare without first outlining a replacement, something the GOP has yet to do.
Polls show thin support for the Republican strategy to repeal now but delay a replacement. No major organizations representing patients, physicians, hospitals or others in the nation’s healthcare system back the GOP approach.
And Trump enters office with historically low public confidence, a weakness that Obamacare defenders figure to exploit.
Democratic senators kept up the pressure Monday, taking to the Senate floor and using Facebook to challenge the Republican repeal effort. In a play on Trump’s signature campaign line, Democrats promise that the GOP strategy would “make America sick again.”
Activists planned a national effort Tuesday to get Americans to call members of Congress and urge them to vote against legislation that would roll back the law.
“This is as important to us as a presidential campaign,” said Mary Kay Henry, president of Service Employees International Union, whose 2-million members played a central role in helping pass Obamacare and are expected to be critical in defending it.
The order is daunting.
Republicans, who will control both the White House and Congress for the first time in more than decade, credit their victories in part to a relentless campaign against Obamacare.
And with some Americans struggling with large insurance premiums, GOP lawmakers have had no trouble finding horror stories to bolster their repeal effort.
“Obamacare is ripping apart at the seams, and things are only getting worse,” Rep. Diane Black (R-Tenn.) said in the party’s weekly radio address. The Tennessee insurance market has experienced some of the worst turmoil in the country over the last year.
At the same time, Democrats have taken a hands-off approach to the law in recent years, wary of being linked to its struggles.
But as this new chapter in the healthcare debate begins, they have some key advantages.
“Democrats who were always a little squirrely on robustly defending the Affordable Care Act are on very firm ground in fighting repeal,” said Sen. Christopher S. Murphy (D-Conn.).
Though public opinion about Obamacare is still split, most provisions of the law are extremely popular, even with Republican voters. That may fuel a major backlash if the GOP moves to take them away.
Eight in 10 Americans in another poll say they like provisions in the law that eliminate out-of-pocket costs for many preventive services such as cancer screenings or provide federal aid to states so they can expand Medicaid coverage for poor patients.
The same strong majority supports the law’s system of insurance marketplaces – such as HealthCare.gov – in which people who don’t get coverage through an employer can shop for health plans.
And 80% of Americans favor the government subsidies provided through the law to help low- and moderate-income people buy insurance.
GOP leaders have called for major cutbacks in Medicaid and a fundamental change in insurance rules that would only guarantee coverage for people who didn’t have gaps in coverage. Republicans also would no longer require insurers to offer basic benefits.
Democrats plan to prominently feature people who stand to lose some of these protections if the law is scrapped.
President Obama, in an interview last week with Vox, called out Natoma Canfield, a cancer survivor who struggled to obtain affordable insurance before the law was enacted.
"When most people, even if they’re not Obama supporters, hear Natoma’s story or the stories of other people who have been helped, they know it’s wrong to just take away their healthcare," Obama said. "And it becomes less about who’s winning here in Washington. It becomes about how are we doing right by our fellow Americans."
At a meeting with congressional Democrats last week, the president encouraged lawmakers to look at the successful approach the nascent tea party movement took in 2009 and 2010 against Obamacare — including flooding lawmakers’ town hall meetings in their districts.
Also aiding the Obamacare defense could be in the GOP’s interest to make broader changes to other popular safety net programs, including Medicaid and Medicare.
Medicare provides coverage to more than 50-million elderly and disabled Americans. And Medicaid covers more than 70 million poor children, adults and seniors, many of whom depend on the program for nursing home coverage.
Leading Republicans – including House Speaker Paul Ryan (R-Wis.) and Rep. Tom Price (R-Ga.), Trump’s pick to be health secretary – have advocated major cuts in the programs that would likely slash coverage for the poor and shift more healthcare costs onto seniors.
“This is not just about the Affordable Care Act,” said Richard Kirsch, former national campaign manager of Health Care for America Now, a coalition of liberal grass-roots groups that played a pivotal role in helping pass Obamacare in 2009 and 2010.
“They are talking about replacing Medicare, cutting funding for Medicaid. … This would be devastating to affordability and accessibility of healthcare for millions of Americans, and we are going to making it clear that this is one big attack on people’s health.”
Kirsch is helping restart the campaign, which has already organized demonstrations in 19 states.
On Capitol Hill, Rep. Eric Swalwell (D-Dublin), who is leading messaging efforts for younger voters on Obamacare, said the fate of the entitlement programs will also figure prominently in Democratic lawmakers’ efforts.
"More than ever, the family’s income is tied together," he said, summarizing the message as: “Don't end my mom’s Medicare. Don’t take my dad’s healthcare. … If our parents’ healthcare security is in jeopardy, the whole family’s financial security is in jeopardy.”
Creating Obamacare wasn’t a picnic. Repeal can’t be, either.
by Amy Fried - Bangor Daily News
Repealing Obamacare would hurt patients, providers and the economy. Rural hospitals would be at risk and emergency departments could close, making it less likely rural people with heart attacks and strokes survive.
Simply wiping out the Affordable Care Act would be reckless governance. Voting now for repeal with a replacement to be crafted later is also terrible policy with awful consequences.
Obamacare wasn’t created rapidly. Seven and a half years ago former Maine Sen. Olympia Snowe sat at a table working out details for what was to become the Affordable Care Act. To keep negotiators going, Senate Finance Committee Chairman Sen. Max Baucus, D-Montana, and his staff put out munchies such as pretzels and beef jerky.
While Snowe noted, “The food leaves something to be desired,” she praised the environment created by the chairman, saying, “The talks are free-flowing. Max is very inclusive.”
There may have been snacks that summer of 2009, but expanding health care has never been a picnic.
Despite the months of hearings by five congressional committees and the bipartisan negotiations, no Republican was to vote for the Affordable Care Act. The rise of the tea party and the GOP leadership’s stated interest in denying President Obama support for his legislative agenda saw to that.
The Affordable Care Act, which brought the percentage of Americans without health insurance to its lowest level in American history, built on the work of presidents going back to Franklin Roosevelt. Now Speaker of the House Paul Ryan wants to go beyond repealing it to privatizing Medicare and turning Medicaid into block grants. President-elect Trump has long promised to repeal the ACA right away.
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Just on fiscal grounds a repeal would be damaging. The Committee for a Responsible Federal Budget reports that, “A full repeal of the ACA would cost $350 billion through 2027 under conventional scoring and $150 billion under dynamic scoring.” Attempts to replace the ACA at some point would run into money trouble since “Repealing the entire ACA would leave no funds available for ‘replace’ legislation, and in fact would require further deficit reduction to avoid adding to the debt.”
Repeal would also hit our economy hard. The Commonwealth Fund projects a loss of 2.6 million jobs nationally, largely in the private sector. There would be a “$2.6 trillion reduction in business output from 2019 to 2023. States and health care providers will be particularly hard hit by the funding cuts.” As two conservative health economists recently concluded, repealing and replacing later would destabilize insurance markets.
Maine’s health care sector has been a bright spot for the state’s economy, but a repeal would damage it, threatening rural hospitals the most as the costs of providing uncompensated care spike.
Most important is the impact on people who gained coverage. According to the Urban Institute, a partial repeal that uses the budget reconciliation process, as is often discussed, would lead 29.8 million people, 80 percent of whom work, to lose insurance, including 4.4 million children. Some 95,000 Mainers would lose coverage. Between 2019 and 2028, Maine would lose $4.7 billion in federal funds.
Those big numbers obscure the human costs to losing coverage, including to two people I know who have cancer.
Any replacement should go through the same process as the ACA, with hearings, negotiations, budgetary estimates and time for analysis and critiques. That will allow all to see who and how many would be covered and at what cost.
Because it took time to develop, the ACA has mechanisms that work together. Cheaper prescription drugs for Medicaid recipients and free preventive care for all lower health care costs. The unpopular individual mandate is needed in order to preserve popular elements such as requiring insurance companies to sell to people with preexisting conditions and having no lifetime caps on coverage. Modifying elements willy-nilly would increase the ranks of the uninsured while rapidly increasing prices.
Sen. Susan Collins opposes the terrible idea of repealing Obamacare without any replacement because it would cause “a gap in coverage” but would accept another inadequate scheme, “a detailed framework that tells the American people what direction we’re headed.” It’s positive that Collins voted against making it easier to change Medicare and Medicaid and opposes immediately dropping current funding mechanisms for Obamacare that would be needed to support any replacement.
What is clear is that a flat repeal or “repeal and run” approach would create enormous damage.
State fines Anthem Health Plans for poor consumer complaint response
The Maine insurer admits failing to follow its own policies and state law and agrees to pay $225,000.
by J. Craig Anderson - Portland Press Herald
State regulators have slapped health insurer Anthem Health Plans of Maine Inc. with a $225,000 civil penalty for its failure to adequately track and respond to customer complaints.
Maine Insurance Superintendent Eric Cioppa said Monday in a news release that Anthem, a subsidiary of New Hampshire-based Anthem Blue Cross and Blue Shield, repeatedly failed to follow up on complaints filed by its customers with the Maine Bureau of Insurance in a timely manner. State law requires that insurers respond to complaints within 14 days, the bureau said, but in nearly two-thirds of all cases Anthem failed to do so.
The bureau’s Market Conduct Unit performed a review of Anthem’s handling of complaints in 2014 after investigators reported several late and missing responses to complaints forwarded to Anthem by the bureau, according to the news release.
“We expect insurers to respond in a timely and substantive manner to issues raised by consumers,” Cioppa said. “Failure to respond to the bureau’s inquiries is a serious issue, as it directly impacts our ability to assist consumers and protect their contractual and legal rights.”
Anthem also did not adequately respond to bureau inquiries about customer complaints, provide requested documents or establish and implement a satisfactory complaint resolution plan, Cioppa said.
The insurer has agreed to pay the $225,000 fine as part of a consent agreement. In addition to the civil penalty, Anthem is required to submit a corrective action plan to the bureau within 30 days of signing the agreement.
Company spokesman Colin Manning blamed the problem on a former employee and acknowledged that Anthem failed to comply with its own policies and state law.
“Anthem Blue Cross and Blue Shield is committed to providing the highest-quality service to our members. Unfortunately, the actions of one individual did not live up to that commitment,” Manning said in a written statement. “We take our obligations very seriously, and the cases identified by the Bureau of Insurance were not handled in accordance with our own internal policies or state law. We took immediate steps to address these issues as soon as they were brought to our attention in 2014, well in advance of the issuance of the bureau report.”
Manning said the employee responsible for the customer complaint failure, along with that employee’s manager, are no longer with the company.
“Additionally, internal policies have been strengthened to help prevent similar actions by individuals in the future,” he said. “Anthem cooperated fully with the bureau during the examination, and we remain committed to providing access to quality, affordable care to all of our members.”
The bureau said its examination of Anthem’s complaint resolution procedures uncovered numerous problems and violations.
Of the 106 customer complaints filed with the bureau during the period examined, Anthem responded within the required 14-day window in only 39 instances, it said.
“Of the 67 complaint inquiries that contained untimely responses, 24 responses were received within 15 days of the statutory deadline, 25 responses were received 15 to 30 days late, seven were received 30 to 45 days late, and 11 were received more than 45 days late,” the bureau said.
The company also did not maintain an accurate written record of customer grievances, according to the bureau. Anthem ultimately admitted that it had failed to register all of the customer complaints it had received.
In addition, the bureau said Anthem did a poor job of responding to its inquiries.
“Throughout the examination, there were numerous instances where Anthem had difficulty providing bureau staff, in a timely and substantive manner, with requested data, information, records, documents and other materials related to the examination,” it said.
Finally, the bureau determined that while Anthem did have a written procedure in place for handling customer complaints, it did not always follow the procedure.
“Anthem’s failure to consistently implement the procedure resulted in Anthem’s inability to maintain an adequate grievance register and ultimately contributed to Anthem’s repeated untimely responses to the complaint inquiries,” the bureau said.
Cioppa said the bureau will be reviewing Anthem’s corrective action plan and will continue to monitor the company’s handling of complaints to ensure that the corrective action has resolved the problem.
Bureau spokesman Doug Dunbar said the regulatory agency has fined insurers in the state as much as $1 million for similar violations in the past, and that the civil penalty against Anthem “is certainly not unprecedented.”
LePage budget plan would disqualify thousands from MaineCare benefits
Tightening eligibility for the federal health care program would save the state $33 million while making it one of the stingiest in the nation for helping able-bodied poor adults.
by Joe Lawlor - Portland Press Herald
The LePage administration’s proposal to further tighten Medicaid eligibility requirements would make Maine one of the stingiest states in the nation when it comes to allowing able-bodied, low-income adults to qualify for the federal health care program.
“The implications are dire,” said Robyn Merrill, executive director of Maine Equal Justice Partners. The advocacy group for low-income Mainers estimates that Gov. Paul LePage’s budget would trim Medicaid rolls by up to 20,000 people.
Under the budget proposal, released Friday night, adults with children could earn no more than $9,720 – 40 percent of the federal poverty level of $24,300 for a family of four – to qualify for MaineCare, the state’s name for Medicaid. The children would still receive MaineCare.
Meanwhile, adults removed from MaineCare under LePage’s proposal would not qualify for federal subsidies to purchase Affordable Care Act insurance because the subsidies do not kick in until a person earns at least 100 percent of the poverty level.
While 31 states have expanded Medicaid coverage under the ACA, Maine has made it more difficult to qualify for Medicaid since LePage took office in 2011, joining states such as Alabama, Mississippi, Idaho, Texas and Kansas that have traditionally restricted access. LePage also has vetoed efforts by the Legislature to expand Medicaid, and has cut back the program by reducing eligibility and making other changes.
The governor’s budget proposal noted that tightening Medicaid eligibility would save $33 million, which he wants to divert to other health and human services programs for the “neediest and most vulnerable” populations, such as the elderly and disabled.
DHHS spokeswoman Samantha Edwards said in an email response to questions that reducing the tax burden for Mainers as the LePage budget aims to do would do a better job of reducing poverty than traditional welfare programs such as Medicaid.
“We cannot continue to focus our budgets and public policy based on the dependency that has been created by years of promoting welfare programs, but rather must focus on reducing the size and cost of state government,” Edwards wrote. “Through these efforts to increase jobs in Maine, we will do far more to support longer-term success for those who have been trapped in poverty by short-sighted welfare policies that have perpetuated dependency.”
But Dr. Patricia Hymanson, a Democratic state representative from York and co-chair of the Legislature’s Health and Human Services committee, said cutting off Medicaid for low-income parents is “cruel” and helps keep families trapped in poverty.
“If the parents are struggling with their health, the children struggle, too,” Hymanson said.
Overall, the DHHS budget would be trimmed by $140 million, according to the 30-page budget analysis released Friday.
“Given the significant pressures on U.S. health care costs – and the rapidly increasing Medicaid expenditures seen in other states – the ability of DHHS to rein in MaineCare spending is a significant accomplishment,” LePage’s budget overview states.
Andrew Coburn, a research professor and director of the Maine Rural Health Research Center at the University of Southern Maine, said given that Maine lawmakers nearly approved Medicaid expansion, it seems unlikely that the Legislature, where Democrats hold the majority in the House and Republicans hold the Senate by one seat, would approve such a deep cut to MaineCare.
Support for Medicaid expansion included some State House Republicans, including Sens. Roger Katz of Augusta, Tom Saviello of Wilton and David Woodsome of North Waterboro.
“It seems almost like this budget is a political statement,” Coburn said. “I’m hard-pressed to think of a rationale for this.”
Coburn said MaineCare cuts would harm families, as well as shift costs and create ripple effects in other parts of the health care system, such as requiring hospitals to provide more free care to the uninsured and create upward pressure on the price to provide private employer-based insurance.
People without insurance tend to wait until they have an emergency to go to the hospital, which is more costly to the system than getting preventive care available under Medicaid.
“It’s a proposal that would have serious consequences,” Coburn said.
Maine Equal Justice Partners is organizing a petition drive to place Medicaid expansion on the ballot as a statewide referendum, either in 2017 or 2018. At the same time, Congress is mulling whether to repeal the ACA, but no comprehensive replacement plan has been identified.
Medicaid is a federal program administered by the states and paid for with a blend of state and federal dollars. While states must cover the disabled and children with Medicaid, they have wide latitude when it comes to adults.
Maine currently ranks as the 18th stingiest state when measuring Medicaid eligibility for able-bodied single adults and parents, according to the Kaiser Family Foundation, a nonprofit that conducts health care research. If LePage’s proposal is approved, Maine would become the 10th stingiest state in terms of Medicaid eligibility.
Adults without children were removed from Maine’s Medicaid rolls about three years ago, but adults who had children in the home currently still qualify for Medicaid in Maine if they earn up to 100 percent of the federal poverty level, or $24,300 for a family of four.
Some states make it nearly impossible to qualify for Medicaid for adults who are not disabled.
For instance, in Texas and Alabama, adults without children do not qualify, and adults with children become ineligible for Medicaid if they earn more than 18 percent of the federal poverty level.
By contrast, the District of Columbia, Connecticut, Alaska and Indiana make it easier for their residents to qualify for Medicaid benefits than it would be under Medicaid expansion through the Affordable Care Act, which allows people who earn up to 138 percent of the federal poverty limit.
About 287,000 Mainers are on MaineCare, and the cutbacks would make up to 20,000 adults ineligible for Medicaid, according to Maine Equal Justice Partners. Maine also used to allow low-income parents with children in the home to qualify for MaineCare for those who earned up to 200 percent of the poverty limit, but that was cut to 100 percent of the poverty limit in recent years.
Merrill said other LePage cutbacks to the social safety net proposed in the just-released two-year budget – such as the elimination of General Assistance and cutbacks to Temporary Assistance for Needy Families – threaten to increase poverty levels in Maine.
“This can destroy people’s lives, put them into bankruptcy or make them lose their home,” Merrill said.
LePage has made welfare reform one of the cornerstones of his two terms as governor, but some of the changes have been heavily criticized by Democrats and advocacy groups.
State Sen. Eric Brakey, R-Auburn, and co-chair of the Health and Human Services Committee, said he’s still examining the LePage budget in detail, so he doesn’t have a stance yet on the Medicaid proposal.
“That said, I’m very open-minded about any proposals that seek to prioritize our limited welfare resources for Maine’s most vulnerable,” Brakey said in a written statement to the Press Herald.
Merrill said the LePage administration proposal is real and coincides with the governor’s political ideology, so it shouldn’t be assumed that it will be defeated.
“Let’s hope reason and compassion prevail,” she said.
Study reveals hidden world of insurer, doctor bargaining
The research offers a look at how health care providers set prices, and who comes out on top.
by Max Ehrenfreund - Washington Post
The price of health insurance just keeps going up. Until recently, though, a crucial part of that process was invisible to the public: the negotiations between doctors and insurance companies that determine how much patients are charged.
The story of that contest, carried on fiercely behind closed doors for decades, is now partially in public view, and the new data contains tantalizing clues about where prices for health care really come from.
Health care providers and insurers have to agree on how much doctors will be reimbursed before doctors begin treating insurers’ clients. Those fees, which depend on the relative clout of the negotiating parties, are an important component of the premiums that patients pay to their insurance companies every month.
A survey of the numbers, published this week in Health Affairs, shows that small-time doctors’ offices and insurance companies are getting squeezed by their larger competitors. For instance, small insurers are billed an average of $86 for a routine visit to the doctor’s office, while insurers of medium size are billed $70.
COMPANIES MOVE TO CONSOLIDATE
Those discrepancies illustrate why joining forces can be so attractive, for both providers and insurers. Currently, four major health insurers have proposed mammoth mergers. Aetna wants a deal with Humana, and Anthem is aiming to acquire Cigna.
Lawyers for the Obama administration are seeking to prevent those firms from merging, arguing that the combined companies would increase prices for patients and put more financial strain on doctors.
In some cases, mergers can benefit patients. Larger hospitals or doctor’s offices might be able to operate more efficiently, reducing costs. Large insurance companies, by bargaining down rates, might be able to offer their customers a better deal.
On the other hand, major providers can demand more generous reimbursements from insurers, increasing costs instead. If insurance conglomerates are not concerned about competition from smaller rivals, meanwhile, the evidence suggests that they simply pocket additional profits rather than reducing prices for patients.
“Consolidation is often associated with higher prices,” said Laurence Baker, an economist at Stanford University who was not involved in the new study. “Really, if you’re a small player, you get a take-it-or-leave-it offer.”
The data in the study comes from claims compiled by Fair Health, a national clearinghouse for health-care data headquartered in New York. The organization is a product of a lawsuit that lawyers for that state brought against the industry; it was settled in 2009.
STUDY LOOKS AT MARKET SHARE
“What we’ve contributed here is looking at prices in a very detailed way that has rarely been possible,” said Eric Roberts, a health economist at Harvard University and one of the study’s authors. “These dollar discounts represent, actually, a large total sum of money.”
Roberts and his colleagues, Harvard’s Michael Chernew and physician Michael McWilliams, classified doctor’s offices and insurers based on their share of the market in each county. The smallest category included firms with less than 5 percent of the market. Firms with more than 15 percent formed the largest category, and a third category comprised those in between.
Small doctor’s offices billed insurers of medium size $72 on average for an uncomplicated, routine visit. A large office would bill the same insurers an average of $86 for the same visit.
Since doctor’s offices often agree to calculate all their prices using a single formula, these figures suggest that a group of doctors working in an independent office could increase revenue by nearly 20 percent if they sold out to a larger partnership.
INCENTIVE TO ‘BULK UP’
The figures in this study suggest that the greatest financial benefits of size seem to go to small insurers.
Yet the authors focused on only three categories and did not break down prices paid by insurers with substantially more than 15 percent of the market. As a result, the figures in the paper could underestimate the benefits of being a very large insurer. Stanford’s Baker noted that if two companies such as Anthem and Cigna merged, the resulting conglomerate would have well above that threshold in many parts of the country.
The study describes the balance of bargaining power between insurers and doctors at one point in time (the data is from 2014), so the numbers reveal little about how recent mergers might have affected the strategic situations for participants in this market or about how future mergers might affect premiums for ordinary people.
One possibility is that mergers among insurers will induce doctors and hospitals to conglomerate as well, which in turn will encourage greater consolidation in the insurance sector, said Diana Moss. She is an economist and the president of the American Antitrust Institute, which advocates competitive markets.
“If the insurers bulk up to become better bargainers, that creates incentives for the providers to bulk up,” Moss said.
Letter to the editor: If Republicans repeal ACA, end their taxpayer-funded health insurance
Portland Press-Herald
The repeal of the Affordable Care Act may have deadly consequences.
The “death panels” that the Republican Party thought would occur as a result of the ACA may become a reality for low-income people. Insurance companies will decide who deserves and who doesn’t deserve health insurance.
U.S. representatives and senators ought to have their health insurance stopped as soon as the Republicans repeal the ACA. Why should they have health insurance funded by taxpayers?
Members of Congress can afford to purchase private health insurance. Paying for their health insurance is taxation without representation. It needs to be stopped.
I wonder if any insurance company raised its premiums on congressional members after former Vice President Dick Cheney had heart replacement surgery, or if the insurance company quit and left because of the high cost of offering coverage.
How many insurance companies have left the Maine market? Their departure left many people without health insurance until the ACA offered an insurance option. Congress ought to keep the ACA in place and work together to fix problems. Repealing it is a draconian measure.
Send your medical bills to your members of Congress. After all, you are paying for their health insurance, so our congressional leaders ought to have plenty of discretionary income and ought to share in paying our medical bills. Call or write your elected officials and stop the free ride on health insurance for the privileged.
Paul Baresel
Buxton
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