The headline findings in the Congressional Budget Office’s analysis of the Obamacare repeal bill produced by House Republicans are brutal enough:24 million Americans losing their health coverage, healthcare costs soaring for many millions more, and the evisceration of Medicaid, all while handing the richest Americans a handsome tax cut.
But in its fine print, the CBO report identified at least seven other ways the GOP proposal would damage the U.S. healthcare system. Some would have effects reaching far beyond the middle- and low-income buyers of insurance on the individual market who are the Affordable Care Act’s chief beneficiaries.
1. Shopping for health insurance will become tremendously more complicated. The Affordable Care Act standardized individual policies into four tiers based on “actuarial value” — the percentage of medical care costs covered by the insurer, ranging from bronze (60% actuarial value), silver (70%), gold (80%) and platinum (90%). This simplification allows buyers to compare plans on price alone, since within each tier every plan must offer roughly the same coverage. Insurers are required to offer at least one silver and one gold plan to participate in the individual marketplaces.
The rules didn’t entirely eliminate the complexity of shopping, since insurers can meet their actuarial value requirements by adjusting premiums or deductibles, or both. But they helped. The Republicans’ American Health Care Act repeals the actuarial value requirement. “Under the legislation, plans would be harder to compare, making shopping for a plan on the basis of price more difficult,” the CBO concluded.
2. Individual insurance plans will tend to offer skimpier benefits. By repealing the actuarial value rules, the GOP proposal removes the lower boundary of plan quality, at least to an extent.
Because the measure leaves in place the ACA’s mandate that all plans offer a roster of minimum essential benefits, including maternity, hospital coverage and mental health services, the CBO feels that insurers will be hard-pressed to offer plans with actuarial values below 60%. But it expects health plans to drift down toward the lowest possible value. Such plans would attract younger, healthier buyers because of their lower costs. But insurers would tend to avoid offering high actuarial value plans “out of a fear of attracting a greater proportion of less healthy enrollees.”
David Anderson of Duke believes that insurers could probably fashion plans with actuarial values as low as 55%; lower-value plans will effectively become the standard. “It will be very hard for people to buy a non-bronze plan because insurers won’t offer them except at exorbitant prices,” he writes. The bottom line: a drift toward lower-quality health insurance.
3. Out-of-pocket costs will be much higher. With low premiums becoming the key lure for buyers, insurers will tend to raise deductibles and co-pays. These consequently will “tend to be higher than those anticipated under current law” (that is, Obamacare), the CBO forecasts.
Another blow will be the GOP plan’s repeal of Obamacare’s cost-sharing subsidies, starting in 2020, which go to especially low-income households. About 57% of all buyers on the individual market receive those subsidies, so the repeal of this provision will hit about 5 million Americans hard.
4. Employer-sponsored insurance might start to disappear. The CBO projected that the passage of the ACA would trigger a decline in employer-sponsored insurance, which covers about half of all Americans. That didn’t happen to the extent the CBO expected, but it calculates now that the GOP proposal might do the job. That’s because the GOP bill repeals the penalties for individuals and companies above a certain size that don’t carry coverage. 
The analysis projects that because of these reduced incentives, 2 million Americans would lose or drop out of employer-sponsored coverage by 2020, and 7 million by 2026. The CBO notes further that, since the GOP proposal provides premium subsidies to Americans with higher incomes than are eligible under Obamacare, some better-paid employees might forgo their employer plans and buy coverage on the individual market. Two countervailing factors exist, however: Although subsidies would be available to higher-income workers, on the whole they’d be skimpier than the ACA’s; and the quality of insurance outside the employer-based market might be lower than what’s available on the job.
5. A key program promoting public health will be axed. The GOP plan kills the Prevention and Public Health Fund as of 2019, saving $9 billion. The loss to public health will be incalculable.
The fund is a linchpin of the budget of the Centers for Disease Control and Prevention, accounting for 12% of the CDC’s spending. It pays for the CDC’s vaccine program, for instance. 
“Losing this funding would cripple CDC’s ability to detect, prevent, and respond to vaccine-preventable respiratory and related infectious disease threats including pandemic influenza,” the agency says. Through the CDC, the fund also provides all 50 states with money to address public health crises; pays for childhood lead poisoning prevention programs nationwide; and helps health departments coast to coast to battle healthcare-related infections.
For some reason, Republicans have had the knives out for the Prevention and Public Health Fund for years. In 2010, a Senate Republican aide was quoted dismissing it as “a slush fund for jungle gyms.” 
In fact, as health economist Harold Pollack observed at the time, the fund “serves critical, but often politically marginal constituencies.” 
6. Patients of Planned Parenthood clinics would be cast adrift. The GOP proposal would cut all federal funding for Planned Parenthood for a year following its enactment, though it seems likely that the cutoff would be renewed year by year as long as the Republicans hold the House, Senate and White House.
The victims of this provision would be almost entirely low-income residents of areas already starved of clinics and doctors, especially rural areas. The CBO expects that about 15% of those residents would lose access to healthcare.
Since the services most affected would be those that “help women avert pregnancies,” the CBO paints this provision as the essence of cutting off one’s nose to spite one’s face. Births among the target population would rise by “several thousand.” That would increase costs for Medicaid, which pays for about 45% of all births. Moreover, some of the newborn children would themselves be eligible for Medicaid. The program would face $77 million in increased costs over 10 years, the CBO estimates. Since the GOP is also aiming to cut Medicaid funding, many of those mothers and children would lose access to healthcare entirely.
7. The continuous coverage rule would drive 2 million people out of the market and make the overall insurance pool sicker. One of the GOP plan’s most perverse provisions is the “continuous coverage” rule, which penalizes those who allow their insurance to lapse for more than 63 days during a year. They’re hit with a 30% surcharge for up to a year, once they do sign up.
The rule is ostensibly designed to encourage everyone to carry coverage, but would have the opposite effect, encouraging healthy Americans to put off buying insurance until they fall ill. The CBO estimates that 2 million fewer people would buy insurance each year; judging that the 30% penalty is manageable, they’d choose to roll the dice. 
In sum, then, the GOP’s American Health Care Act would not only roll back all the gains in insurance coverage notched by the ACA over the last four years, but would make millions of Americans poorer and sicker. It’s not a return to the health insurance landscape that existed before the ACA’s enactment in 2010, but a voyage into an immeasurably more dismal, and unhealthier, world.
If you thought the Obamacare backlash was bad, Trumpcare will give Democrats a whipping boy for the ages
by Doyle McManus - LA Times - March 15, 2017
There’s a new rule in American politics: Whichever party owns healthcare will come to regret it.
Seven years ago, Barack Obama’s Democrats passed a health insurance law that promised to cover almost everyone and make medical care more affordable. Best of all, Obama said, the new plan wouldn’t inconvenience anybody — except the high-income folks who got hit with a tax increase.
“If you like your healthcare, you can keep it,” he pledged. Big mistake.
Obama succeeded in his basic aims, but he couldn’t keep all his promises — especially that one.
Ever since, whenever anything’s gone wrong in the health sector — whenever prices rose, or an insurance company dropped a line of business — Republicans have had an easy target: Obamacare.
As we all know, the same Republicans who said Obamacare was fatally flawed swore they would replace it with a better, cheaper system — just as soon as they regained power. Now they have, and just like Obama, they’ve overpromised.
“We’re going to have insurance for everybody,” President Trump said in January. People “can expect to have great healthcare. It will be in a much simplified form. Much less expensive and much better,” with “much lower deductibles.”
But the healthcare bill House Republicans unveiled on Monday can’t keep all those promises. It doesn’t even pretend to.
And in a telling mirror image, Democrats immediately dubbed the new plan “Trumpcare.”
From now on, you can depend on them to hang that label on any part of the American health system that isn’t working, just as Republicans did with Obamacare.
The Republican bill would undo much of Obama’s expansion of insurance coverage, especially for low-income people.
It provides much lower subsidies, on average, for people who buy health coverage on the individual market. The cuts are deep for people just above the poverty line, individuals earning between $15,000 and $30,000 a year.
The bill ends Obama’s expansion of Medicaid, the insurance program for very low-income people, three years from now. At that point, the GOP bill would change the funding formula for Medicaid, making it easier to cut the program’s expenditures in future years.
Not everyone will suffer: The GOP bill includes a nice tax cut for the wealthy, canceling the taxes they paid to support Obamacare.
And it preserves the most broadly popular parts in the Obamacare law: the ban on insurance companies refusing coverage to anyone with a preexisting condition, the ban on lifetime benefit limits and the rule allowing parents to keep children on their plans up to age 26.
Bottom lines:
The bill does not seek universal coverage. Republicans say their goal is universal “access,” but this bill doesn’t provide subsidies big enough to make that practical.
The bill rewards some Republican constituencies: High-income taxpayers get a tax cut, businesses are freed from coverage requirements, middle-income older voters get bigger subsidies.
But it does that by reducing subsidies for low-income people, including low-income workers.
The inevitable result is that fewer people will buy health insurance — and many of those will opt for cheaper, bare-bones insurance policies with high deductibles (not the “lower deductibles” Trump promised).
Don’t take me at my word. Here’s what Robert Laszewski, a nonpartisan insurance expert (and flinty critic of Obamacare) wrote on Tuesday: “It won’t work.”
Obamacare’s flaw, he wrote, was that it took care of the poorest people but gave a raw deal to middle-income workers who couldn’t afford its premiums. That was because the Democrats who passed it took care of their political base first and didn’t have enough money left to subsidize everyone.
“Now the Republicans are making the same mistake: taking care of their base and giving the Democratic base a lousy deal,” Laszewski wrote.
“What good will it do a person making $15,000 a year to get a credit only large enough to buy a plan with a $3,000 or $5,000 deductible?” he asked.
“Half the country will hate it — just a different half.”
Or listen to Avik Roy, a Republican healthcare scholar, who has argued that his party should be more generous to the poor. The House bill suggests that the GOP has a “stubborn desire to make health insurance unaffordable for millions of Americans, and trap millions more in poverty,” he wrote.
In short, the GOP would replace one flawed plan with another and transfer most of the pain from high-income taxpayers and middle-income insurance-buyers to low-income families. Democrats won’t let voters forget that.
If the bill passes, millions of people will discover that their Obamacare subsidies have been reduced and their health insurance is less affordable — and Democrats will blame Trumpcare.
Millions who have coverage now will lose it. There will be heart-rending stories about people who had insurance but couldn’t afford to keep it — only to contract a life-threatening illness. Democrats will blame Trumpcare.
Health costs will go up; they always do. Democrats will blame Trumpcare.
Insurance forms will still be infuriating, and insurance companies will still hassle their customers. Democrats will blame Trumpcare.
And Trump’s fatal promise — “We’re going to have insurance for everybody” — will be repeated by his opponents as often as Obama’s.
They broke it. They’ll own it.

Close Trump friend says ditch Paul Ryan's plan and embrace universal health care

Newsmax CEO Christopher Ruddy calls for Medicaid for all.

Updated by Matthew Yglesias - VOX - MARCH 14, 2017
A key Trump friend and ally is urging the president to dump Paul Ryan’s Affordable Health Care Act and embrace something that sounds sort of like a lightweight version of a single-payer health care system. Christopher Ruddy, CEO of the conservative Newsmax brand, isn’t normally considered a major thought leader on policy issues, but he is a longtime friend of Trump’s, and counts as one of a relatively small number of conservative players who have closer ties to Trump than to congressional Republican leaders. 
And he is warning loud and clear that Trump “could inherit the bad political baggage of both Obamacare and the House Republicans” if he insists on going along with Ryan’s version of repealing and replacing Obamacare.
Instead, Ruddy puts forward the rather radical notion that Trump should attempt to live up to his campaign promises on health care rather than signing on to legislation that betrays them all. To do it, he encourages Trump to ditch his effort to court the Freedom Caucus and instead come up with a bipartisan plan that accepts a large government role in providing insurance coverage.

The Ruddycare seven-point plan

In an op-ed published Tuesday, Ruddy argues that Trump “should be sticking to his own gut on healthcare reform.” He did this during the campaign, which helped him “win Democratic states like Wisconsin, Michigan and Pennsylvania.” 
And he offers the following seven-point “game plan for Trump to regain the initiative”:
  1. Ditch the Freedom Caucus and the handful of Senate Republicans who want a complete repeal of Obamacare. They don't agree with universal coverage and will never be placated.
  2. Find a few parts of Ryancare II [i.e., the AHCA; Ryancare I refers to Paul Ryan’s longstanding desire to privatize Medicare] that can win passage in the House and Senate with either GOP support or bipartisan support. Declare victory. 
  3. Rekindle the bipartisanship in Congress that President Obama destroyed. Impanel a bipartisan committee to report back by year's end with a feasible plan to fix Obamacare.
  4. Reject the phony private health insurance market as the panacea. Look to an upgraded Medicaid system to become the country's blanket insurer for the uninsured.
  5. Tie Medicaid funding to states with the requirement that each pass legislation to allow for a truly nationwide health care market.
  6. Get Democrats to agree to modest tort reform to help lower medical costs.
  7. While bolstering Medicare and improving Medicaid, get Republicans and Democrats to back the long-term fix of health savings accounts. This allows individuals to fund their own health care and even profit from it.
As a pure political strategy, the key elements here are probably the first three points. A commission probably won’t lead to any major changes, but that’s okay. According to the Congressional Budget Office, the Affordable Care Act exchanges will probably stabilize in the next year or two even if nothing changes. Trump can do nothing and fix it. 
But steps 4 through 7 do suggest a route to a possible future vision of American health care.

Medicaid for all?

The standard progressive prescription for American health insurance has, for decades, been that a Medicare-like program should cover all Americans. That’s what Harry Truman proposed, but interest group politics eventually led Medicare to be defined down to a seniors-only program in order to secure passage in the early 1960s. 
But while Medicare is the gold standard of government-provided health insurance for the United States, there is also the cheaper Medicaid for low-income families. Medicaid offers stingier reimbursement rates to health care providers, which makes it less costly to the government. But it also makes Medicaid patients much less desirable to doctors and other providers, many of whom don’t accept Medicaid patients. Yet despite the program’s limitations, the evidence is overwhelming that people who receive Medicaid like it. 
Indeed, surveys tend to show that people who obtained Obamacare coverage via Medicaid are happier with their coverage than those who get subsidized private insurance on the new marketplaces. 
One could thus imagine “Medicaid for all” as a lower-cost alternative to “Medicare for all.” More affluent people would probably find Medicaid coverage to be excessively restrictive for their taste, in which case they would probably seek to obtain supplemental insurance — a practice that’s common in France and some other countries with national health care systems. But the private insurance system would exist as a layer on top of a basic blanket of security that guarantees health care fundamentals for everyone. You could certain tack health savings accounts (Ruddy’s point 7) on top of this as well. 
Now, needless to say, embracing this idea would be a huge break with the ideological orthodoxy of the Republican Party. But Trump really did campaign on a promise of universal coverage. And as he told CBS’s Scott Pelley back during the primary, “the government's gonna pay for it.”
The GOP establishment’s bet since Inauguration Day has been that Trump didn’t really mean it when he said that. And so far, their bet has paid off. Ruddy is suggesting that maybe Trump should stick to the ideas that let him beat the establishment and win the election. It’s an idea that’s so crazy it just might work.

On Obamacare, Paul Ryan has no idea what he's talking about
by David Lazarus - LA Times - March 14, 2017

House Speaker Paul Ryan defended the Republican healthcare-reform plan by saying it’s not necessarily a bad thing that it will cover fewer people than Obamacare.
And by fewer, we’re talking about the Congressional Budget Office’s estimate Monday that 24 million people would lose health insurance over the next decade if the Republican bill becomes law.
Fewer people may be covered, a stoic Ryan said over the weekend on CBS’ “Face the Nation,” “because this isn’t a government mandate.”
The Republicans aren’t running a government, he said, “that makes you buy what we say you should buy.”
That might be a persuasive argument if it was grounded in any kind of economic logic. But it isn’t, so it’s not.
Conservatives have built much of their case for repealing and replacing Obamacare on the idea that a health-insurance mandate is unfair and downright un-American — Big Brother running amok, forcing decent, hardworking families to purchase something they don’t want.
The intellectual bankruptcy of this position serves only to demonstrate that critics of the Affordable Care Act are either deliberately deceiving the American people or that they have no idea how insurance markets work.
Giving them the benefit of the doubt (because I’m a good guy), let’s assume it’s the latter.
So let’s talk about health-insurance mandates.
I spoke to a number of healthcare economists, and every one of them — every one of them — said you can’t guarantee affordable, comprehensive coverage to people regardless of preexisting medical conditions unless you have a way to get younger, healthier people into the risk pool.
“I’m a lifelong Republican,” said Craig Garthwaite, co-director of the Health Enterprise Management Program at Northwestern University. “If you’re going to require that an insurer has to provide insurance to everyone, then you have to have a way to get people into the market when they’re healthy. Otherwise, insurers have to raise prices because everyone they cover will be sick.”
Since many conservatives seem to have skipped Econ 101 the day risk management was taught, the economic principle at work here is known as “adverse selection.”
“That means people who expect to have higher medical expenses are more likely to sign up for health insurance, and people who expect lower medical expenses are less likely to sign up,” said Martin Gaynor, a professor of economics and health policy at Carnegie Mellon University.
The upshot of adverse selection is that the proportion of sick people in the risk pool ends up being higher than that of healthy people, which forces insurers to raises rates to accommodate the unexpectedly large number of claims.
As rates go up, more healthy people drop out, causing insurers to boost premiums again, which prompts more healthy people to walk, and so on.
When pundits talk about an insurance death spiral, that’s what they’re referring to. Before long, insurance becomes so expensive, no one can afford it and the entire system collapses.
The CBO estimates that average premiums under the Republican plan would jump by as much as 20% in 2018 and 2019, but they’d be about 10% lower than under Obamacare after a decade.
That’s not a reflection of a system that works better. It’s a reflection of insurers lowering costs by offering less coverage than people now receive, with higher out-of-pocket costs.
As a result, the individual insurance market will remain relatively stable, according to the CBO, so a death spiral is unlikely. But that’s setting the bar pretty low for a bill that purports to improve the U.S. healthcare system.
The Republican plan wants it both ways. On the one hand, it maintains the most popular aspect of Obamacare, the requirement that insurers cover everyone regardless of medical condition.
Prior to Obamacare, someone with diabetes, say, would be turned away by insurers in the individual-insurance market because he or she would be deemed too great a risk. Chronic diseases cost money.
Obamacare fixed that by prohibiting insurers from rejecting people with chronic ailments or other health issues — what’s known as “guaranteed issue.” To mitigate insurers’ increased risk, the law included a mandate that almost everyone had to buy insurance or face a financial penalty.
“There’s no way you can have guaranteed issue without a mandate,” said James Rebitzer, a healthcare economist at Boston University. “You’re completely locked in, according to the laws of economics.”
What he means is that efficient markets won’t tolerate half measures. Once a society commits to a specific course — universal coverage, say — you’re committed to guaranteed issue, which commits you to a mandate, which commits you to finding the most equitable way of getting everyone into the system.
On the other hand, Rebitzer said, if your primary goal is to limit the government’s ability to coerce citizens into doing things they don’t want, then you’ll eliminate insurance mandates, which means you’ll allow insurers to keep rate hikes in check by rejecting coverage for the sick.
“You can’t be a wuss about it,” he said. “Once you decide on your social values, you have to commit.”
Ryan and other Republicans say they’re committed. Their plan includes a provision that if you let your coverage lapse for a couple of months, you’ll face a one-year 30% rate hike when you buy insurance again.
Jonathan Skinner, an economics professor at Dartmouth College, called this “exactly the wrong way to structure something that you want people to buy.” By effectively penalizing people for returning to the risk pool, he said, the Republican plan creates an incentive for healthy people not to buy insurance.
“It’s like a perfect storm of disincentives,” Skinner said.
I’ve tried to avoid wonkiness and political ideology. As Rebitzer said, this is a matter of the laws of economics, and those laws are clear: You can’t have affordable and comprehensive coverage for everyone without getting everyone, young and old, sick and healthy, into the system.
“People are going to do what they want to do with their lives because we believe in individual freedom in this country,” Ryan said on “Face the Nation.”
“So the question is: Are we providing a system where people have access to health insurance if they choose to do so? And the answer is yes. But are we going to have some nice-looking spreadsheet that says, ‘We, the government of the American — the United States, are going to make people buy something and therefore they’re all going to buy it’? No.”
Either he’s trying to deceive you or he doesn’t know what he’s talking about.

The CBO wallops Paul Ryan
by Jennifer Rubin - Washington Post - March 14, 2017

The Congressional Budget Office’s scoring of the American Health Care Act was expected to be bad. It was not, among Republicans, expected to be as bad as it was, and that’s the fault of House Speaker Paul D. Ryan (R-Wis.), who did not properly prepare his members. The GOP defense was haphazard and contradictory. The Post reported:
[President] Trump’s budget director, Mick Mulvaney, said the report is “just absurd,” and Health and Human Services Secretary Tom Price said: “We disagree strenuously” with it.
Ryan defended the report, saying that it proves that the proposal will “dramatically” reduce the deficit and usher in “the most fundamental entitlement reform in a generation.”
The CBO is wrong. The CBO is actually good news. The CBO doesn’t matter. (Ryan insisted, “Our plan is not about forcing people to buy expensive, one-size-fits-all coverage.”) Which is it, fellas? Democrats could barely contain their glee, demanding that Ryan “pull the bill” and deeming it “immoral.” They had a point.
House Speaker Paul D. Ryan’s proposal to revise the Affordable Care Act would lower the number of Americans with health insurance by 24 million while reducing the federal deficit by $337 billion by 2026, congressional budget analysts said Monday.
According to a Congressional Budget Office projection, 14 million fewer people would have health insurance next year alone. Premiums would be 15 percent to 20 percent higher in the first year compared with the Affordable Care Act and 10 percent lower on average after 2026. By and large, older Americans would pay “substantially” more and younger Americans less, the report said.
The report from the Congressional Budget Office fueled concerns that the GOP health-care plan would prompt a dramatic loss in health-insurance coverage, potentially contradicting President Trump’s vow that health-care reform would provide “insurance for everybody” and threatening support from moderate Republican lawmakers.
Democrats found evidence that the bill constitutes a stunning transfer of wealth, as House Minority Leader Nancy Pelosi (D-Calif.) said. She argued that while 24 million will lose coverage, the Republicans are “implementing the biggest transfer for wealth in our history, $600 billion gone from working families to the richest people and corporations in our country.” The bill improves the deficit picture only because it takes away more from the less well-off than it gives to the rich. The CBO explains that it will narrow the deficit “by $337 billion over the 2017-2026 period. … That change would result from a $1.2 trillion decrease in direct spending, partially offset by an $883 billion in revenues.”

ACA vs. AHCA: How the Republican plan stacks up against Obamacare

Play Video4:22
The American Health Care Act falls far short of repealing and replacing the Affordable Care Act, but there are some big potential changes. (Daron Taylor/The Washington Post)
The CBO confirmed that the bill saves money by cutting Medicaid and subsidies to other programs and loses money because of the tax cuts for primarily rich taxpayers. “The largest savings would come from reductions in outlays for Medicaid and from the elimination of the Affordable Care Act’s (ACA’s) subsidies for nongroup health insurance,” it said. “The largest costs would come from repealing many of the changes the ACA made to the Internal Revenue Code — including an increase in the Hospital Insurance payroll tax rate for high-income taxpayers, a surtax on those taxpayers’ net investment income, and annual fees imposed on health insurers — and from the establishment of a new tax credit for health insurance.”
Once upon a time, Trump promised not to cut Medicaid. That, however, is precisely what the bill does:
The 31 states and the District of Columbia that have already expanded Medicaid to the newly eligible cover roughly half of that population nationwide. CBO projects that under current law, additional states will expand their Medicaid programs and that, by 2026, roughly 80 percent of newly eligible people will reside in states that have done so. Under the legislation, largely because states would pay for a greater share of enrollees’ costs, CBO expects that no additional states would expand eligibility, thereby reducing both enrollment in and spending for Medicaid. According to CBO’s estimates, that effect would be modest in the near term, but by 2026, on an average annual basis, 5 million fewer people would be enrolled in Medicaid than would have been enrolled under current law . . . CBO also anticipates some states that have already expanded their Medicaid programs would no longer offer that coverage, reducing the share of the newly eligible population residing in a state with expanded eligibility to about 30 percent in 2026.
And the CBO confirmed that older participants get treated the worst. (“Premiums in the nongroup market would be 20 percent to 25 percent lower for a 21-year-old and 8 percent to 10 percent lower for a 40-year-old — but 20 percent to 25 percent higher for a 64-year-old.”)
Ryan continues to insist that if people choose not to buy insurance under the new plan that is no concern of his. However, if they choose not to insure because they can no longer afford to, Ryan will have created the Unaffordable Care Act and stranded millions of people. It remains to be seen if the bill can make it through the House. One thing is for sure: A bill that transfers wealth from poor to rich is going to blow up the notion that Trump is a populist.

The GOP Obamacare replacement is heartlessness distilled
by Steve Stromberg - Washington Post - March 14 2017

House Speaker Paul D. Ryan (R-Wis.) speaks about the American Health Care Act, the Republican replacement of Obamacare, in Washington on March 8. (Joshua Roberts/Reuters)
Among the devastating conclusions in the the Congressional Budget Office’s new analysis of the GOP Obamacare replacement plan, this one cannot be repeated enough: The proposal would not just balloon the number of uninsured, it would also single out the needy and vulnerable for pain. Many people would go without coverage they require. Many others would pay for lower-quality coverage they cannot use, with higher deductibles and other out-of-pocket costs.
The Congressional Budget Office released estimates, March 13, for how House Republicans’ proposal to revise the Affordable Care Act might affect Americans.(Sarah Parnass/The Washington Post)
“The legislation would increase the number of uninsured broadly,” the CBO found. But “the increase would be disproportionately larger among older people with lower income; in particular, people between 50 and 64 years old with income of less than 200 percent of the [federal poverty limit] would make up a larger share of the uninsured.” This is the result of the Republican drive to replace Obamacare’s carefully tuned insurance expansion with a much shoddier policy.
The shoddiness begins with Republicans’ replacement for the hated individual mandate, which requires Americans to maintain health coverage. The mandate exists to encourage younger and healthier people to buy into the insurance system, keeping the insurance market stable, rather than simply waiting until they are sick to seek coverage. Republicans would replace it with a policy that would do the opposite.
The GOP’s idea is to allow insurers to jack up people’s premiums if they seek coverage after going without for at least 63 days. After 2018, the CBO found, “roughly 2 million fewer people would purchase insurance because they would either have to pay the surcharge or provide documentation about previous health insurance coverage. The people deterred from purchasing coverage would tend to be healthier than those who would not be deterred and would be willing to pay the surcharge.” In other words, their individual-mandate replacement would tend to harm market stability rather than help it.
The CBO nevertheless concluded that the GOP plan would not result in dreaded insurance market “death spirals,” in which escalating costs drive everyone but the sickest people out of the market. That is in part because of a new $100 billion stability fund, and in part for reasons that are not comforting. The CBO predicts that the Republican plan would “lower average premiums enough to attract a sufficient number of relatively healthy people” into the individual health-care market — in part by “substantially reducing premiums for young adults and substantially raising premiums for older people.” In other words, more old and sick people would be priced out of the market, while young and healthy people could easily afford coverage. The insurance pool would be healthier because more sick people would be left out.
Moreover, to the extent they could, insurers would game the policies they offered to attract only healthy people. Republicans would help them by eliminating restrictions on the quality of the health policies they are allowed to sell, enabling them to slash the share of people’s health costs they would cover. Insurers could adjust the value of their plans downward “so that a younger person would have low out-of-pocket costs for premiums and would be more likely to enroll.” Meanwhile, “insurers might be less likely to offer plans with high actuarial values out of a fear of attracting a greater proportion of less healthy enrollees to those plans.” This is another way in which the market would reorient itself away from serving needy populations and toward covering healthier and wealthier people. This might result in a stable market, but it would also lead to a large increase in human misery.
Rolling back Medicaid, meanwhile, would leave many near-poor people at the mercy of this insurance market. The GOP euphemism for this strategy is “expanding choice.” Speaking of which, the CBO also found that “shopping for and comparing plans could be harder” after the bill’s deregulatory provisions take effect.
All of this to “save” Obamacare markets that require only modest adjustments, to eliminate the individual mandate and, according to the CBO, to see an eventual 10 percent cut in premiums. At this point, those who still back the GOP plan — a group that, notably, does not include a variety of liberal and conservative health-care experts — are either heartless or blind. Unfortunately, for many, those conditions appear to be preexisting.

The CBO report demolishes the GOP’s edifice of deception
by Greg Sargent - Washington Post - March 14, 2017
At a listening sessions at the White House, March 13, President Trump said the best thing Republicans in Congress "could do politically is wait a year," to alter the Affordable Care Act, but that that would be "the wrong thing to do for the country."(The Washington Post)
THE MORNING PLUM:
On Tuesday morning, the White House kept up its attacks on the Congressional Budget Office, which has found, devastatingly, that the GOP health-care plan supported by President Trump would result in 24 million fewer people with health coverage. As budget director Mick Mulvaney put it on Fox News: “Welcome to Washington, where the CBO says it’s sunny and 75 degrees.”
At the same time, however, the response from certain GOP senators has been far more cautious. Some are saying that they have not read the CBO report and want to reserve judgment. Others are expressing serious worry about the GOP bill’s impact on their states. Louisiana’s Bill Cassidy said that the report’s projection of massive coverage loss is “awful.” Arizona’s John McCain added: “I’m very worried about what the House bill would do to Arizona.”
The American Health Care Act falls far short of repealing and replacing the Affordable Care Act, but there are some big potential changes. (Daron Taylor/The Washington Post)
The disconnect highlights the real significance of the CBO report for the prospects for the GOP health bill — and for our politics in a broader sense. The CBO has laid bare the GOP’s true health-care priorities with a clarity that has long been absent from the political argument over reform, making it harder to conceal them inside a fog of obfuscation and deception.
It probably isn’t an accident that some senators expressing concern about the CBO score come from states that have opted into the Medicaid expansion. One of CBO’s most startling findings concerns Medicaid: the GOP plan would cut Medicaid spending by $880 billion over ten years, resulting in 14 million fewer enrollees. Beginning in 2020, it would scrap Medicaid as an entitlement for those eligible for the expansion, by instituting per-capita limits and a reduction in the cost share picked up by the feds. This would likely result in a greater burden on states, which could lead some states to reduce or restrict benefits, or to opt out of the Medicaid expansion altogether, and thus to a large rollback of assistance to the poorest Americans. This is a big way the GOP bill saves money, enabling it to deliver a massive tax cut to the richest Americans.
This will — or should — put many GOP senators in a very difficult position. If they vote this bill into law, it will mean their states will have to make some very tough choices about their own populations, and many of their own constituents could be harmed. Nearly 20 GOP senators come from states that have expanded Medicaid. (They are: Portman, Toomey, Paul, Flake, McCain, Cotton, Ernst, Capito, Gardner, Murkowski, Heller, Cassidy, Grassley, Hoeven, Daines, Boozman, Sullivan, Kennedy, and McConnell.) It’s telling that some of these have already expressed concerns; now they all will have to decide whether to vote to phase out their state’s Medicaid expansions (among other damaging provisions) while deeply cutting taxes for the rich.
It should be noted that many Republicans support the priorities embedded in the GOP bill for reasons grounded in real principles. Many sincerely believe redistributive policy is morally wrong; that less-regulated markets are the best way to increase access to affordable coverage and won’t foster dependency precisely because it isn’t an entitlement; that insurance should be more minimal than ACA proponents think it should be; and so forth. And they often make general versions of these arguments.
But the point is that many Republicans have deceptively refrained from being forthright about whether they support the specific policy outcomes those priorities would produce, particularly in the short term. Senators who are now expressing concern about losing their state’s expansions have been supporters of repeal. During the 2014 elections, multiple GOP senate candidates ran on repeal while dissembling and evading endlessly on whether they’d also support rolling back their state’s Medicaid expansions.
And then there’s Donald Trump. He has claimed that the replacement he champions will mean “insurance for everybody.” In his speech to Congress, he called for reforms that “expand choice” and “increase access” and “lower costs” while making “health insurance available to everyone.” Of course, Trump doesn’t really know much about health-care policy or care about the details. But he does know that he’s a winner and Obama is a loser, so his plan simply must and will deliver more than Obamacare for less. The CBO’s answer to that: Sorry, No.
The basic party-wide argument has been that if only Republicans could do away with the hated monstrosity of Obamacare, they’d be able to deliver a replacement that delivers health care to everybody (including the poor and sick) while lowering costs and cutting taxes and getting rid of Washington mandates — in other words, a plan that delivers the good stuff in the ACA without the bad. As long as repeal was not an actual possibility, Republicans could maintain this stance without having to create a plan that would accomplish this, or answer for that plan’s likely outcomes or the true priorities it reflects. Thanks to the CBO, that years-long dodge is no longer possible.
It’s hard to say whether this will end up forcing GOP senators to turn on the plan in large enough numbers to kill it. But at least it will be harder for them — and Trump — to evade responsibility for what their party’s plan would actually do.
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* GOP PLAN MASSIVELY REDISTRIBUTES WEALTH UPWARD: Vox’s Dylan Matthews looks at the CBO score of the GOP health plan, which would result in 24 million fewer insured by 2026 while delivering a huge tax cut for the rich:
The plan, the CBO concludes, would take more than $1 trillion away from programs targeting poor and middle-class families, to fund an $883 billion tax cut targeted at the wealthy … “No legislation enacted in recent decades cut low-income programs this much — or even comes close,” Robert Greenstein, the … president of the Center on Budget and Policy Priorities … says.
The biggest driver of that cut is the $880 billion in cuts to Medicaid — almost exactly the amount of the tax cuts, which overwhelmingly benefit the wealthiest.
* SANDERS SAYS ‘THOUSANDS OF AMERICANS WILL DIE': Bernie Sanders slams the GOP health plan:
“Throwing 24 million Americans off of health insurance, raising premiums for older low-income Americans, while giving $285 billion in tax breaks to the top 2% is a disgusting and immoral proposal. Thousands of Americans will die if this legislation is passed and we have to do everything that we can to see that is defeated.”
For some reason, it is considered out of bounds to discuss the actual consequences of policy in such overly blunt terms, but now we will get a real debate on exactly that.
The CBO says the clear losers would be older, low-income Americans between 50 and 64, just below the Medicare eligibility age. In other words, a lot of Trump voters … If Obamacare were still in place in its current form a decade from now, a 64-year-old earning $26,500 … would pay $1,700 for premiums in a year after accounting for federal assistance. Under the GOP plan, a 64-year-old at the same income level would pay $14,600 in premiums for coverage that would also have higher out-of-pocket costs.
And don’t forget that a lot of Trump voters are currently benefiting from the Medicaid expansion, which would also be slashed to ribbons.
* GOP BOAST ABOUT PREMIUMS IS OFF BASE: Republicans are seizing on the fact that the CBO report said premiums might go down for some people. But Margot Sanger-Katz exposes the problem with this claim:
The way the bill achieves those lower average premiums has little to do with increased choice and competition. It depends, rather, on penalizing older patients and rewarding younger ones. According to the C.B.O. report, the bill would make health insurance so unaffordable for many older Americans that they would simply leave the market and join the ranks of the uninsured. The remaining pool of people would be comparatively younger and healthier and, thus, less expensive to cover.
As noted above, many Trump voters might be the losers.
* WHITE HOUSE LIES ABOUT ACA PROCESS, DEBUNKED: White House budget director Mick Mulvaney has been arguing that the process leading to the GOP bill was more transparent than that creating the ACA. Glenn Kessler blows the claim to pieces with a detailed chronology of the pre-ACA hearings, which were far more numerous.
Kessler’s conclusion: “The process that led to the Affordable Care Act was lengthy and complex, but involved numerous hearings and ample time for public comment and input. Any suggestion to the contrary is ridiculous.”
* THE REAL LESSON FROM THE CBO REPORT: Paul Krugman is on point:
Obamacare is actually an intelligently designed system, and Republican claims that they could do much better even while slashing funding so they could cut taxes on the rich were always obvious nonsense. Trumpcare is a slapdash, incompetent piece of legislation; but even a much more competent set of people couldn’t have done better given the constraints of Republican Party ideology.
The key point here is that Republicans could keep the true implications of their ideological designs hidden, as long as actual repeal-and-replace remained a political impossibility.

Trumpcare vs. Obamacare: Apocalypse Foretold

by Paul Krugman - NYT - March 13, 2017

The Congressional Budget Office report on Trumpcare is out, and it’s devastating: 14 million people losing insurance in the first year, 24 million over time, with premiums soaring for older, lower-income Americans — in many cases, the very people who went strongly for President Trump. The C.B.O. thinks it would reduce the deficit, but only marginally, around $30 billion a year in a $19 trillion economy.
Let me offer one assertion and ask two questions.
The assertion is that something like this was to be expected. The C.B.O. came in even worse on coverage than most predicted, but it was obvious that the news would be terrible because that’s what the logic of the situation told us. Obamacare imposes a mandate to induce healthy people to sign up, offers means-tested subsidies to make insurance affordable and expands Medicaid to take care of people with really low incomes. Trumpcare eliminates the mandate, slashes subsidies overall and redirects them to those who don’t need them and sharply cuts Medicaid. Of course that leads to a huge drop in coverage.
Or to put it differently, Obamacare is actually an intelligently designed system, and Republican claims that they could do much better even while slashing funding so they could cut taxes on the rich were always obvious nonsense. Trumpcare is a slapdash, incompetent piece of legislation; but even a much more competent set of people couldn’t have done better given the constraints of Republican Party ideology.
Now my questions: First, can this legislation still go through? I have learned never to underestimate the cravenness of Republican “moderates,” who may posture to the center but almost always cave to the hard right when it matters. But even so, it’s hard to imagine this act of cruelty getting 50 senators. And if it can’t pass the Senate, won’t right-wing purists in the House decide to advertise their purity by voting against a bill that still falls short of free-market ideals rather than vote for Obamacare 0.5?
Second, what were Republican leaders thinking? Something like this C.B.O. score was a foregone conclusion; would it really have mattered much if it were 15 millionlosing insurance, not 24 million? How was this supposed to work out politically?
Again, I wouldn’t count out the possibility that this law will be rammed through regardless, with budget analyses relegated to the category of fake news. Democrats might even want to hope that this happens, so that there is no question about who to blame if insurance collapses. But the lemming-like way Republicans rushed into this disaster is still amazing.

Trumpcare: Fiction and Fact

by Steven Rattner - NYT - March 13 2017

Watching administration officials play cat and mouse with Sunday talk show hosts is a hoary Washington tradition. But yesterday, Trump spokesmen offered a remarkably large number of flat out untruths as they attempted to defend the Republican health care plan.
Untruth #1:
“I firmly believe that nobody will be worse off financially in the process we are going through.” – Tom Price, Secretary of Health and Human Services, on Meet the Press.
Fact #1:
Millions of Americans will be worse off. For those currently purchasing insurance on the exchanges using Federal subsidies, that support will be replaced by tax credits that, for many, will be substantially smaller, as this chart shows:
For those in the 31 states and the District of Columbia that are participating in the Medicaid expansion, Trumpcare will provide far less Federal support, as the chart below indicates. After 2020, states will no longer be able to accept additional enrollees and no one who loses eligibility (such as by getting a higher paid job) will be able to return to the program even if their income drops. All told, the Administration plans to save $370 billion over the next 10 years from these cuts – which will surely make many Americans worse off.
Untruth #2:
“The fact that certain groups will pay less tax is not…central to the issue. We’ve done this in a fashion that allows the people who cannot afford health care now to afford it.”
—Mick Mulvaney, director of the Office of Management and Budget on This Week
Fact #2:
That’s two misstatements in quick succession. The plan to repeal $600 billion of taxes that almost entirely benefit the wealthy is very much at the heart of the matter. Those revenues are currently being used to expand Medicaid for the poorest Americans and subsidize health insurance for families with incomes between $24,600 and $98,400 per year. Removing a large chunk of those subsidies surely makes health care less affordable for those with lower incomes.
Untruth #3:
“The number of individuals who actually got coverage through the exchange who didn’t have coverage before…is relatively small.”
—Mr. Price on Meet the Press
Fact #3:
What is he talking about? Of the 11 million people who are buying health insurance coverage through the exchanges, all but 1.7 million are receiving subsidies through Obamacare. As the drop in the total number of uninsured indicates, it’s impossible to imagine that most of them were previously buying unsubsidized insurance directly from providers.
Untruth #4:
“The President is focused on health care, not insurance coverage.”
—Mr. Mulvaney on This Week.
Fact #4:
President Trump was very clear during the campaign: “We’re going to have insurance for everybody,” he said in an interview with the Washington Post on January 14. “Much less expensive and much better.” According to early estimates from Standard & Poor’s and Brookings, between six and 15 million Americans would lose insurance coverage under Trumpcare.
Even House Speaker Paul Ryan, appearing on Face the Nation, seemed to acknowledge that some who currently have health insurance would lose it. “I can’t answer that question,” he said. “It’s up to the people.”
Untruth #5:
“If you want to have coverage – and we think that everyone should have coverage – we’re providing you access to coverage.”
—Gary Cohn, director of the National Economic Council, on Fox News Sunday
Fact #5:
That’s technically true but of course, with or without any federal assistance, individuals are always free to buy health insurance. Mr. Cohn’s comment came in response to repeated questioning by host Chris Wallace about what would happen to the more than 20 million people who have gained coverage under Obamacare. As noted, it’s inconceivable that millions of Americans who are currently insured won’t lose their coverage.
Untruth #6:
“I love the folks at the C.B.O. … but sometimes we ask them to do stuff they’re not capable of doing and estimating the impact of a bill of this size probably…isn’t the best use of their time.”
—Mr. Mulvaney on This Week.
Fact #6:
Estimating the impact of proposed legislation is precisely what the Congressional Budget Office was set up to do back in 1974. And while the C.B.O.’s early estimates of the impact of the Affordable Care Act were, in fact, slightly optimistic, they were closer to the mark than many other forecasters, as this chart shows:
Evaluating complex policy proposals is, indeed, difficult but Mr. Mulvaney’s apparent preferred alternative – doing no impact analysis at all – makes no sense. Just because weather predictions are often wrong, would you not check the forecast before you venture outside?
Finally, a reminder to Mr. Mulvaney: The current director of the C.B.O., Keith Hall, was picked by the Republican leadership on Capitol Hill and served in the administration of President George W. Bush.
Untruth #7:
“Obamacare…is blowing up our fiscal problem.”
—Mr. Ryan on Face the Nation
Fact #7:
The Affordable Care Act was crafted with a mix of tax increases and Medicare cost cuts alongside the new benefits in order to – shockingly – provide a modest amount of deficit reduction. Over its initial decade, the entire Obamacare package was projected to reduce the total deficit by $124 billion. In addition, in its most recent assessment, the C.B.O. said repealing Obamacare would increase the deficit by $353 billion between 2016 and 2026.
Furthermore, the net expenditures on coverage have been revised down several times. In 2010, the C.B.O. projected that benefit costs would total $132 billion in 2016; by last year, that estimate had been reduced to $110 billion.
Untruth #8:
“Obamacare is just not working. You know, in the last year alone, premiums are up 25 percent.”
—Mr. Cohn on Fox News Sunday
Fact #8:
That often-cited statistic applies only to individuals who buy unsubsidized insurance through the exchanges (1.7 million people) and those who get their insurance directly from providers (another six million Americans). These two groups account for just 3 percent of Americans.
And while by talking about “last year alone,” Mr. Cohn implies that this is the latest of a long string of large increases, in fact, premiums increased by 7 percent in 2016 and 2 percent in 2015.
Untruth #9:
“The people who are just above Medicaid but still have difficulty buying their own premiums will…have the ability to use [Health Savings Accounts] to pay for their…healthcare on a tax-advantaged basis.”
—Mr. Mulvaney on Meet the Press
Fact #9:
He is talking about people whose incomes are well below median levels and is offering them the opportunity to save money they don’t have and get the benefit of taxes they generally don’t pay because their incomes are too low. How does taking away the Obamacare benefits and giving them refundable tax credits of $2,000 to $4,000 per person replace subsidies that currently run to as much as $9,874 for older low-income individuals?
Untruth #10:
“I was on Obamacare when I was in the House. My family’s deductibles were over $15,000 a year.”
—Mr. Mulvaney on Meet the Press
Fact #10:
Mr. Mulvaney didn’t provide enough information for me to be sure but for one thing, the out-of-pocket maximum for a marketplace plan in 2016 was $13,700. For another, while Mr. Mulvaney is correct that senators and representatives are required to buy their insurance through the District of Columbia exchange, they get a pretty good deal.
According to Congressional Research Service, if they buy a gold plan, the government (meaning us taxpayers) paid up to 75 percent of the premiums. I went to the District of Columbia health care exchange and for a family of 5, like the Mulvaneys, the yearly cost of plans currently being offered is approximately $25,000. That would mean premium costs of just over $6,000 a year. The required deductibles range from zero to $2,000. So I have no idea where Mr. Mulvaney’s assertion came from.
Untruth #11:
Kentucky is a “textbook case of Obamacare’s failures.”
—Vice President Pence in Louisville on Saturday
Fact #11:
While not said on a Sunday show, Mr. Pence’s comment must be noted. In fact, Kentucky has seen the largest drop of any state in the uninsured rate under Obamacare, as this chart shows: