G.O.P. Senators Vow to Unveil Health Bill Thursday, Despite Deep Divisions
by Thomas Kaplan and Robert Pear - NYT - July 11, 2017
WASHINGTON — Senate Republican leaders, facing their restive colleagues after the Fourth of July recess, vowed on Tuesday to press ahead with their effort to repeal and replace the Affordable Care Act, with a new version of their bill on Thursday and a vote next week — regardless of the deep divisions in the party.
The weeklong recess only seemed to generate more doubts about the Senate bill, but Senator Mitch McConnell of Kentucky, the majority leader, signaled that he was not ready to give up on his party’s seven-year-old promise to gut President Barack Obama’s signature domestic achievement. Accusing Democrats of obstructionism, he announced he would delay the Senate’s scheduled August recess by two weeks so that senators could keep working.
But pessimism among Republicans still pervaded the Capitol on Tuesday after a week in their home states that did little to resolve the disputes that thwarted a vote last month.
Senator Charles E. Grassley, Republican of Iowa, said Tuesday that he was “very pessimistic” about passing a bill, while Senator John McCain, Republican of Arizona, said it was “very possible, very probable” that the Senate bill was dead.
Senator Susan Collins, Republican of Maine, said, “Minor changes and tweaks will not be sufficient to win my support for the bill.”
Changes are coming, but none that are likely to radically alter the estimate by the Congressional Budget Office that 22 million fewer people would have health insurance in 2026 under the Senate health care bill than under the Affordable Care Act. A new estimate is expected from the budget office early next week.
The revised bill is expected to include a $45 billion fund to help combat the opioid epidemic, as well as a provision allowing consumers to use health savings accounts to pay for premiums.
Senate Republicans are also likely to keep a pair of taxes imposed by the Affordable Care Act on people with high incomes. The law increased the payroll tax rate for many high-income taxpayers and imposed a tax on their investment income. Both taxes would be eliminated by the repeal bill passed by the House in May and by the original version of Mr. McConnell’s bill.
Keeping those taxes would undercut a major argument against the bill by Democrats, who have branded it as a tax cut for the rich disguised as a health bill.
But the largest changes to the health care system are likely to remain in the bill. About two-thirds of the increase in the projected number of uninsured Americans would result from deep cuts in expected Medicaid spending, the budget office said. The bill would impose caps on Medicaid spending and would roll back the expansion of the program under the Affordable Care Act.
The Senate measure will be considered under special procedures that limit debate to 20 hours, preclude a Democratic filibuster and allow passage with a simple majority vote. It is unclear whether Mr. McConnell would start the debate next week if he lacks firm commitments from enough senators to ensure passage.
“Anybody who thinks that it’s going to get easier by waiting,” said Senator John Kennedy, Republican of Louisiana, “that’s a testament to the power of human denial as far as I’m concerned.”
At least 10 Republican senators, led by David Perdue of Georgia, had urged the majority leader to work into the month of August, so lawmakers could show some results to their constituents.
Mr. McConnell said delaying the recess would provide time to work on other matters after the Senate deals with health care next week. But the Senate Democratic leader, Chuck Schumer of New York, suggested a different motivation for Mr. McConnell’s announcement.
“They’re struggling with health care,” Mr. Schumer said. “They don’t want to go home and face their constituents.”
“The problem is not the timing,” he added. “It’s the substance.”
Senate Republicans are still skirmishing over a proposal by Senator Ted Cruz, Republican of Texas, that would allow insurers to sell stripped-down insurance policies if they also offered at least one plan that complied with federal insurance standards under the Affordable Care Act. Under this proposal, insurers could, for example, omit coverage of certain services like maternity care or mental health care.
Mr. Cruz says his proposal would give consumers new, lower-priced insurance options. On Tuesday, he called it “the necessary ingredient to getting the votes” to repeal the health law.
“I believe we can get there,” he said. “It remains challenging. More work remains to be done. But there is a path forward, and that path revolves around lowering premiums.”
But Mr. Cruz’s proposal underscored the problem that Mr. McConnell faces: Making a change to please some Republican senators could alienate others. With Democrats united in opposition, he can afford only two Republican “no” votes.
Ms. Collins, who is already dissatisfied with the Senate bill, warned about the potential negative consequences of the Cruz amendment. Critics of his proposal say it would create two insurance markets: an inexpensive one for the young and healthy, and another, far more expensive one for sick and older Americans that could price those with pre-existing medical conditions out of the market.
“If it is as described,” Ms. Collins said, “I believe it would further destabilize the individual markets, undermine the protections for people with pre-existing conditions and cause premiums to increase for people with pre-existing conditions.”
“I certainly don’t think that that is the answer,” she added.
Also on Tuesday, the Trump administration approved a waiver sought by the state of Alaska for an innovative program to help stabilize the individual insurance market.
The state, which has exceptionally high health care costs and insurance premiums, has established a “reinsurance program” to help pay claims for consumers with certain very high-cost medical conditions like metastatic cancer, H.I.V. and AIDS.
The House and Senate bills would provide tens of billions of dollars for such programs, intended to help keep premiums down and encourage more insurers to participate in the market.
The Senate health bill is almost an orphan with few real supporters
by Paul Kane - Washington Post - July 11, 2017
The Senate did not author the proverb about success having many fathers while failure is an orphan, but the words often typify how senators react to legislation that is struggling to win approval.
On Tuesday, after a roughly 90-minute huddle with his caucus, Senate Majority Leader Mitch McConnell (R-Ky.) began his weekly news conference on “the news of the day” — the struggling effort to pass health-care legislation that would repeal and replace portions of the Affordable Care Act.
For less than 25 seconds, McConnell gave a basic update on the timing of the legislation, never made the case for why Republicans should support it and then moved on for another minute to attack Democrats on unrelated issues.
That’s the way it has gone for the Better Care Reconciliation Act ever since it was unveiled nearly three weeks ago. In public appearances, and often in private GOP meetings, Republican after Republican outlines the reasons that they stand opposed to the legislation, as written, with almost no one taking up the mantle of defending a proposal that was unpopular from Day One.
Sunday’s political talk shows included four senators, two of whom, Sens. Ted Cruz (R-Tex.) and Bill Cassidy (R-La.), tried to sell changes in the legislation that they were demanding before promising their support. One senator, John McCain (R-Ariz.), pronounced that the legislation is “probably going to be dead.”
Part of the Republicans’ hesitation to directly promote their own health proposal is its uncertain fate, its unpopularity in repeated public polling and the sense that it might die on the Senate floor in what will be a politically embarrassing defeat for a party that promised to repeal the ACA the moment that Democrats approved it seven years ago.
Another problem is that McConnell chose a process to craft the legislation that has literally left the proposal orphaned.
By not going through the Senate’s precedent-bound process of “regular order,” the bill has bypassed committee hearings as well as the loving care that a legislative sponsor would normally provide. As a result, it has no real parent figure, no one invested in its success, no one primarily responsible for promoting it to other colleagues and the media.
McConnell avoided public scrutiny in the Finance, Budget and Health committees that normally would have taken up such a complicated matter. Instead, he assigned the task to an ad hoc group of Republicans who met in his office over the course of two months to come up with the nearly 150-page proposal.
The decision carried its benefits: While McConnell absorbed public criticism for the closed process, he limited the political risk and exposure to individual Republicans, and his senators got to keep their distance.
Now, however, there is so little investment in the legislation by rank-and-file Republicans that the questions continue to pile up about what changes need to be made. By late last week, the discourse had turned into a feeding frenzy, with even the most loyal Republicans openly questioning the measure while they were home over the Fourth of July.
“It’s worthy of a national debate that includes legislative hearings,” Sen. Jerry Moran (R-Kan.) said after a 90-minute town hall in rural Kansas. “It needs to be less politics and more policy.”
Eight years ago, House and Senate Democrats conducted a process that appeared brutal to the public at large. There were committee hearings and committee votes on the various iterations of the Affordable Care Act — and then a pause to hold closed-door meetings to do backroom deals, then more committee votes, then more backroom bargaining.
Republicans ridiculed Democrats for never reading the actual legislation, but in the end the ACA won approval. Three House committees and two Senate committees passed pieces of the bill, so that by the time the entire House and Senate considered their versions, those five committee chairmen served as ambassadors promoting the legislation — and dozens upon dozens of Democrats had already voted to approve portions of the bill.
There was already plenty of buy-in, and many Democrats were pushing to get the ACA over the finish line.
There is no such buy-in among Republicans in the Senate.
That was on display during the nearly 12 minutes they spent in front of the press Tuesday, with McConnell and five of his lieutenants rarely referencing the underlying legislation that they are trying to pass later next week.
They instead chose to continue to ridicule the ACA, warning that its insurance exchanges were imploding and that something must be done.
Two Republicans didn’t even bother talking about health care, opting instead to accuse Democrats of slow-walking President Trump’s nominees to sub-Cabinet positions — and to blame them for McConnell’s decision to cut down by two weeks a planned 40-day recess over August and early September.
Only Sen. John Barrasso (R-Wyo.), an orthopedic surgeon, devoted any time talking about some of the specifics in the legislation and what it would change from current law.
“We’re eliminating the mandates — the employer mandates and the individual mandates that people have to buy a government-approved product. We eliminate the taxes that raise the cost of insurance for the American public. And we lower premiums,” Barrasso said.
That was a better sales effort than McCain’s appearance Sunday on CBS’s “Face the Nation.”
“I fear that it’s going to fail,” McCain predicted.
If he’s right, it might be because the legislation was set up as an orphan from the outset.
Senate Republicans head back to work with no health-care deal
by David Weigel - Washington Post - July 10, 2017
Senate Republicans returned to Washington from a holiday recess with new and deepening disagreements about their health-care bill, with key Republicans differing Sunday not merely on how to amend the bill, but also on whether a bill could pass at all.
“I would probably put that as 50-50,” Sen. Bill Cassidy (R-La.) said in a “Fox News Sunday” interview.
“They will get a repeal and replace bill done,” White House Chief of Staff Reince Priebus said on the same show.
“My view is it’s probably going to be dead,” Sen. John McCain (R-Ariz.) said on CBS’s “Face the Nation.”
President Trump on Monday added to the friction within the GOP. In a tweet, Trump effectively warned Republican senators not to leave on their summer break without moving ahead on a health-care plan.
“I cannot imagine that Congress would dare to leave Washington without a beautiful new HealthCare bill fully approved and ready to go!” Trump wrote.
Senate Majority Leader Mitch McConnell’s decision to push debate on the Better Care Reconciliation Act past the Independence Day recess was supposed to create space for dealmaking. “Legislation of this complexity almost always takes longer than anybody else would hope,” McConnell (Ky.) said at a June 27 news conference announcing the delay.
Instead, Republicans have run in different directions, proposing everything from a bipartisan deal to pay for insurance subsidies to a “repeal and delay” plan that would give them a few years before the Affordable Care Act would be fully gutted.
Sen. Ted Cruz (R-Tex.), the author of a “Consumer Freedom Option” amendment designed to bring conservatives on board with the bill, spent part of Sunday insisting that its critics were wrong. His amendment, also supported by Sen. Mike Lee (R-Utah), would allow insurers to once again offer cheaper plans that did not include the Affordable Care Act’s essential health benefits.
“You have millions of people who are winners straight off: young people,” said Cruz in a “Face the Nation” interview. “Young people get hammered by Obamacare. Millions of young people suddenly have much lower premiums.”
Over the recess, however, key Republicans told local media outlets that the amendment weakened protections that the party had promised to keep in place.
“I think that reopens an issue that I can’t support, that it would make it too difficult for people with preexisting conditions to get coverage,” Sen. Shelley Moore Capito (R-W.Va.) told the Charleston Gazette-Mail on Friday.
“There’s a real feeling that that’s subterfuge to get around preexisting conditions,” Sen. Charles E. Grassley (R-Iowa) told Iowa Public Radio on Wednesday. “If it is, in fact, subterfuge, and it has the effect of annihilating the preexisting conditions requirement that we have in the existing bill, then obviously I would object to that.”
On ABC’s “This Week,” Cruz said that colleagues such as Grassley were simply being misled. “What’s being repeated there is what [Senate Minority Leader Charles E.] Schumer said this week, which is that he called it a hoax,” he said. “Chuck Schumer and Barack Obama know a lot about health-care hoaxes.”
Schumer’s Democrats, meanwhile, have continued campaigning against the BCRA, saying that they will come to the table on health care only if Republicans give up on repeal. Throughout the recess, progressive activists, urged on by Democrats, protested and occupied the offices of Republican senators. On Friday, 16 protesters were arrested at the Columbus office of Sen. Rob Portman (R-Ohio), joining dozens arrested in civil disobedience around the country.
“We aren’t going to allow a handful of Socialists, many of whom are from New York, to disrupt our ability to serve the needs of the Ohio constituents who contact us in need of vital services every day,” Portman’s office said in a statement.
Still, opponents of the health-care bill were far more visible than its supporters. The pro-Trump organization America First Policies floated then abandoned a plan to organize pro-BCRA rallies. While no prominent Senate Democrats appeared on Sunday’s talk shows, Sen. Bernie Sanders (I-Vt.) spent the day rallying voters in West Virginia and Kentucky against the bill.
“Mitch McConnell is now trying to make side deals in order to win votes,” Sanders said in West Virginia. “I say to Senator Capito: Please do not fall for that old trick. This legislation is fatally flawed, and no small tweak here or there will undo the massive damage that it will cause to West Virginia and the entire country.”
Republicans, meanwhile, were openly talking about next steps if they could not amend the BCRA to win 50 votes. (Vice President Pence, who has signaled that the White House would sign off on any repeal bill, would cast the tiebreaking vote.) On “Fox News Sunday,” Cassidy suggested that his own bipartisan legislation to continue much of the Affordable Care Act could get a second look, and that in the meantime, Republicans could work with Democrats to provide more subsidies for private plans.
“I do think we have to do something for market stabilization,” said Cassidy. “Otherwise, people who are paying premiums of $20,000, $30,000 and $40,000 will pay even that much more.”
Other Republicans, including McConnell, had warned that the BCRA’s failure would lead to a deal on subsidies. Yet conservatives, not ruling out the bill’s passage, spent the weekend talking up another backup plan. At a Republican fundraising dinner in Iowa, Sen. Ben Sasse (R-Neb.) suggested that Republicans could repeal most of the ACA, forcing Democrats to the table to work on a replacement.
“If we can’t replace and repeal at the same time, then repeal the law and stay and work on replace full time,” said Sasse.
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On Fox, Cassidy — one of the Senate’s few physicians — said the repeal-and-delay plan was a fantasy.
“It gives all the power to people who actually don’t believe in President Trump’s campaign pledges, who actually don’t want to continue to cover and care for preexisting conditions and to lower premiums,” Cassidy said. “It gives them the stronger hand. I think it’s wrong.”
Why Obamacare’s Loudest Critics Aren’t as Loud Anymore
by Kate Zernike - NYT - July 9, 2017
Members of Congress returning home for the July 4 recess last week were met with rallies, sit-ins and Independence Day demonstrators, as activists on the left intensified their push to defeat Republican legislation to repeal and replace the Affordable Care Act.
The groups on the right that once fueled the party’s anti-Obamacare fervor might as well have been on vacation.
“Not too many are focused on health care currently,” said Levi Russell, a spokesman for Americans for Prosperity, a group founded and funded by the Koch brothers.
Instead of health care, he said, the organization’s state chapters were holding town hall-style meetings about veterans’ concerns during recess week. Two other major groups, FreedomWorks and the Tea Party Patriots, said they were planning rallies in August and September that would push for an overhaul of the tax code; Americans for Prosperity was already running ads toward that.
The shift in priorities is remarkable. Since the summer of 2009, when Tea Party activists angrily confronted Democrats who were drafting the Affordable Care Act, the Republican Party has been driven and defined by outrage over it. But now, with the Republican health care legislation hanging in the balance, President Trump and congressional leaders are getting little support from what were once the loudest anti-Obamacare voices. The lack of grass-roots enthusiasm will make it even harder for the party’s Senate leaders to line up votes for their troubled bill when they return on Monday.
Activists on the right said they felt betrayed by the Republicans they helped elect, who pledged that when they had a Republican president they would repeal the act “root and branch,” as Senator Mitch McConnell, the majority leader, once declared.
“This is not anywhere close to that, and I think it has left a number of conservative activists saying I’m not advocating for this,” said David Bozell, the president of ForAmerica, an organization founded in 2010, the year the Affordable Care Act was passed, to help spread conservative ideas on social media.
These activists want the subsidies that help people buy insurance repealed, not just reduced. They want the Medicaid expansion eliminated, not slowed.
“You’re not going to get a grass-roots activist to spend their valuable time calling their senator because, ‘Well, this is better than nothing,’” Mr. Bozell said.
Public opinion polls show support for repeal-and-replace slipping among the very groups that once demanded it. Support for the Republicans’ efforts among Trump supporters, while still a healthy 55 percent, dropped 14 percentage points since May, according to a Kaiser Family Foundation poll in mid-June. Among Republicans over all, support had dropped 11 points, to 56 percent. Just 8 percent of Republicans polled thought repeal should be the top priority of Congress and the president.
While Republicans have become more lukewarm on their party’s efforts, Democrats are more fiercely defending the Affordable Care Act. Fifty-three percent of Democrats in the Kaiser poll had a “very favorable” view of the health care law, while 21 percent of Republicans had the same view of their party’s plan to repeal it. In May 2010, two months after the law passed, 30 percent of Democrats had a very favorable view of it. Republicans were heatedly against it: 69 percent had a “very unfavorable view.”
“There’s definitely an enthusiasm gap,” said Liz Hamel, the director of public opinion and survey research for Kaiser, a nonpartisan research group. “It’s not that they’re not interested in repeal,” she said. “They just have other priorities.”
In the June poll, 74 percent of Republicans said their families would be better off without the health care law. But a majority expressed support for its major provisions: 59 percent want the federal government to continue prohibiting insurers from charging more to people with pre-existing conditions; 52 percent said the federal government should continue to require insurance plans to cover a list of “essential health benefits,” like maternity care and treatment for drug abuse.
Advertising, too, has been one-sided against the Republican legislation. Groups from Planned Parenthood to the AARP have bought television and radio spots in states with wavering Republicans imploring them to vote against the plan. Groups on the right were mostly silent; FreedomWorks has run digital ads in Tennessee alone, showing Senator Bob Corker, who has criticized his fellow Republicans for proposing to eliminate the act’s 3.8 percent tax on investment income, cozying up to President Barack Obama.
Like Republican lawmakers, some of the groups have found that fixing complex legislation is far more challenging than opposing it. “It’s easier to generate a crowd when you don’t have to be in on the sausage-making,” said Adam Brandon, the president of FreedomWorks.
“The Democrats, their strategy is outrage,” he said. “I get that strategy. I lived that strategy. It’s a unifying strategy to be outraged at the other guy. The hard part is when you get in and have to deliver.”
Jenny Beth Martin, the president and co-founder of the Tea Party Patriots, said the group’s email blasts against Obamacare still trigger hundreds of responses from activists angry about it. The group helped make more than 100,000 phone calls over 48 hours when the House was voting on its bill in the beginning of May to repeal and replace.
But, she said, “We’re not yet on the yes side with what the Senate is doing.”
Grass-roots activists like Pat Daugherty, who once marched on Washington against Obamacare, now sound as disgusted with Republicans in Congress as they were in the early days of the Tea Party, when they helped primary challenges against lawmakers they derided as “Republicans in Name Only.”
“Every Republican in Congress ran on repealing Obamacare,” said Ms. Daugherty, a retired university administrator in Athens, Ga. “Why do we suddenly have a hard time repealing Obamacare when Republicans are in the majority?
“I know a lot of conservatives who are more upset with Republicans than with Democrats,” she said.
David Zupan helped organize Tea Party groups in Ohio against the Affordable Care Act, which he blamed for driving up health care costs and forcing him to shutter his technology support business. Before the law, he said, he paid $910 per month to insure him and his wife, with a $750 annual deductible. When he renewed his policy last year, he said, the rates had increased to $2,845 per month, with a $3,500 deductible.
Mr. Zupan had hoped to confront Senator Rob Portman over the recess to demand that he and his fellow Republicans push for a full repeal. Mr. Portman has expressed concern that the Senate bill would roll back Medicaid too far, particularly jeopardizing treatment for opioid addiction. But Mr. Zupan gave up after being unable to figure out where Mr. Portman would be.
Mr. Zupan, too, expressed a certain resignation with Republicans.
“Nothing they’re going to do to this bill is going to make it better,” he said.
“I honestly don’t believe that the majority of the people in the House and the Senate want limited government,” he said. “They’d rather have the government in there controlling the 17 percent of our economy that is health care. It means more money over all that they get to control.”
Some groups, including the Tea Party Patriots, are supporting a proposal by Senator Ted Cruz of Texas that would allow insurers to offer plans without the full complement of essential health benefits, which Republicans believe will lead to cheaper premiums, as long as they offer at least one plan that covers those benefits.
And some activists endorsed a tweet from Mr. Trump on June 30 encouraging Republicans to scrap the current bill attempting to replace the Affordable Care Act and resurrect one from 2015 that just repealed it. That bill won almost unanimous support from Republicans, but was vetoed by Mr. Obama.
Mr. Brandon, at FreedomWorks, said activists were beginning to think that Republicans had voted for that bill only because they knew Mr. Obama would block it. That suspicion — “they were just being political” — fosters apathy now, he said.
“You think of the origins of the Tea Party and the origins of why Donald Trump won,” he said. “People are sick of the political show.”
Three Legs Good, No Legs Bad
by Paul Krugman - NYT - July 10, 2017
Will 50 Republican senators be willing to inflict grievous harm on their constituents in the name of party loyalty? I have no idea.
But this seems like a good moment to review why Republicans can’t come up with a non-disastrous alternative to Obamacare. It’s not because they’re stupid (although they have become stunningly anti-intellectual). It’s because you can’t change any major element of the Affordable Care Act without destroying the whole thing.
Suppose you want to make health coverage available to everyone, including people with pre-existing conditions. Most of the health economists I know would love to see single-payer — Medicare for all. Realistically, however, that’s too heavy a lift for the time being.
For one thing, the insurance industry would not take kindly to being eliminated, and has a lot of clout. Also, a switch to single-payer would require a large tax increase. Most people would gain more from the elimination of insurance premiums than they would lose from the tax hike, but that would be a hard case to make in an election campaign.
Beyond that, most Americans under 65 are covered by their employers, and are reasonably happy with that coverage. They would understandably be nervous about any proposal to replace that coverage with something else, no matter how truthfully you assured them that the replacement would be better.
So the Affordable Care Act went for incrementalism — the so-called three-legged stool.
It starts by requiring that insurers offer the same plans, at the same prices, to everyone, regardless of medical history. This deals with the problem of pre-existing conditions. On its own, however, this would lead to a “death spiral”: healthy people would wait until they got sick to sign up, so those who did sign up would be relatively unhealthy, driving up premiums, which would in turn drive out more healthy people, and so on.
So insurance regulation has to be accompanied by the individual mandate, a requirement that people sign up for insurance, even if they’re currently healthy. And the insurance must meet minimum standards: Buying a cheap policy that barely covers anything is functionally the same as not buying insurance at all.
But what if people can’t afford insurance? The third leg of the stool is subsidies that limit the cost for those with lower incomes. For those with the lowest incomes, the subsidy is 100 percent, and takes the form of an expansion of Medicaid.
The key point is that all three legs of this stool are necessary. Take away any one of them, and the program can’t work.
But does it work even with all three legs? Yes.
To understand what’s happened with the A.C.A. so far, you need to realize that as written (and interpreted by the Supreme Court), the law’s functioning depends on lot on cooperation from state governments. And where states have in fact cooperated, expanding Medicaid, operating their own insurance exchanges, and promoting both enrollment and competition among insurers, it has worked pretty darn well.
Compare, for example, the experience of Kentucky and its neighbor Tennessee. In 2013, before full implementation of the A.C.A., Tennessee had slightly fewer uninsured, 13 percent versus 14 percent. But by 2015 Kentucky, which implemented the law in full, had cut its uninsured rate to just 6 percent, while Tennessee was at 11.
Or consider the problem of counties with only one (or no) insurer, meaning no competition. As one recent study points out, this is almost entirely a red-state problem. In states with G.O.P. governors, 21 percent of the population lives in such counties; in Democratic-governor states, less than 2 percent.
So Obamacare is, though nobody will believe it, a well-thought-out law that works where states want it to work. It could and should be made to work better, but Republicans show no interest in making that happen. Instead, all their ideas involve sawing off one or more legs of that three-legged stool.
First, they’re dead set on repealing the individual mandate, which is unpopular with healthy people but essential to making the system work for those who need it.
Second, they’re determined to slash subsidies — including making savage cuts to Medicaid — in order to free up money that they can use to cut taxes on the wealthy. The result would be a drastic rise in net premiums for most families.
Finally, we’re now hearing a lot about the Cruz amendment, which would let insurers offer bare-bones plans with minimal coverage and high deductibles. These would be useless to people with pre-existing conditions, who would find themselves segregated into a high-cost market — effectively sawing off the third leg of the stool.
So which parts of their plan would Republicans have to abandon to avoid a huge rise in the number of uninsured? The answer is, all of them.
After all these years of denouncing Obamacare, then, Republicans have no idea how to do better. Or, actually, they have no ideas at all.
Don’t Leave Health Care to a Free Market
by Farzon Nahvi - NYT - July 10, 2017
When it comes to health care coverage, House Speaker Paul Ryan says, “We’re going to have a free market, and you buy what you want to buy,” and if people don’t want it, “then they won’t buy it.” In this model of health care, the patient is consumer, and he must decide whether the goods and services he wants to protect his life are worth the cost.
But this is often impossible. And what Republicans, and many Democrats, forget to stress, is that in a totally free market health care system, you must be willing to let some patients die.
As an emergency medicine physician in a busy urban hospital, I have patients brought to me unconscious several times a day. Often, they are found down in the street by a good Samaritan who called 911 on their behalf. We are required to care for them, and most of these patients are grateful at my attempts to help them. More than once, however, such patients have regained consciousness furious. It wasn’t that they didn’t want to live — they were all simply upset at the costs their hospitalization incurred.
Last week I took care of a middle-school teacher who was out jogging on a hot June day. Dehydrated, she lost consciousness when some tourists called an ambulance over to her. A month before that, I cared for a young man who passed out at his desk from a bleeding ulcer in his colon. His co-workers called 911 while he lay in a puddle of his own blood. And about one year ago, I cared for a 56-year-old patient who was found lying in the gutter at 3 a.m. A passer-by called 911 thinking he was drunk. It turns out he had been hit on the head with an iron rod by muggers while on his way home from work as a waiter.
All three of them had ambulances called on their behalf by bystanders. All three of them, unconscious for some or all of their care, had no say in whether they would be treated. All three of them were saddled with gigantic medical bills that they had absolutely no say in.
Most dismaying for me as a physician is that after all of my attempts to apply my compassion and training to save their lives, all three of these patients told me some variant of: “Thanks for what you’re doing, but I would rather that you hadn’t.” Even the man with the brain bleed, who certainly would have died without our immediate intervention, expressed dismay. In the neurology intensive care unit, with a bolt through his skull to measure the pressure around his brain, he told me that while he did not have health insurance, he did have life insurance. He said he would rather have died and his family gotten that money than have lived and burdened them with the several-hundred-thousand-dollar bill, and likely bankruptcy, he was now stuck with.
A believer in free-market medicine, Mr. Ryan has said about health care: “You get it if you want it. That’s freedom.” Yet being given services without your consent, and then getting saddled with the cost, is nothing like freedom.
Imagine Verizon sending you a bill for hundreds of thousands of dollars (roughly the cost of the medical care of the patient with the brain bleed who required an emergency neurosurgery and prolonged I.C.U. stay) and then telling you, “We called you to offer you some extra services. You didn’t answer the phone because you were in a coma, but we guessed that you’d want them, so we went ahead and added them on and charged you for them.” Clearly you would be outraged.
So why does this happen with health care? The answer is that we don’t truly believe in free-market medicine. We know that in an empathetic and caring society, life is valued above all else, especially when the life in question is in the most helpless condition possible. Deep down inside, we all intuitively know that health care is not a free market, or else society would not allow me to routinely care for people when they are in no position to make decisions for themselves.
Republicans need to be honest with themselves and the public: If they want medicine to be truly free-market, then they have to be willing to let the next man or woman they find lying unconscious in the street remain there and die. In a truly free market, we cannot treat someone — and charge someone — without their consent and against their will. If we believe, however, that those lying there in their most vulnerable moments deserve a shot, then we need to push forward with the idea that health care, at its core, must be designed around a caring system that serves all people fairly.
Republicans Take a Hatchet to Health Care
by Vikas Bajaj and Stewart A. Thomson - NYT - July 7, 2017
Share of uninsured nonelderly adults, by 2022
The latest Republican plan to overhaul the health care system would eliminate insurance coverage for millions of their own constituents, which should greatly concern senators who support the bill.
An analysis by the Urban Institute shows how states will be affected by the Better Care Reconciliation Act, the Senate proposal that is still in negotiation after the majority leader, Mitch McConnell, canceled a vote in late June. While all Democratic senators oppose the bill, only 14 Republican senators have raised doubts about the plan. The rest appear to support the bill.
States With Expanded
Medicaid Are Hit Hardest
The plan will be particularly devastating for the 31 states that expanded Medicaid under the Affordable Care Act. More than 14 million people gained health insurance under the expansion. The legislation would phase out the expansion. In addition, it would cap federal spending on Medicaid and allow it to grow by the general inflation rate, which tends to increase much more slowly than the cost of medical care.
Change in the number of uninsured, compared with the Affordable Care Act, by 2022
States that expanded
Medicaid
Source: Urban Institute
The expansion states include Arkansas, Kentucky, Ohio and West Virginia, which have at least one Republican senator each. Under the Senate bill, nearly 2.3 million people in just those four states would lose access to Medicaid by 2022, according to the Urban Institute. While a small fraction of these people could possibly gain access to coverage through employers or the private market, experts say most of them would become uninsured.
People Who Use Exchanges
Could Lose Insurance
Increase in number of people uninsured, compared with the A.C.A., by 2022
In Republican-run states like Florida, Georgia and Texas that have not expanded Medicaid, the Senate bill would most hurt people who buy insurance on the health care exchanges created by the A.C.A. Nearly 2.3 million people in those three states would likely lose their private insurance policies by 2022, according to the Urban Institute.
The Senate bill hurts those people by greatly reducing the subsidies the A.C.A. provides families who buy their own insurance. These cuts will most hurt lower-income and middle-class families. The legislation would also let insurance companies charge older Americans much more for coverage. And the Republican bill would let insurers sell policies with higher deductibles.
Change to health insurance premiums
Note: For a single individual with an annual income of $26,500 using a “silver” plan.
Source: The Congressional Budget Office
For example, a 40-year-old earning $26,500 can now buy a policy with relatively modest deductibles for $1,700 a year, according to the Congressional Budget Office. But under the Senate bill that person would pay $3,000 for a policy with higher deductibles. And a 64-year-old with the same income would see premiums jump from $1,700 to $6,500 under the Senate bill.
The Cost in Republican States
While most Senators have made up their minds on the bill — with Democrats universally opposed — a handful of Republican senators are undecided, and hundreds of thousands of their constituents are wondering whether they’ll lose coverage. Below, the number of additional people by people without insurance under the new plan, compared with the A.C.A. — and the Republican senator who is putting them at risk.
Republican Senators Undecided on the Bill
Lisa Murkowski
Alaska
67,000
more people wouldn't be covered vs. the A.C.A.
Cory Gardner
Colorado
575,000
more people wouldn't be covered vs. the A.C.A.
Jerry Moran
Kansas
120,000
more people wouldn't be covered vs. the A.C.A.
Rand Paul
Kentucky
541,000
more people wouldn't be covered vs. the A.C.A.
Bill Cassidy
Louisiana
410,000
more people wouldn't be covered vs. the A.C.A.
Susan Collins
Maine
60,000
more people wouldn't be covered vs. the A.C.A.
Dean Heller
Nevada
328,000
more people wouldn't be covered vs. the A.C.A.
John Hoeven
North Dakota
70,000
more people wouldn't be covered vs. the A.C.A.
Rob Portman
Ohio
1,122,000
more people wouldn't be covered vs. the A.C.A.
James Lankford
Oklahoma
157,000
more people wouldn't be covered vs. the A.C.A.
Ted Cruz
Texas
1,123,000
more people wouldn't be covered vs. the A.C.A.
Mike Lee
Utah
245,000
more people wouldn't be covered vs. the A.C.A.
Shelley Moore Capito
West Virginia
218,000
more people wouldn't be covered vs. the A.C.A.
Ron Johnson
Wisconsin
286,000
more people wouldn't be covered vs. the A.C.A.
Republican Senators Who Support the Bill,
or Their Stance Is Unclear
Richard C. Shelby
Alabama
164,000
more people wouldn't be covered vs. the A.C.A.
Luther Strange
Alabama
164,000
more people wouldn't be covered vs. the A.C.A.
Dan Sullivan
Alaska
67,000
more people wouldn't be covered vs. the A.C.A.
John McCain
Arizona
395,000
more people wouldn't be covered vs. the A.C.A.
Jeff Flake
Arizona
395,000
more people wouldn't be covered vs. the A.C.A.
John Boozman
Arkansas
367,000
more people wouldn't be covered vs. the A.C.A.
Tom Cotton
Arkansas
367,000
more people wouldn't be covered vs. the A.C.A.
Marco Rubio
Florida
1,525,000
more people wouldn't be covered vs. the A.C.A.
Johnny Isakson
Georgia
400,000
more people wouldn't be covered vs. the A.C.A.
David Perdue
Georgia
400,000
more people wouldn't be covered vs. the A.C.A.
Michael D. Crapo
Idaho
107,000
more people wouldn't be covered vs. the A.C.A.
Jim Risch
Idaho
107,000
more people wouldn't be covered vs. the A.C.A.
Todd Young
Indiana
666,000
more people wouldn't be covered vs. the A.C.A.
Charles E. Grassley
Iowa
232,000
more people wouldn't be covered vs. the A.C.A.
Joni Ernst
Iowa
232,000
more people wouldn't be covered vs. the A.C.A.
Pat Roberts
Kansas
120,000
more people wouldn't be covered vs. the A.C.A.
Mitch McConnell
Kentucky
541,000
more people wouldn't be covered vs. the A.C.A.
John Kennedy
Louisiana
410,000
more people wouldn't be covered vs. the A.C.A.
Thad Cochran
Mississippi
100,000
more people wouldn't be covered vs. the A.C.A.
Roger Wicker
Mississippi
100,000
more people wouldn't be covered vs. the A.C.A.
Roy Blunt
Missouri
297,000
more people wouldn't be covered vs. the A.C.A.
Steve Daines
Montana
113,000
more people wouldn't be covered vs. the A.C.A.
Deb Fischer
Nebraska
105,000
more people wouldn't be covered vs. the A.C.A.
Ben Sasse
Nebraska
105,000
more people wouldn't be covered vs. the A.C.A.
Richard M. Burr
North Carolina
553,000
more people wouldn't be covered vs. the A.C.A.
Thom Tillis
North Carolina
553,000
more people wouldn't be covered vs. the A.C.A.
James M. Inhofe
Oklahoma
157,000
more people wouldn't be covered vs. the A.C.A.
Patrick J. Toomey
Pennsylvania
1,221,000
more people wouldn't be covered vs. the A.C.A.
Lindsey Graham
South Carolina
215,000
more people wouldn't be covered vs. the A.C.A.
Tim Scott
South Carolina
215,000
more people wouldn't be covered vs. the A.C.A.
John Thune
South Dakota
28,000
more people wouldn't be covered vs. the A.C.A.
Michael Rounds
South Dakota
28,000
more people wouldn't be covered vs. the A.C.A.
Lamar Alexander
Tennessee
353,000
more people wouldn't be covered vs. the A.C.A.
Bob Corker
Tennessee
353,000
more people wouldn't be covered vs. the A.C.A.
John Cornyn
Texas
1,123,000
more people wouldn't be covered vs. the A.C.A.
Orrin G. Hatch
Utah
245,000
more people wouldn't be covered vs. the A.C.A.
Michael B. Enzi
Wyoming
23,000
more people wouldn't be covered vs. the A.C.A.
John Barrasso
Wyoming
23,000
more people wouldn't be covered vs. the A.C.A.
Congress Is Facing a Time Crunch to Repeal Obamacare
by Margot Sanger-Katz - NYT - July 10 2017
Mitch McConnell, the Senate majority leader, told his Republican colleagues that they needed to vote on their health bill before the July 4 holiday — then he gave them an extension.
But don’t expect the health care debate to drag on forever. There are legal and political reasons that Republicans really do need to decide in the next few weeks whether their legislative effort will succeed or go back on the shelf.
The process could drag on past July, but there is tremendous pressure for Congress to act quickly.
Waiting imperils tax reform
Republicans chose to pass their health bill through a special budget process called reconciliation, which has a lot of rules. That choice has advantages — most important, it allows Republicans to avoid a filibuster and pass the legislation with 50 Senate votes (and a tiebreaking vote from Vice President Mike Pence), without any of the Democrats. But it also means that the health bill impedes other priorities.
Leaders want to use the same budget procedure to pass tax reform, but Senate rules allow only one such reconciliation maneuver at a time. That means that, as long as health care drags on, tax reform can’t move forward, unless Republicans can attract Democratic support under normal procedure (where 60 votes is needed for a filibuster-proof majority).
Inaction on health reform complicates some of the policy choices in tax reform, too. The current Senate health bill includes substantial tax cuts and several hundred billion dollars in projected savings. If that bill is not going to become law, it could alter the choices about which taxes get cut or raised as part of the tax-only bill.
ongress likes its summer vacation
If health reform isn’t wrapped up by the end of the month, it bumps up against Congress’s scheduled summer recess, a time when legislators like to go home to their districts, take a break from lawmaking, spend time with their families, and raise money. Many congressional staff members also go on vacation during the recess. Leaders could, of course, tell lawmakers and their staffs that they need to stick around and keep working until they pass a bill, but the scheduled recess tends to act as a deadline.
September is going to be really busy
Obamacare repeal is a big political priority for Republican leaders and the White House. But several other bills need to pass to keep vital parts of the government working. Those are likely to take priority in the weeks after the summer recess. Congress will need to raise the debt ceiling, pass a reauthorization of the Children’s Health Insurance Program, and pass new bills to fund government functions, to name a few. In April, the last time Congress had an important must-pass spending bill, the health reform measure was pushed aside.
Fiscal New Year’s Eve is coming, maybe
The health reform bill is attached to a budget for the 2017 fiscal year. The 2017 fiscal year ends on Sept. 30. At that point, the health bill could conceivably turn into a pumpkin, but experts in Senate budget procedure have differing opinions. A final determination would need to be made by the Senate parliamentarian.
If the fiscal New Year comes, and the parliamentarian rules the expired budget is irrelevant, Republicans will need to start from scratch on health care by passing a new budget for 2018 with instructions to reform the health system, and by passing a health care bill through the House again. Neither of those steps would be assured of success, and both would complicate efforts to pass a tax reform bill, which leaders hoped to tie to the 2018 budget process.
Time may not help lawmakers reach consensus
Mr. McConnell had hoped that speed would be his friend in passing the health bill through his chamber. His staff drafted much of the bill in secret, and he hoped to bring it up for a vote a week after first making its details public.
That strategy didn’t work, we now know. But since that missed deadline, more Republican senators have publicly stated their opposition to the bill. During last week’s July 4 recess, several crucial senators heard criticisms of the bill and voiced strong critiques, according to reporting from my colleagues who attended their town hall meetings. The divisions in the caucus don’t necessarily doom the measure: House Speaker Paul Ryan pulled his health bill from the floor, then passed an amended bill a few weeks later. But so far, it looks as if consensus is weakening even as the time pressures build.
https://www.nytimes.com/2017/07/10/upshot/congress-is-facing-a-time-crunch-to-repeal-obamacare.html?
The Senate Health Care Charade
by The Editorial Board - NYT - July 10, 2017
It is tempting to think that the Republican health care proposal, which would do so much damage to so many Americans, will collapse in the Senate, since conservatives and centrists alike have come out against it. But that would be premature. After all, House leaders managed to cobble together a narrow majority for their bill after similar protests in that chamber.
At least some of the Senate opposition to Majority Leader Mitch McConnell’s opening bid in the health care wars is mere political theater. Far-right senators who are protesting that the bill does not do enough to get rid of the dreaded Affordable Care Act, or Obamacare, are almost certainly posturing. These lawmakers want to be seen as making the bill more extreme to burnish their conservative bona fides. But they do not want to be blamed for blocking legislation that by any objective analysis achieves the Republican goal of destroying the A.C.A. and more. It would greatly weaken Medicaid, a program that many in the party have long despised. And it would leave more people uninsured than if Congress repealed Obamacare without putting anything in its place, according to a recent analysis by the Urban Institute.
Senator Ted Cruz of Texas has already floated a potential compromise that could get him and at least one more conservative, Mike Lee of Utah, to vote for the bill. His proposal would let insurers sell two different kinds of policies: ones that meet the requirements of the A.C.A. and ones that do not. The idea is to let younger, healthier people buy skimpier, cheaper plans that do not cover many medical services and that have very high deductibles. Older and sicker people would be able to buy plans that are more comprehensive.
But experts say dividing the insurance risk pool in this way would force insurers to raise premiums a lot, because plans that cover more services would primarily attract people who have more health problems. Many middle-class families would not be able to afford those plans, since they earn too much to qualify for subsidies. This so-called compromise smacks of the kinds of changes demanded by the Freedom Caucus, whose members objected to Speaker Paul Ryan’s original bill in the House. As a result of their demands, the measure passed by the House would let insurers discriminate against people with pre-existing conditions.
In reality, the lawmakers who will make or break the Senate bill are centrist Republicans and lawmakers who represent states that expanded Medicaid under the A.C.A. These groups include Susan Collins of Maine, Shelley Moore Capito of West Virginia, Cory Gardner of Colorado, Dean Heller of Nevada, Lisa Murkowski of Alaska and Rob Portman of Ohio. Mr. McConnell, President Trump and other Republicans are putting lots of pressure on them — and are trying to win them over with modifications that may seem like improvements but do not change the bill’s substance.
For example, Mr. McConnell has reportedly agreed to allocate $45 billion over 10 years to deal with the opioid epidemic, up from $2 billion in his original proposal. This change is aimed at winning the support of Republican senators from states that are struggling with the scourge of addiction. Granted, this would be a big increase, but experts say it is hardly enough given the scope of the problem. And it cannot make up for the faults in the rest of the bill, which would most hurt people in states at the epicenter of the opioid crisis.
The Congressional Budget Office estimates that the legislation will take health insurance away from 22 million people by 2026, including 15 million who will be kicked off Medicaid. More federal spending on the opioid problem might help some of those people get addiction treatment if they need it, but it will not help them if they happen to need, say, chemotherapy, insulin or heart surgery.
Expect Mr. McConnell to offer more such sweeteners to his members, because his bill would reduce the federal deficit by $321 billion over 10 years, nearly three times as much as the House bill, according to the budget office. This leaves Mr. McConnell with enough room to throw some trinkets at legislators who are on the fence or need cover for their vote. The legislation achieves these savings by dramatically slashing government spending on health care. Unsurprisingly, Mr. McConnell uses a big chunk of those savings to cut taxes on wealthy families and corporations.
This all-out effort to sway votes is all the more shameful given how unpopular the bill is with Americans. Just 17 percent of the country approves of the legislation, according to a recent NPR/PBS NewsHour/Marist poll. By contrast, about 63 percent say Congress should either leave the A.C.A. untouched or change it so that it does more.
Some senators are surely eager to make a deal and will accept whatever Mr. McConnell offers them. But conscientious lawmakers who care about the health care of millions of Americans should know that tinkering around the edges will not make this bill any less dreadful or any more deserving of their vote.
Health Reform, Both Real and Conservative
by David Leonhardt - NYT - July 11, 2017
WARWICK, R.I. — The American health care system has two core problems. It’s the world’s most expensive, and it still leaves many people uninsured.
Congressional Republicans have not tried to solve either problem. They have instead offered a plan that cuts spending on the middle class and the poor, funnels the money into a tax cut for the affluent and masquerades as health policy.
One of the great shames of their approach is that a different one is available. Conservative health reform is not an oxymoron. Nor is bipartisan health reform. It’s possible to combine conservative and liberal ideas to cover more people while holding down costs.
You can find a real-world case study here in Rhode Island.
The state is obviously a small one, but it has a lot in common with the rest of the country. Its poverty rate is similar to the nation’s, and its opioid crisis is even worse. It has a strongly Democratic metropolitan area (Providence), while Donald Trump won the state’s western half.
The story of health reform here involves both Republican and Democratic officials. It involves praise from the conservative Wall Street Journal and the liberal Center for American Progress. Most important, the story involves cost savings, fewer uninsured and a rising quality of care.
I’ve been covering Washington long enough to understand that Trump and Mitch McConnell aren’t going to abandon their health care plan simply because it’s a bad one. They have too much invested (and they believe deeply in upward income redistribution).
But if Republican holdouts in the Senate continue to block the plan, the health policy debate is eventually going to start fresh. When it does, we could use some role models.
Rhode Island’s efforts started almost a decade ago. The governor, a Republican named Don Carcieri, asked the Bush administration for more flexibility with Medicaid in exchange for holding down costs.
It was classic conservatism: reduce federal rules, give states more autonomy and let them keep some of the savings. Yet, unlike the Senate bill, Rhode Island’s plan didn’t slash Medicaid carelessly. It came with safeguards, like ensuring that everyone eligible for Medicaid would keep coverage.
Carcieri made substantial progress, but costs were still a problem when Gina Raimondo, a Democrat, became governor in 2015. Medicaid accounts for close to one-third of Rhode Island’s budget. It crowds out spending on schools, roads and other job-creating investments. Unless she could get Medicaid spending under control, Raimondo told me, she wouldn’t be able to do much else.
Her strategy has been based on the most important — and, in a strange way, most promising — fact about American health care: Much of our spending doesn’t make us healthier.
We go to the emergency room instead of a primary-care doctor. We choose invasive procedures over simpler, more effective ones. We house elderly people in nursing homes instead of offering more pleasant home care.
Raimondo’s administration has used the flexibility that Carcieri won — as well as Obamacare provisions — to move away from the high-cost approach. “I want to pay to get you healthier,” she said, “not pay to have something done to you.”
I recently tagged along on a nurse’s home visit to a 74-year-old woman here named Annie Hall. Hall is a widow who suffers from Parkinson’s and other conditions. She did not get up from her living room chair during the visit.
She likes living where she does: not in a nursing home or hospital, but in the apartment in a wooded area, just off Interstate 95, that she and her husband shared for years. “I don’t want to go to the hospital,” she said. “It’s the worst place to go when you’re sick.”
Not so long ago, Hall would have been moved to a nursing home anyway, because that was the default. Today, she is able to stay home, thanks to the nurses from Integra Community Care Network, paid partly by Medicaid, who visit her every week and check up by phone. Hall calls the nurses “my family.”
The shift toward home-based care is one reason cost growth has fallen here. In Medicaid, spending per enrollee dropped 6.5 percent last year and is now starting to save the state serious money.
Think about how conservative this approach is. It’s based on local, not federal, decision-making. It allows people like Annie Hall to remain in their communities. It saves money for taxpayers. No wonder many Republicans like to point to Rhode Island.
Unfortunately, the Senate bill would cause the progress here to unravel, state officials told me. They would lose so much Medicaid funding that they would have to cut back on care — regardless of the effects — and deny insurance to people.
A handful of Republican senators are all that’s keeping such damage from happening. I hope they understand they are not only protecting vulnerable Americans. They are also defending truly conservative ideas.
Credit Agencies To Ease Up On Medical Debt Reporting
by Michelle Andrews - Kaiser Health News - July 11, 2017
Millions of Americans have medical debt that's hurting their credit. The Consumer Financial Protection Bureau estimated it's as many as 43 million people, according to data released in late 2014.
Now, some relief may be on the way.
Changes in the way credit agencies report and evaluate medical debt are in the works. They should reduce some of the painful financial consequences of having a health care problem.
Starting Sept. 15, the three major credit reporting agencies — Experian, Equifax and TransUnion — will set a 180-day waiting period before including medical debt on a consumer's credit report. The six-month period is intended to ensure there's enough time to resolve disputes with insurers and delays in payment.
In addition, the credit bureaus will remove medical debt from consumers' credit reports once it's paid by an insurer. Some credit scoring models don't penalize paid medical debt from any source.
The changes grew out of two efforts by states to aid consumers: a 2015 settlementnegotiated by New York State Attorney General Eric Schneiderman and the three major credit reporting agencies, and an agreement shortly afterward between the agencies and 31 other state attorneys general. The changes will be instituted nationwide.
For many consumers, an unexpected health care calamity can quickly burgeon into a financial calamity. Just over half of all the debt that appears on credit reports is related to medical expenses, the CFPB found in its 2014 study. For 15 million consumers, medical debt was the only blemish on their credit report.
Perhaps this isn't surprising given the growth in the number of people with high-deductible health plans and significant out-of-pocket financial responsibilities for health care, says Chad Mulvany, policy director at the Healthcare Financial Management Association, a membership organization for finance professionals.
"More people who typically would have been a good credit risk are now saddled with big bills," he says.
The 180-day waiting period is "a big step forward toward a more equitable process," says Julie Kalkowski, executive director of the Financial Hope Collaborative at Creighton University in Omaha, Neb., which provides financial education and coaching to low-income, single mothers.
Rather than attempting to collect past-due medical bills themselves, hospitals and doctors' offices typically engage collection agencies to chase down payments. But the timing on when providers take that step varies widely.
"Without a standardized process, some bills get sent to collections because they're 30 or 60 days past due, as opposed to six months," Kalkowski says, citing several of the women who went through the Creighton program. The total amount owed in most cases was under $150, she says.
In fact, the average amount of medical debt in collections was $579, compared with $1,000 for non-medical debt, the CFPB found in its study. But even small amounts of debt can lead to credit problems. A bad credit score can prevent someone from getting a car loan, credit card or a mortgage, for example.
Lenders use credit reports and credit scores to evaluate the risk that someone won't repay a loan. The credit-scoring companies build algorithms that use the data in people's credit reports to assign a three-digit credit score, typically between 300 and 850, that summarizes someone's credit risk based on the information in a credit report at that time. Higher scores indicate lower risk.
Credit-scoring companies like FICO and VantageScore have been adjusting their formulas to account for the fact that medical debt isn't necessarily an accurate predictor of whether someone is a good credit risk.
"Those with medical accounts are less likely to default on their accounts than non-medical accounts," says Ethan Dornhelm, vice president of scores and analytics at FICO.
To address this issue, newer FICO and VantageScore models differentiate between medical and non-medical debt. People with medical debt in collections receive a smaller penalty than those with non-medical collections, says Sarah Davies, senior vice president at VantageScore Solutions.
Under FICO9, the newest model, someone whose only major credit blot is one or more medical collections would see their median score improve roughly 25 points over older versions, says FICO's Dornhelm.
But there's a catch: Many banks and other lenders haven't yet adopted the newer versions of the credit-scoring models. So even though medical debt shouldn't have as strong an impact on someone's credit score now, in many cases it still could.
What's a consumer to do? You can't control which scoring model a lender uses, but you can check your credit report regularly to make sure it's accurate. Consumers are entitled to a free credit report from each credit reporting company annually.
"If there's medical debt that's been paid, it should be removed going forward, and if it's less than six months old, find out when it's going to be removed," advises VantageScore's Davies.
Don’t Assume That Private Insurance Is Better Than Medicaid
by Aaron Carroll and Austin Frakt - NYT - July 12, 2017
As we recently wrote, it’s better for patients to have Medicaid than to be uninsured, contrary to critics of the program. But is having Medicaid, as those critics also say, much worse than having private insurance?
This idea has become a talking point for conservatives who back big changes to Medicaid, as the Senate health bill proposes. The poor would benefit simply by being ushered off Medicaid and onto private insurance, they write.
But it’s far from proven that Medicaid is worse than private insurance. A lot depends on what kind of insurance is compared with Medicaid, and how they are compared.
Many studies that measure Medicaid against private insurance suffer from the same flaws that compare Medicaid with being uninsured. They’re terribly confounded, and can show only associations, not causation. People with private insurance are healthier and wealthier than those on Medicaid, and in ways not fully controlled for in statistical analyses. These factors almost certainly predispose someone on Medicaid to have worse outcomes than someone with private insurance.
Perhaps the most convincing way to compare Medicaid and private insurance would be with a randomized controlled trial that pits them head to head. No such trials exist. Recall that the Oregon Medicaid study randomly offered, via a lottery, the opportunity for low-income adults to enroll in Medicaid. It did not have another study arm that offered private insurance.
But we do have a decades-old trial that looked at varying levels of cost-sharing: the RAND Health Insurance Experiment. This is relevant because one substantial difference between Medicaid and most private coverage is the level of cost-sharing. Medicaid is nearly free. Most private coverage comes with deductibles and co-payments.
The RAND study randomly assigned 2,750 families to one of four health plans. One had no cost-sharing whatsoever — kind of like Medicaid. The other three had cost-sharing (money people had to pay out-of-pocket for care) at levels of 25, 50 or 95 percent — capped at $1,000 at the time, which is about an inflation-adjusted $6,000 today. This level of personal liability acts like a deductible, making the plan with a 95 percent level of cost-sharing comparable to a “Bronze” plan on the Affordable Care Act’s exchanges today.
The RAND study found that the more cost-sharing was imposed on people, the less health care they used — and therefore the less was spent on their care. The study also found that, over all, people’s health didn’t suffer from lower health care use and spending.
Lower spending and no decline in health — these are the results that everyone cites to justify increased cost-sharing, and to justify shifting people from Medicaid to private plans with high deductibles.
But the results of the RAND study, like so much in health care, are complicated. A deeper dive into the data shows that people decreased their consumption of necessary health care in equal measure to unnecessary health care. As a rule, people are terrible discriminators of what care is needed and what’s not. Since most people under the age of 65 are healthy, even in the RAND study, that doesn’t matter much.
But even if most people are healthy, some are not (and particularly those on Medicaid). In the RAND study, poorer and sicker people — exactly the kind more likely to be on Medicaid — were slightly more likely to die with cost-sharing.
Free care also resulted in improvements in vision and blood pressure for those with low income. As an influential 1983 New England Journal of Medicine paper put it: “Free care does make a difference.”
One limitation of the RAND study is its age. It took place between 1971 and 1982. There have been no studies of cost-sharing to rival it since. Still, the best recent evidence we have is that giving free care to poorer and sicker people improves health and saves lives. It is reasonable to conclude that switching them to a plan with high cost-sharing (even a private plan) would do the opposite.
Some of the more recent studies were nicely summarized in a paper by Katherine Swartz for the Robert Wood Johnson Foundation’s Synthesis project. She found that increased cost-sharing for low-income populations was associated with a shift toward more costly services, like increased emergency room visits because people skipped taking their drugs. She also found that increased cost-sharing affects poor people differently than everyone else, confirming RAND’s findings. A more recent study found that enrollment in plans with high deductibles led to reductions in necessary care, which would have consequences for the poor and sick.
Austin wrote previously here how increased cost-sharing may lead people to take fewer drugs for their high cholesterol, hypertension and diabetes. In his first Upshot column, Aaron wrote that parents delay taking their children for asthma treatment when cost-sharing rises.
Even small premiums can lead to problems. A $10 increase in monthly Medicaid premiums was followed by a 6.7 percent reduction in Medicaid and coverage of CHIP (Children’s Health Insurance Program) for people just above the poverty line.
Unquestionably, private coverage can work very well for many people. Take us, for instance. The insurance that we each have from our employers is probably better for us than Medicaid would be. Though these plans come with cost-sharing, we have incomes that can handle it. Our plans cover things that Medicaid often does not, like dental checkups.
Our plans have great networks, and they reimburse well for the care we receive. Just like Medicaid enrollees, we also receive support from the federal government, which waives tax collections on dollars contributed to premiums. That tax break is higher than the cost of Medicaid in many cases.
We’re also relatively healthy and would probably be fine on any plan (unless and until our health deteriorates).
But because our plans require considerable cost-sharing, even Medicaid enrollees would struggle on them. More important, neither House nor Senate repeal and replace bills offer poor Medicaid enrollees plans as generous as ours.
The Senate’s health care plan, for example, would offer much less generous plans. A 64-year-old woman with an income of $11,400 would face a deductible of at least $6,000. For her, such a plan is not better than Medicaid; it is most likely much worse if she is also sick. Because of the deductible, the care she’d need would be financially out of reach.
A recent paper in Health Affairs documented that outcomes in Arkansas, which allowed poor people to buy private plans on the exchanges, were similar to those in Kentucky, which expanded access to poor people through Medicaid. But those private plans came with significant cost-sharing subsidies, which would be stripped away by the Senate’s bill. Even so, the evidence did not suggest that the private coverage of Arkansas was better than the public coverage of Kentucky.
There are certainly private plans for poor and sick Americans that are better than Medicaid. But plans with very high cost-sharing — which are the ones being offered in Congress as A.C.A. replacements — are not among them.
How the Rich Gain and the Poor Lose Under
the Senate Republican Health Care Plan
by Haeyoun Park and Margot Sanger-Katz - NYT - July 11, 2017
A family making more than $200,000 a year would gain $5,420 on average by 2026, while a family making less than $10,000 a year would lose $2,550 if the Senate Republican health care bill becomes law, according to a new analysis.
Average net change in federal tax and
health benefits in 2026 for a family earning:
The analysis, from the Urban Institute's Health Policy Center and the Urban-Brookings Tax Policy Center, looked at the combined impact of changes proposed under the draft Republican plan, including repealing Obamacare taxes, cutting Medicaid funding and changing the system of government subsidies for people who buy their own insurance.
The groups did an earlier analysis of the health care bill that passed the House in May.
Taxes would decrease for families earning $50,000 or more a year in 2026, when the law's provisions would be in full effect. Families with incomes above $1 million a year would pay about $50,000 less in taxes.
The cuts to Medicaid would hit the poorest families hard. Even though some would be able to take advantage of new subsidies to buy health insurance, the researchers found that, on average, their benefits would decline substantially. Those making less than $30,000 a year would take three-quarters of the total losses.
More than 80 percent of the tax cuts would go to families with incomes above $200,000 a year, and more than 58 percent would go to those making more than $1 million a year.
The Republican plan eliminates taxes that Obamacare imposed mostly on the rich, including taxes on investment income and wages above $200,000. (The money from cuts to other Obamacare taxes, including ones on medical devices, prescription drugs and indoor tanning, would go to the population more broadly.)
Senate leaders have said their bill may be revised in the coming days, and have said a vote may take place next week.
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