'Medicare for All' Only Way for Trump to Keep Healthcare Promises
by Deirdre Fulton - Common Dreams - February 21, 2017
Cut the bureaucratic mess.
Make it great.
President Donald Trump put forth a good number of lofty promises on healthcare on the 2016 campaign trail. A new analysis released Tuesday reveals there's only one way to achieve them: Enact a single-payer, Medicare-for-All system.
In their paper, published in the Annals of Internal Medicine, health policy experts Drs. Steffie Woolhandler and David Himmelstein show that plans put forth by House Speaker Paul Ryan or Health and Human Services Secretary Tom Price are "unlikely" to meet Trump's campaign promises of more coverage, better benefits, and lower costs. (Indeed, even administrative tweaks announced last week by the Trump administration appeared to undercut those promises, as Common Dreamsreported.)
But "single-payer reform could," write the co-founders of Physicians for a National Healthcare Program (PNHP). "Such reform would replace the current welter of insurance plans with a single, public plan covering everyone for all medically necessary care—in essence, an expanded and upgraded version of the traditional Medicare program."
Such reform, also known as Medicare-for-all, could save $504 billion annually on healthcare bureaucracy, they say, plus an additional $113 billion "could come from adopting the negotiating strategies that most nations with national health insurance use, which pay approximately one half what we do for prescription drugs."
These savings would offset the cost of expanding insurance to the 26 million who remain uninsured despite the Affordable Care Act (ACA), as well as "plugging the gaps in existing coverage—abolishing co-payments and deductibles [and] covering such services as dental and long-term care that many policies exclude."
"We're wasting hundreds of billions of healthcare dollars on insurance paperwork and profits," said Woolhandler on Tuesday. "Private insurers take more than 12 cents of every premium dollar for their overhead and profit, as compared to just over two cents in Medicare. Meanwhile, 26 million are still uninsured and millions more with coverage can't afford care. It's time we make our healthcare system cater to patients instead of bending over backward to help insurance companies."
Furthermore, the authors write:
Lawmakers should take heed of the PNHP analysis, as much of the energy around this week's Resistance Recess nationwide is focused on healthcare reform.
As Chris Petersen, described by the New York Times as "a 62-year-old pig farmer and proud progressive Democrat," told Sen. Chuck Grassley (R-Iowa) on Tuesday, by voting to repeal the ACA, or Obamacare, "[y]ou're going to create one great big death panel in this country."
Single-Payer Reform: The Only Way to Fulfill the President's Pledge of More Coverage, Better Benefits, and Lower Costs
by Steffie Woolhandler and David Himmelstein - Annals of Internal Medicine - February 21, 2017
President Donald Trump and congressional Republicans have vowed to repeal and replace the Patient Protection and Affordable Care Act (ACA). Repealing it is relatively easy. Replacing it with “something great” is much trickier. The president has promised universal coverage and reduced deductibles and copayments, all within tight budgetary constraints. That is a tall order and unlikely to be filled by proposals that Republicans have offered thus far.
Speaker of the House Paul Ryan's blueprint (1) would rebrand the ACA's premium subsidies as “tax credits” (technically, the subsidies are already tax credits) and offer them to anyone lacking job-based coverage—even the wealthy—reducing the funds available to subsidize premiums for lower-income persons in the United States. He would allow “mini-med” plans offering miniscule coverage and interstate sales of insurance, circumventing state-based consumer protections. And he would augment tax breaks for health savings accounts, a boon for persons in high tax brackets.
Speaker Ryan would also end the long-standing federal commitment to match states' Medicaid spending, substituting block grants that state governments could divert to nonmedical purposes. Moreover, decoupling federal contributions from actual medical expenditures amounts to a sotto voce cut. For Medicare, he would trim federal spending by delaying eligibility until age 67 years; replace seniors' guaranteed benefits with vouchers to purchase coverage; and tie the vouchers' value to overall inflation, which lags behind health care inflation.
In sum, Speaker Ryan's proposal, and a similar one from Secretary of Health and Human Services Tom Price, would shrink the coverage of poor and low-income persons in the United States while maintaining (or expanding) outlays for some higher-income groups. That approach might save federal dollars by shifting costs onto patients and state budgets. But containing overall health care costs requires denting the revenues (and profits) of corporate giants that increasingly dominate care—an unlikely outcome of policies that expand the role of private insurers and weaken public oversight.
Although Republicans' proposals seem unlikely to achieve President Trump's triple aim (more coverage, better benefits, and lower costs), single-payer reform could. Such reform would replace the current welter of insurance plans with a single, public plan covering everyone for all medically necessary care—in essence, an expanded and upgraded version of the traditional Medicare program (that is, not Medicare Advantage).
The economic case for single-payer reform is compelling. Private insurers' overhead currently averages 12.4% versus 2.2% in traditional Medicare (2). Reducing overhead to Medicare's level would save approximately $220 billion this year (Table) (3). Single-payer reform could also sharply reduce billing and paperwork costs for physicians, hospitals, and other providers. For example, by paying hospitals lump-sum operating budgets rather than forcing them to bill per patient, Scotland and Canada have held hospital administrative costs to approximately 12% of their revenue versus 25.3% in the United States (4). Simplified, uniform billing procedures could reduce the money and time that physicians spend on billing-related documentation.
estimate that single-payer reform could save approximately $504 billion annually on bureaucracy (Table). Any such estimate is imprecise; however, this figure is in line with Pozen and Cutler's estimate ($383 billion, updated to reflect health care inflation) (5), which excludes potential savings for providers other than physicians and hospitals. Additional savings could come from adopting the negotiating strategies that most nations with national health insurance use, which pay approximately one half what we do for prescription drugs.
Of course, single-payer reform would bring added costs as well as savings. Full coverage would (and should) boost use for the 26 million persons in the United States who remain uninsured despite the ACA. And plugging the gaps in existing coverage (abolishing copayments and deductibles, covering such services as dental and long-term care that many policies exclude, and bringing Medicaid fees up to par) would further increase clinical expenditures.
Studies provide imperfect guidance on the probable magnitude of changes in use under single-payer reform. Microlevel experiments indicate that when a few persons in a community gain full coverage, their use surges (6). But when many persons gain coverage, the fixed supply of physicians and hospitals constrains community-wide increases in use. For example, when Canada rolled out its single-payer program, the total number of physician visits changed little; increased visits for poorer, sicker patients were offset by small declines in visits for healthier, more affluent persons (7). Despite dire predictions of patient pileups, Medicare and Medicaid's start-up in 1966 similarly shifted care toward the poor but caused no net increase in use (8).
Despite some uncertainties, analysts from government agencies and prominent consulting firms have concluded that administrative and drug savings would fully offset increased use, allowing universal, comprehensive coverage within the current health care budgetary envelope (9). International experience with single-payer reform provides further reassurance. It has been thoroughly vetted in Canada and other nations where access is better, costs are lower, and quality is similar to that in the United States.
The potential health benefits from single-payer reform are more important than the economic ones. Being uninsured has mortal consequences. Covering the 26 million persons in the United States who are currently uninsured would probably save tens of thousands of lives annually. And underinsurance now endangers many more by, for example, delaying persons from seeking care for myocardial infarction or causing patients to skimp on cardiac or asthma medications. Single-payer reform would also free patients from the confines of narrow provider networks and lift the financial threat of illness, a frequent contributor to bankruptcy and the most common cause of serious credit problems.
The ACA has helped millions. However, our health care system remains deeply flawed. Nine percent of persons in the United States are uninsured, deductibles are rising and networks narrowing, costs are again on the upswing, the pursuit of profit too often displaces medical goals, and physicians are increasingly demoralized. Reforms that move forward from the ACA are urgently needed and widely supported. Even two fifths of Republicans (and 53% of those favoring repeal of the ACA) would opt for single-payer reform (10). Yet, the current Washington regime seems intent on moving backward, threatening to replace the ACA with something far worse.
References
- A Better Way. A better way: our vision for a confident America. 22 June 2016. Accessed at https://abetterway.speaker.gov/_assets/pdf/ABetterWay-HealthCare-PolicyPaper.pdf on 1 February 2017.
- The Boards of Trustees, Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. 2016 annual report of the Boards of Trustees, Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. 22 June 2016. Accessed at www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ReportsTrustFunds/Downloads/TR2016.pdf on 2 February 2017.
- PozenACutlerDMMedical spending differences in the United States and Canada: the role of prices, procedures, and administrative expenses.Inquiry20104712434
- WilderCSVolume of physician visits. United States—July 1966-June 1967.Vital Health Stat 10196810160
- Physicians for a National Health Program. How much would a single payer cost? A summary of studies compiled by Ida Hellander, MD. 2016. Accessed at www.pnhp.org/facts/single-payer-system-cost on 2 February 2017.
- Newport F. Majority in U.S. support idea of fed-funded healthcare system. Gallup. 16 May 2016. Accessed at www.gallup.com/poll/191504/majority-support-idea-fed-funded-healthcare-system.aspx on 2 February 2017.
Ryancare: You Can Pay More for Less!
Editorial Board - NYT - February 19, 2017
President Trump promised to replace the Affordable Care Act with something that is better, is cheaper and covers more people. Scratch that. Republican leaders in the House and Mr. Trump’s secretary of health and human services released a plan last week that would provide insurance that is far inferior, shift more medical costs onto families and cover far fewer people.
In a half-baked policy paper released on Thursday, the House speaker, Paul Ryan, trotted out washed-up ideas for “improving” the country’s health care system that would do anything but. For example, the paper calls for reducing spending on Medicaid, which now provides insurance to more than 74 million poor, disabled and older people. Many millions of them would be cast out of the program. The Republican plan would also force most people who don’t get their health insurance through an employer to pay more by slashing subsidies that the A.C.A., or Obamacare, now provides. The proposal would allow families to sock away more money in health savings accounts, which may sound good at first but would primarily benefit affluent people who can afford to save more.
The paper is Mr. Ryan’s blueprint for effectively repealing and replacing Obamacare. Unsurprisingly, he and his colleagues offered no estimates of how many people would lose coverage or how much premiums and deductibles would rise for middle-class and poor families. Yet those missing details did not stop the Trump administration’s top health official from embracing the proposal. Tom Price, the secretary of health and human services and a former Ryan lieutenant in the House, said the president “is all in on this.”
To understand how far out of the mainstream the House Republican plan is, consider its ideas for Medicaid. It would roll back the A.C.A. provisions that helped more than 11 million people gain Medicaid coverage. Republican governors like John Kasich of Ohio and Rick Snyder of Michigan have praised the expansion because it has helped reduce uncompensated care at hospitals and provided addiction treatment to people suffering from the opioid epidemic. “Thank God we expanded Medicaid, because that Medicaid money is helping to rehab people,” Mr. Kasich said last month.
Next, the Republicans want to slash spending on Medicaid over all by giving states the option of a block grant or a per capita allotment. The current program pays for the health care of everyone who is eligible. During recessions, when the number of people in poverty increases, the government spends more. Without the flexibility that was built into Medicaid, Congress would have to vote to give states more money when health care costs rise. Politically, that is in the “impossible dream” category, which is why most experts believe that, over time, states would cover fewer people and cut benefits.
Another pillar of the Republican proposal scraps the income-based Obamacare subsidies that help families buy affordable insurance. Instead, Mr. Ryan wants to offer a flat subsidy that would be the same whether families earn $500,000 or $50,000. Residents of Minnesota would get the same support as residents of Alaska, where premiums on average are three times as high. The subsidies would vary by age to give older people more support, but the Republicans have not said how much more.
The House proposal is part of a broader attack on the A.C.A. Last week, the Department of Health and Human Services proposed regulatory changes to the law, one of which would allow insurers to reduce benefits and force people to pay higher deductibles on future policies. And the Internal Revenue Service said it would no longer require people to answer a question on their tax returns about whether they had insurance the previous year. The question remains on the form, but filers can chose not to answer it. Under Obamacare, people must buy insurance or pay a penalty enforced by the I.R.S. By backing off, the I.R.S. will encourage people to forgo insurance and take a chance that it will not seek more information or penalize them. When fewer people, especially the young and healthy, buy insurance, overall costs go up, because the people who do sign up tend to need more medical care.
Congress is in recess this week. If people can reach their representatives and senators — many lawmakers have cowardly canceled town halls to avoid angry constituents — they can send a strong message that Americans want legislation that improves health care and makes it more affordable for everyone, not the opposite.
Deceit, an attack on abortion rights, and pampering of the rich: The Republicans' new plan for repealing Obamacare
by Michael Hltzik - LA Times - February 17, 2017
Congressional Republicans who have visited their home districts over the last few weeks have gotten a faceful of constituent rage about their plans to eviscerate the Affordable Care Act, which brings health coverage to more than 20 million Americans. If past is prologue, those heading home now for the Presidents Day recess are likely to feel a lot more heat.
That may be why House Republicans this week rushed out a “policy brief” on “Obamacare Repeal and Replace.” Unfortunately for the poor souls who will be meeting with constituents, the brief answers none of the key questions about the GOP’s plans for the ACA. It doesn’t certify that, whatever those plans are, they would avoid throwing millions of Americans out of the insurance pool, or that they would save money. It doesn’t give many specific details. It doesn’t say anything about the costs of its proposals, or how those costs would land on Americans of various income levels. It’s backed up by claims about the ACA that have been shown to be wrong or deceitful, or both.
The appearance of the policy paper also is important because of rising disquiet among insurers about the future of the ACA individual marketplaces. Earlier this week, Humana said it would withdraw from the market in 2018. Mark Bertolini, the chairman and CEO of Aetna, declared that the marketplaces were experiencing a “death spiral,” which feeds into the GOP’s talking point that the ACA is doomed and therefore warrants repeal.
The insurers’ announcements deserve some scrutiny. Humana was a relatively small player in the ACA, with only about 152,000 customers in 11 states enrolled in ACA plans. As David Anderson of Duke University observes, its pricing strategy was not especially competent, tending to discourage healthy individuals from signing up while leaving its plans “attractive to an older population that is likely to be sicker.” Hence, losses.
As for Aetna, its assertions about the ACA have been a model of public dishonesty. As we reported here and here, Aetna’s announcement in August that it was withdrawing from 11 of the 15 states where it offered ACA plans because it was losing money was deceitful. That was the conclusion of a federal judge, who found last month that the real reason for its withdrawal was to gain an advantage over the government in the latter’s lawsuit to block its merger with Humana. (The judge rejected the merger.) In fact, Aetna was turning a profit in at least some of the states that it exited.
Bertolini’s assertion notwithstanding, there is no evidence that the ACA marketplace is experiencing a “death spiral,” which results when price increases drive away more and more healthy customers, leaving sick individuals in the pool and forcing prices inexorably higher. The evidence is to the contrary: Matthew Fiedler of the Brookings Institution reports that “data on final HealthCare.gov sign-ups provide strong evidence that premium increases did not cause dramatic enrollment declines, much less spark a death spiral.” That’s understandable, since about 95% of ACA customers are eligible for subsidies that reduced their real premium increases to zero.
Insurers have been making clear that it’s GOP dithering over the ACA that is contributing to their uneasiness. The death spiral hasn’t emerged yet, but as insurers ponder whether to participate in the individual exchanges in 2018 — a decision that many must make by April — the GOP’s lack of planning could produce it.
Now to the GOP repeal and replace proposal. In major ways, the proposal would hammer low-income Americans with higher healthcare costs while providing a greater cushion, even a handout, to the wealthy. Here’s how:
Block-granting and capping Medicaid. The Republicans give this the deceitful label of “modernizing” Medicaid, which provides ACA coverage to as many as 11 million Americans. Under the ACA, the federal government’s share of the expansion cost — 95% this year — will be ratcheted down to 90% in 2020 and beyond.The GOP plan proposes to phase out this program entirely by eventually reducing the federal match to the same level as the match for traditional Medicaid, which covers low-income families, mostly those with children. That match varies by state but can be as low as 50%. The GOP also would convert Medicaid funding to a block-grant — a set sum for states to spend as they choose.
Block-granting Medicaid, a hobby horse of House Speaker Paul Ryan (R-Wis.) and Tom Price, the new secretary of Health and Human Services, would guarantee drastic cuts in funding for the program. That’s because the formulas proposed by the Republicans would allow the grants to grow at a lower pace than the current system, so the funding relative to needs would deteriorate over time. A study by the Urban Institute of an earlier proposal by Ryan found that it would throw as many as 21 million people off traditional Medicaid.
Amazingly, the GOP depicts these changes as an attempt to redress the “unfairness” of providing a higher federal match for Medicaid for “able-bodied adults” — that is, those receiving Medicaid via the ACA --than it does for the aged, blind and disabled, and children. The ACA Medicaid expansion covers adults and families up to 138% of the federal poverty line, or $33,600 for a family of four. These are the people the GOP proposed to throw off Medicaid — not even including those under traditional Medicaid whose benefits would necessarily be slashed. They call this “putting Medicaid on a budget,” but it really means wrecking the household budgets of the neediest Americans.
Premium subsidies that leave middle- and low-income families behind.The GOP proposes to continue offering tax subsidies to cover premiums, but converts them from income-based to age-based. Let’s be plain: The idea of matching tax credits to age makes no sense; it means providing a bigger subsidy to, say, Bill Gates (age 61) than to a husband and wife in their 30s with $50,000 income and two kids. Although healthcare spending tends to rise with age, older Americans tend to have more resources, too. The governing factor in the affordability of health coverage is household income.
The GOP asserts that eliminating the income test will “help simplify the verification process,” but that’s a marginal gain. It claims that basing the subsidy on age rather than income will avoid the “labor market distortions and perverse incentives” of the ACA. To support this, it misrepresents a Congressional Budget Office study about the job effects of the ACA. The GOP implies that the study pointed to “lost hours” as if these were jobs lost involuntarily; in fact, the CBO projected that by severing the link between employment and insurance, the law would free more people to voluntarily leave employment to do something else with their lives, whether caring for family members, starting entrepreneurial companies, or retiring.
That’s exactly what has happened: Since the ACA, full-time employment in the U.S. has increased, as has voluntary part-time labor. The Republican party used to think that eliminating the “job lock” of employment-based insurance was a good thing because it increased individual choice. Now they call it a “distortion” of the labor market.
An assault on abortion rights. Buried in the GOP plan is a single line specifying that its premium subsidy won’t be “available to be used for plans that cover abortion.”
This is a flagrant and despicable attack on individual choice. It represents the endorsement of sex discrimination as an element of our healthcare system, after passage of the Affordable Care Act started to wipe it out by requiring that pregnancy and maternity benefits be covered by every insurance policy. Nor is it about using federal dollars for abortions—that’s already covered by the egregious Hyde Amendment, which would remain in effect and, as Jordan Weissmann of Slateobserves, already prevents abortions from being covered by Medicaid. The new proposal would forbid using subsidies on plans that merely offer abortion coverage, even if it’s not used by the enrollees.
Health Savings Accounts for the rich. The GOP proposes to nearly double the maximum contributions to these accounts, which allow for tax-advantaged spending on medical costs, to $6,550 per year for individuals and $13,100 for families. We’ve reported before on how these plans essentially are bounties for the wealthy.
The tax benefits of HSAs grow along with taxpayers’ liabilities; low-income families with low tax bills that already struggle to pay for medical care won’t find it any easier to scrape together money to fund their accounts. For the wealthy, however, they’re another tax break to fatten their retirement next eggs. Meanwhile, they peel healthier individuals and families out of the overall risk pool, making insurance more expensive for everyone else.
The fantasy of high-risk pools. Another hobby horse of Ryan’s, high-risk pools aim to serve people with chronic diseases or catastrophic illnesses. The idea is that insurance for the rest of the individual market will be cheaper, because it won’t be subsidizing the terribly ill. As we have reported in the past, high-risk pools were tried by 35 states prior to the ACA. They don’t work. They were vastly expensive and deeply underfunded; as a result, most such pools imposed ruinous premiums on their enrollees and subjected them to sky-high deductibles, benefit limits, enrollment caps, coverage exclusions, and waiting lists.
The GOP policy paper says “the next generation of high-risk pools” will be funded by federal “innovation grants” to avoid but, tellingly, is silent on how much, even though the funding level is the key. One study placed the cost at $178 billion per year, far more than the Republican Congress is likely to allocate.
Instead, the paper asks for our trust: The innovation grants, it says, “are designed to help vulnerable patients. Why would anyone allow them to potentially harm the very patients they are intended to help?”
Franklin Roosevelt had an answer to this bid for trust. At the New York State Democratic Convention in 1936, he ridiculed the GOP claim that it believed in Social Security, in job creation and in saving homes. “Cross our hearts and hope to die [the Republicans claim], we believe in all these things….Just turn them over to us. We will do all of them we will do more of them we will do them better; and, most important of all, the doing of them will not cost anybody anything."
FDR warned his audience that “the first essential of doing a job well is to want to see the job done...The Republican leadership is against the job's being done.”
McConnell: Republicans will replace health care act, overhaul tax code without Democrats
The Senate majority leader predicts a "Republicans'-only' approach to key legislation.
by Erica Werner - Associated Press - February 18, WASHINGTON Republicans will repeal and replace the Affordable Care Act and overhaul the tax code without Democratic help or votes, Senate Majority Leader Mitch McConnell said Friday.
“It’s clear that in the early months it’s going to be a Republicans-only exercise,” the Kentucky senator said at a news conference before lawmakers left for a weeklong Presidents Day recess. “We don’t expect any Democratic cooperation on the replacement of Obamacare, we don’t expect any Democratic cooperation on tax reform.”
McConnell has condemned Democrats for passing the health care law in the first place, in 2010, without any Republican votes, claiming the partisan exercise set up the law to fail. “The mess to come was inevitable,” McConnell wrote in his memoir last year.
But now he’s promising the same approach himself, in a sign that the partisanship and polarization dividing the country and Congress under President Trump will not end anytime soon.
“Clearly this is not one of those bipartisan ‘Kumbaya’ moments, and so we, as Republicans, expect that both of those issues will be – which are very big issues – will have to be tackled Republican-only,” McConnell said.
A strictly partisan approach on major legislation is a departure in the Senate, where most significant bills require involvement by both parties. Republicans plan to use a parliamentary maneuver to get health care and tax legislation through the narrowly divided Senate as part of a budget bill that requires only a simple majority to pass and can’t be blocked by Democrats.
But McConnell said the polarization in Congress is Democrats’ fault because they haven’t come to terms with the fact that Trump won the election.
“I’m hopeful that, as I said earlier, when the fever breaks, that maybe we’ll be able to move on,” said McConnell, in a turn of phrase that former President Obama sometimes used to express hope that opposition from the tea party right might recede, which it never did.
McConnell made his comments as the Senate confirmed Oklahoma Attorney General Scott Pruitt to lead the Environmental Protection Agency. It was the 14th Senate vote to approve Cabinet and Cabinet-level nominations by Trump, most of them pushed through on nearly party-line votes. “It is the worst Cabinet, I think, in the history of America, certainly in my lifetime,” said Minority Leader Chuck Schumer.
Insurance companies take the lead on Obamacare replacement ideas
by Jessica Glenza - The Guardian - February 18, 2017
As Republicans struggle to unify around a plan to replace the Affordable Care Act, and at the same time attempt to keep insurance companies in state marketplaces, health insurance executives appear to have found a friendly ear for their demands for change.
The most striking inclusion of industry ideas in policy appeared this week, when the Department of Health and Human Services (HHS) issued a draft rule that could dramatically affect individuals who buy insurance on state marketplaces.
Proposed changes would shorten the window to enroll in coverage from three months to six weeks, increase out-of-pocket costs to consumers and give regulatory authority for health plans to states – all proposals that insurance companies have called for since Donald Trump’s inauguration.
The public has just 20 days to comment on the draft rule change – rather than the usual 30. That is despite HHS officials’ findings that the proposed changes “could reduce the value of coverage for consumers, which could lead to more consumers facing increases in out-of-pocket expenses, thus increasing their exposure to financial risks associated with high medical costs”.
Benefits to consumers, the rule argued, would come through stabilized premiums and would prompt insurance companies to remain in the market despite the current uncertainty surrounding Republicans’ plans for the system.
“I don’t believe that for a minute,” said Linda Blumberg, an insurance policy expert at the Urban Institute, of the supposed benefits to consumers. “The ways it can hurt consumers are multiple.”
Blumberg and other experts have argued the rule does little to stabilize the insurance market, which she and others said could best be done by recruiting more healthy people to join.
“These are very much directed toward segmenting the risk pool, segmenting the cost of the healthy from the cost of the sick,” said Blumberg. “This has always been the way insurers most profit. They will make much more money doing that than they will by managing the medical care of a broad diverse population.”
The new rule comes amid Republican disagreement over how to move forward with repealing the Affordable Care Act, a seven-year campaign promise from conservatives. Many Republican plans to replace the ACA exist, but none have found a way to stitch together the conservative and moderate members of the party.
On Thursday, House Republican leaders discussed broad outlines for a replacement for Barack Obama’s signature health policy, which led to 20 million people gaining health coverage. The House speaker, Paul Ryan, said that after Congress’s forthcoming weeklong recess, “we intend to introduce legislation to repeal and replace Obamacare”, without giving further details.
Republicans Rand Paul and Mark Sanford have proposed legislation that would completely repeal the Affordable Care Act and expand savings accounts that come with tax benefits intended for emergency use. But it is unclear which of their ideas might end up in an eventual GOP bill.
Trump himself claimed at an eccentric press conference on Thursday: “We’re doing Obamacare. We’re in final stages. We should be submitting the initial plan in March, early March, I would say.”
Without a unifying plan from Republicans looking to avoid political blame for sowing chaos, the insurance industry has offered ideas to stabilize the markets under threat of pulling out altogether.
“Their advertised objective here is to stabilize the market,” said Marc Goldwein, vice-president of policy at the conservative Center for a Responsible Federal Budget. “One way to keep insurance companies selling insurance is to give them some of the things they’re asking for.
“Whether those are things that hurt the consumer, or benefit the consumer, or are neutral to the consumer, will depend,” said Goldwein.
The proposed rule was released just nine days after executives of Blue Cross Blue Shield met administration officials, when a list of “actions” needed to “stabilize the private health insurance market” was distributed. Many of those same actions appeared in a Blue Cross Blue Shield policy document from 30 January, titled “Moving forward: a health insurance market for 2017 and beyond”.
The proposed rule, if approved by the department now headed by the vehement Obamacare critic Tom Price, would have a tangible impact on when individuals can buy health insurance, and what they get when they do.
“The biggest issue, and what’s most important for people to know, is this rule does nothing to help people get coverage or afford care,” said Lydia Mitts, associate director at Families USA, a left-leaning patient advocacy group. “This is not a rule that puts consumers first – this is just giving insurers a wishlist of what they want, making it harder for people to get the coverage they need.”
First, the period to sign up for health insurance would shorten. Last year, 11.3 million people signed up for health insurance through exchanges between 1 November and 1 January. The proposed rule would shorten that period to six weeks, from 1 November to 15 December.
Next, insurers could require more verification paperwork from consumers looking to take part in so-called “special enrollment periods”. These are special opportunities to sign up for healthcare offered to people who may have lost a job or become pregnant.
Third, if a customer’s insurance policy were canceled because the customer did not pay, insurance companies could require full repayment before allowing customers to sign up for a new plan. This proposal, the rule argues, would encourage people to “maintain continuous coverage”.
Because the ACA required insurers to offer a set of benefits, the new rule would also allow insurance companies to offer less valuable plans, meaning that out-of-pocket costs would increase, and subsidies could go down. The rule would also lower requirements for the number of some types of doctors insurers are required to have in plans.
“I’m not privy to what is going on in the administration, but these are things that I think are coming from the insurance industry more than they are from policymakers,” said Blumberg.
“There seems to be a lot of consistency between the big insurers and the policies that are being promoted by critics of the ACA.”
https://www.theguardian.com/us-news/2017/feb/18/obamacare-repeal-insurance-companies-replacement-plan
Health Insurance Woes Add To The Risky Business Of Farming
by Kathleen Masterson - Maine Public - February 21, 2017
There are many challenges to farming for a living: It's often grueling work that relies on unpredictable factors such as weather and global market prices. But one aspect that's often ignored is the cost of health care.
A University of Vermont researcher found that nationally, most farmers cited health care costs as a top concern.
Shoshanah Inwood is a rural sociologist at UVM. She has been studying the aging and shrinking farm population, and what components are needed to build a prosperous farm economy.
Inwood says she hadn't thought about health care in particular as a factor until she conducted an unrelated survey in 2007 of farmers working the land in areas facing population growth and development pressures. The survey asked, "What are the issues affecting the future of your farm?"
"And we assumed when we got that survey back, we would get things like the cost of land, the cost of inputs, neighbors. The number one issue facing farmers was the cost of health insurance. They identified that as the biggest threat to their farm," she said.
Inwood says this held true for small and large farms: Two-thirds of commercial farmers cited the cost of health insurance as the biggest threat.
Typically, strategies to build a robust farming industry have focused on access to land, capital and changes to market infrastructure.
"But then you ask people, 'Well, how many people know a farmer that has an injury? Or a farm family that has a chronic health issue? Or a mental health issue?' And everybody's hand goes up," Inwood said. "And that's the one issue we really never talk about, are some of those social needs that farm families have."
How health care influences farm decisions
While it may be underrepresented in farm planning discussions, on the farm, families are talking about it.
Take Taylor Hutchinson and Jake Mendell. The two fell in love with farming — and each other — on a small educational farm in California. When the two decided to take the plunge and start their own farm, they decided to head back east to Jake's hometown area.
Over the past three years they've transformed three acres of his family's land in Starksboro, Vt., into a small farm business, selling vegetables, eggs and some meat through Community Supported Agriculture (CSA).
Access to free land puts them well ahead of many starting farmers, financially. But one thing they didn't initially factor into their business budget was health insurance.
"We both came of age at the beginning of the Affordable Care Act. It's not something that we've really had to think about, paying in full for a health insurance plan," says Mendell.
By "coming of age," he means he aged off his parents' health insurance at 26. Mendell was able to stay on his parents' plan beyond college under a provision in the Affordable Care Act. Then he switched onto a heavily subsidized plan through Vermont Health Connect.
His partner, Taylor Hutchinson, is covered by Medicaid because her income falls just below the threshold.
"It's a very fine line for me personally, that I'm skating under right now," Hutchinson said.
An unpredictable risk
With government assistance, right now health insurance is not among their highest expenses. But that all could change. If their income grows, Hutchinson would no longer eligible for Medicaid. Or if health care policy changes, their subsidies could go away.
Both scenarios would have very real impacts on their farm business.
"It's concerning now that, I mean, I just don't know how we could manage $800 a month, when right now it ends up being combined $60 a month," says Mendell.
The whole situation gets even trickier if or when the couple were to get married. That act alone would bring their shared income above the Medicaid line, meaning they'd have to pay a significantly higher price for health insurance. And then — someday — there are kids to consider.
"Something that I think about is when we have kids, in order to be able to afford the medical bills for that, as well as daycare, it is very likely that I will be stepping back from the farm," says Hutchinson. "It's something that I'm thinking about now. Would I get a part-time job? Or would I try for a full-time job that I could get benefits that would cover us all?"
That calculation is not unique. Nationally, slightly more than half of farmers also work off the farm. Historically it has been women who work two jobs, but that dynamic is changing as more women are getting into full-time farming.
Inwood says the need to work another job just to support the farm is a real roadblock to growing a "prosperous, bright farm population." And it comes at a time when the overall farm population in the U.S. is aging and shrinking.
"We need folks who have strong backs, who are able to do work," Inwood says. "And one of the things that happens is when you're young, that tends to intersect with the age when you're really ready to have children, that's when health insurances concerns really start to enter into people's minds."
As recently as 2012, the number of new farmers was down about 20 percent from five years earlier. There are many factors — financial and otherwise — that make becoming a farmer incredibly challenging.
Teaching advisors to talk about health insurance
But Inwood says one key learning from her research is that advisers who work with farmers need to be better prepared to help them navigate the ever-changing world of health insurance.
"A lot of farm viability planning and farm business planning, they generally will tend to mention health insurance, but there's no planning for it," says Inwood. "None of the workbooks currently really talk about how are you going to do this ... How does having health insurance fit into your overall farm plan?"
Back on the farm in Starksboro, Hutchinson says if it weren't for the Affordable Care Act, she likely wouldn't have health insurance.
"I think that the subsidies have been crucial for us to have been able to start our farm, and to be able to keep our personal costs ridiculously low for the first few years," she says.
Hutchinson says she knows many who are in the same situation. She is on the leadership team of the National Young Farmers Coalition; she says she knows many farmers either on Medicaid or highly subsidized insurance.
And she says that in a recent meeting, many farmers mentioned that they're considering getting an off-farm job or even liquidating the business because they're worried that the health insurance situation could change.
This story comes from the New England News Collaborative: Eight public media companies coming together to tell the story of a changing region, with support from the Corporation for Public Broadcasting.
Copyright 2017 Vermont Public Radio. To see more, visit Vermont Public Radio.
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