Health Care Reform Articles - December 15, 2018

We read Democrats’ 8 plans for universal health care. Here’s how they work.

by Sarah Cliff - VOX - December 13, 2018

Sure, Democrats are lining up behind Medicare-for-all. But what exactly does that mean? 

This year, dozens of Democratic candidates ran — and won — on a promise to fight to give all Americans access to government-run health care. A new Medicare-for-all Caucus in the House already has 77 members. All the likely 2020 Democratic nominees support the idea, too. 

“Medicare-for-all” has become a rallying cry on the left, but the term doesn’t capture the full scope of options Democrats are considering to insure all (or at least a lot more) Americans. Case in point: There are half a dozen proposals in Congress that envision very different health care systems. 

“Democrats ran on health care,” says Hawaii Sen. Brian Schatz. “We now control one chamber of Congress. We have an opportunity and an obligation to demonstrate what we’d do if we were in charge of both chambers. We have an obligation to hear from experts and figure out the best path forward.”

We spent the past month reading through the congressional plans to expand Medicare (and a few to expand Medicaid, too) as well as proposals at major think tanks that are influential in liberal policymaking. We talked to the legislators and congressional staff who wrote those plans, as well as the policy experts who have analyzed them. 

These plans are the universe of ideas that Democrats will draw from as they flesh out their vision for the future of American health care. While the party doesn’t agree on one plan now, they do have plenty of options to choose from — and many decisions to make. 

The eight plans fall into two categories. There are three that would eliminate private insurance and cover all Americans through the government. Then there are five that would allow all Americans to buy into government insurance (like Medicare or Medicaid) if they wanted to, or continue to buy private insurance. 

The bills we reviewed are:

We learned these plans are similar in that they envision more Americans enrolling in public health plans. They would all give the government a greater role in everything from setting health prices to deciding what benefits get included in an insurance plan. Experts say all these bills would almost certainly create an insurance system that does better to serve Americans with high health care costs.

“If you’re really sick and have high drug costs, it would be hard not to benefit from these bills,” says Karen Pollitz, a senior fellow at the Kaiser Family Foundation who recently co-authored a report comparing the different Democratic plans to expand public coverage.

But the Democrats’ plans differ significantly in how they handle important decisions, like which public health program to expand and how aggressively to extend the reach of government. Some would completely eliminate private health insurance, eventually moving all Americans to government-run coverage, whereas others still see a role for companies providing coverage to workers. 

Some bills require significant tax increases to pay for the expansion of benefits — while others ask those signing up for government insurance to pay the costs.

And while Democrats aren’t under any illusion that they’ll pass Medicare-for-all this Congress, they see the next two years as key to figuring out where consensus in the party lies. More plans are coming too: Jacob Hacker of Yale University, for example, has outlined the contours of a plan called Medicare Part E, and House legislation is in the works to flesh out the details.

“We want to have public hearings on this, we want to see movement on the issue,” says one Democratic House aide working on this legislation. “The Senate is still Republican but right now, Democrats have the opportunity to build support, have public hearings, and help move this idea along and educate members.”

Here are the key questions those hearings and that education will grapple with.

How many people get covered?

Bottom line: Some plans from the Democrats would cover all Americans — while others would provide insurance to more but leave some number of people uninsured.

In a way, this is the fundamental question. Even under the Affordable Care Act, 30 million Americans don’t have health insurance. The left believes health care is a human right, and mainstream Democrats aren’t far behind them. The whole reason Democrats are ready to take up health care reform again so soon after the ACA is to fix this problem. 

Medicare-for-all (Senate and House): Every single American would be covered by a government insurance plan, after a short phase-in period.

Medicare and Medicaid buy-ins (congressional plans): Millions more Americans would likely be covered, but experts don’t expect the various buy-in plans to achieve universal coverage. They would still, after all, be optional programs.

Medicare Extra for All (Center for American Progress): The health care plan from the leading Democratic think tank would achieve universal coverage for all legal residents, through a combination of private and public insurance — at least for the next few decades. It eventually foresees getting to a very similar level of coverage as the Medicare-for-all proposals in Congress, by enrolling all newborns into a government health plan and taking steps that would diminish the role of employer-sponsored coverage.

Healthy America (Urban Institute): This center-left plan is explicitly not a plan for universal coverage, by attempting to work within certain political constraints. But it would, according to Urban’s estimates, cut the number of uninsured by 16 million in its first year. 

A big part of the remaining uninsured would be undocumented immigrants. The plan’s authors said the program could be adjusted to cover that population but didn’t think there’d be political will to do so. 

What happens to employer-sponsored insurance?

Bottom line: Democrats are split over whether expanded Medicare should make space for employer-sponsored plans — or get rid of them completely. 

Nearly half of all Americans get their insurance at work — and Democrats’ various health care plans make different decisions about whether that would continue. 

Currently, the American health care system provides employers with a big incentive to provide coverage: Those benefits are completely tax-free. This means companies’ dollars stretch further when they buy workers’ health benefits than when they pay workers’ wages.

This, however, creates an uneven playing field. Fortune 500 companies get, in effect, a huge federal subsidy to insure their workers, while an individual who doesn’t get coverage through their job and makes too much money to receive subsidies under the Affordable Care Act doesn’t get any advantageous treatment under the tax code.

Medicare-for-all (Senate and House): Both the Medicare-for-all plans would make the biggest change and eliminate employer-sponsored coverage completely. Under these options, all Americans who currently get insurance at work would transition to one big government health care plan. 

Medicare/Medicaid buy-ins

The question of work-based insurance is prickliest for the Medicare buy-in plans. Broadly speaking, under those bills, more Americans would be allowed to purchase a public insurance plan under the Medicare umbrella. Everybody who currently buys insurance on the individual market would be allowed to buy a Medicare plan, under each of the buy-in bills.

But they differ in important ways in how much they would let people leave their current job-based insurance for the new government plan.

The “Choose Medicare” Act (Merkley and Murphy): Merkley described his bill with Murphy as, potentially, a glide path to true single-payer Medicare-for-all. Under their Medicare buy-in framework, workers could leave their company’s insurance for the new public plan — but only if their employer decides to allow it. Otherwise, they’d be shut out.

(The bill does include a provision, however, allowing workers to keep the government plan once they sign up, even after they leave their current job.)

We asked Merkley why they left the decision up to the employers, not the employees. He pointed to a workers’ compensation program that had been successful in Oregon that was modeled the same way. He’s also worried about adverse selection (employers sending sick employees to the public plan while healthier workplaces stay in the private market). 

Lastly, he emphasized the workers who transition to new jobs or go for a period without coverage would have a chance to sign up for Medicare and then keep that plan even after they get a new job.

“Workers can go to their employer and say, ‘I really would prefer to be in the public option,’” Merkley says. “We wanted to avoid the situation of employers pushing people out.”

The CHOICE Act (Schakowsky and Whitehouse): Small employers who are currently eligible to buy insurance through the ACA’s marketplaces would be allowed to participate in the Medicare buy-in. Workers at larger firms would be frozen out, however.

Medicare X (Bennet, Kaine and Higgins): Likewise, small employers eligible for ACA coverage could buy into Medicare under this legislation, but large employers could not. Medicare X would actually be limited to customers in Obamacare markets that had only one insurer or particularly high costs, for the program’s first few years, before expanding to the rest of the individual market nationwide.

Think tank plans

Medicare Extra for All (Center for American Progress): This plan does let employers continue to offer coverage to their workers so long as it meets certain federal standards. At the same time, it would give employers an alluring, simpler option: stop offering coverage and instead pay a payroll tax roughly equivalent to what they currently spend on health coverage.

As to how alluring that plan would be, that depends a lot on how generous this new Medicare Extra program is. A generous plan with low premiums would likely lure many away from their employer-sponsored coverage, whereas a skimpier plan with higher premiums could convince workers to stick with what they already have. These are policy details that aren’t currently specified in the CAP plan. 

What’s more, Medicare Extra makes another policy decision that would erode employer-sponsored coverage: It automatically enrolls all newborns into the public program. That means a new generation of Americans likely won’t get coverage through their parents’ workplaces — and would assure the Medicare plan a constantly growing subscriber base.

Healthy America (Urban Institute): The Urban Institute explicitly designed its Healthy America plan with the goal of disrupting the large employer market as little as possible. They expect only lower-wage workers whose current insurance isn’t very good anyway to move over into the brand new insurance marketplaces that would be set up under their plan. 

Those markets would combine the Medicaid population with the people currently covered by Obamacare but more or less leave people who get insurance through their jobs alone.

“That’s a real barrier to doing anything big,” John Holahan at Urban said. “Most people with employer plans are reasonably happy with them.”

What public program will expand?

Bottom line: The vast majority of proposals expand Medicare, the plan that covers Americans over 65. But there is one option that would expand Medicaid, the plan that covers low-income Americans — and another option that creates a new government program entirely.

The American government already finances two major health coverage plans: Medicare and Medicaid. Taken together, these two programs cover one-third of all Americans: 19 percent of Americans get their coverage from Medicare, and 14 percent from Medicaid.

What’s more, both of these programs are popular. One recent poll found that 77 percent of Americans think Medicare is a “very important” program. Voters have recently given a boost to Medicaid, too: Voters in Idaho, Nebraska, and Utah all passed ballot initiatives that will expand the program in their states to thousands of low-income Americans.

Given the popularity and size of Medicare and Medicaid, nearly all the Democrats’ proposals use these programs as a base for universal coverage, changing the rules to make more people eligible. But there are differences in which programs they pick, and one plan that starts a new government program entirely. 

Medicare-for-all, Medicare buy-in, Medicare Extra for All: As their names imply, all these plans use Medicare as the base program for expanding health insurance coverage. Medicare is, after all, the only major health program run exclusively by the federal government (Medicaid is run jointly with the states), which can make it an appealing choice for a national coverage expansion.

Traditionally, Democrats have focused on Medicare as a base for expanding coverage. And five of the six legislative proposals we looked at use the program that covers the elderly as the one that would absorb additional enrollees.

Medicaid buy-in (Senate and House bills): Recently, Democrats have begun to eye Medicaid as another option, suggesting that we should focus on expanding the health plan that covers the poor to Americans with higher incomes.

Sen. Brian Schatz (D-HI), for example, has offered a bill that would allow every state to let residents buy into Medicaid. A companion bill is offered by Rep. Ben Ray Lujan (D-NM) in the House. 

This plan wouldn’t mean moving all Americans into Medicaid — instead, it would give people the option to sign up for the public program, which would presumably offer lower premiums because it would pay doctors and hospitals lower reimbursement rates than private plans typically do. 

In an interview with Vox, Schatz said he likes the idea of this Medicaid buy-in because the program has proved popular across the political spectrum. In the 2018 midterms, for example, three red states (Idaho, Nebraska, and Utah) voted to participate in Obamacare’s Medicaid expansion. “Medicaid is popular in blue, red, and purple states,” he says. “It’s not politically fraught anymore. So it’s a good place to land for progressives who want to make progress for everyone.”

Healthy America (Urban Institute): Rather than rely on any existing program, Healthy America would create a new one. Obamacare and Medicaid would effectively be combined into a brand new insurance market covering upward of 100 million people, and there would be a public insurance plan under the Healthy America brand.

What benefits get covered?

Bottom line: Democrats generally agree that health insurance should cover a wide array of benefits, although there is some variation around how different plans cover long-term care, dental, vision, and abortion.

Every country with a national health care system has to decide what type of medical services it will pay for. Hospital trips and doctor visits are almost certainly included. But there is wide variation on how health care systems cover things like vision, dental, and mental health.

Covering more services mean citizens have more robust access to health care. But that also costs money — and a more generous health care plan is going to require more tax revenue to pay for all that health care. 

Even Medicare, as it currently stands, has a relatively limited benefit package. It does not cover prescription drugs, for example, nor does it pay for eyeglasses or long-term care. 

Instead, many seniors often take out supplemental policies to pay for those services — or end up selling off their assets to pay for care in a nursing home. 

Medicare-for-all (Senate and House) 

Both single-payer options envision Medicare covering more benefits than it currently does. The Sanders bill, for example, would change Medicare to cover vision, dental, and prescription drugs, as well as long-term care services as nursing homes. It would also cover a wide breadth of women’s reproductive health services including abortion, a feature that would likely draw controversy.

The House bill covers a slightly different set of benefits but, according to one Democratic House aide, is undergoing revisions to look more similar to the Sanders package. “We want to make sure we’re able to align the coverage services [of our bill] with the Sanders plan,” said the aide, who asked to speak anonymously to discuss the ongoing negotiations.

Medicare/Medicaid buy-ins

All three notable Medicare buy-in plans would cover the 10 essential health benefits mandated by Obamacare: outpatient care, emergency services, hospitalization, maternity and newborn care, mental health and substance abuse services, and prescription drugs. None of them include vision or dental care.

The “Choose Medicare” Act (Merkley and Murphy): This bill covers essential health benefits, as well as the benefits included in Medicare’s current inpatient, outpatient, and prescription drug plans. Abortion and other reproductive services would also be covered.

The CHOICE Act (Schakowsky and Whitehouse): The ACA’s essential health benefits would be covered.

Medicare X (Bennet, Kaine and Higgins): Same. The new public plan would cover the essential health benefits dictated by the 2010 health care reform law.

“The policy would have all the ACA benefits. We’d give HHS the time and seed money to figure this out and price it,” Sen. Tim Kaine (D-VA) told Vox previously. “There are studies, back from 2010, that suggest a public option would not only save money but it would make the markets more competitive.”

Think tank plans

Medicare Extra for All (Center for American Progress): The Medicare Extra plan mandates that all health insurance cover a robust set of benefits including prescription drugs, hospital visits, doctor trips, maternity services, dental, vision, and hearing services.

Healthy America (Urban Institute): The benefits package is again based on Obamacare’s essential health benefits.

How much does it cost enrollees?

Bottom line: Democrats do not agree on whether patients should pay premiums or fees when they go to the doctor. Some plans get rid of all cost sharing, while others (largely those that allow employer-sponsored coverage to continue) keep those features of the current system intact. 

Medicare is currently similar to private health insurance in that it expects enrollees to pay a significant share of their medical costs.

The public program, for example, currently charges seniors a $134 monthly premium (and a higher premium for wealthier enrollees). Traditional Medicare also has deductibles and co-insurance. An estimated 80 percent of Medicare enrollees have additional coverage to help cover those costs.

The plans offered by Democrats have really different visions for whether enrollees in a newly expanded Medicare would end up paying these kinds of costs — or if premiums, deductibles, and copayments would become a thing of the past. 

Medicare-for-all (Senate and House)

Both Medicare-for-all bills would eliminate cost sharing completely. This means no monthly premiums, no copayments for going to the doctor, and no deductible to meet before coverage kicks in.

The only place where enrollees might pay out of pocket is under the Sanders plan, which does give the government discretion to allow some charges for prescription drugs — but even that would be capped at $200 per year.

This is very similar to how the Canadian health care system works but is actually quite different from European countries. Most countries across the Atlantic actually do require patients to pay something for going to the doctor. In France, for example, patients are expected to pay 30 percent of the cost of their doctor visit — and in the Netherlands, copayments range from $10 to $30.

In a previous interview with Vox, Sanders said he considered copayments for his proposal but “the logic comes down on the way of what the Canadians are doing.”

The senator who rails regularly against “millionaires and billionaires” doesn’t see value in asking those people to pay when they show up at the doctor. They’ll pay more in taxes to finance a system without copayments, but when they go to the doctor, he argues, they ought to be treated the same as the poor.

Medicare/Medicaid buy-ins

There is one important common thread through these bills: Premiums would be set to cover 100 percent of the actual medical costs that the government plan expects to cover, as well as any administrative expenses — but nothing more. There would not be any profits or robust executive compensation, as there still is in the private market. Premiums could be adjusted by a limited number of factors: a patient’s age, where they live, the size of their family, and whether they smoke tobacco.

The most notable difference in the buy-in proposal is in how much patients would be expected to pay out of pocket.

The “Choose Medicare” Act (Merkley and Murphy): This is the most generous Medicare buy-in plan. The new government plan would cover 80 percent of health care costs, matching the “gold” plans on the ACA marketplaces. The bill would also add new out-of-pocket caps for the traditional Medicare population, people 65 and older.

The CHOICE Act (Schakowsky and Whitehouse): This bill would offer several versions of the public plan, with varying out-of-pocket costs: They would cover between 60 and 80 percent of expected medical expenses.

Medicare X (Bennet, Kaine and Higgins): By default, the government plan would be offered at two tiers: one that covers 70 percent of medical costs and another that covers 80 percent. The health secretary could also decide to offer health plans covering 60 percent of costs or 90 percent, but it is not required.

Medicaid buy-in (Sen. Schatz and Rep. Lujan): The Schatz proposal would give the states leeway to decide how they want to set premiums, copayments, and deductibles. They would cap premiums at 9.5 percent of a family’s income (a provision that already exists for those covered under Affordable Care Act plans) or the per-enrollee cost of Medicaid buy-in, whichever is less.

Think tank plans

Medicare Extra for All (Center for American Progress): The plan from the center-left think tank would, unlike the congressional Medicare-for-all options, continue having some Americans pay premiums tethered to their incomes. This reduces the tax revenue necessary to finance an expanded Medicare program — but also requires a slightly more complex system that can calculate each family’s premium and collect that payment.

Low-income Americans would be enrolled in Medicare without any premiums. Higher-income Americans would be expected to pay a monthly premium (at most, 10 percent of their income) — and pay deductibles and copayments (the exact amount of these is not set in the CAP plan).

Healthy America (Urban Institute): Premiums would range from 0 percent of a household’s income, for people who make less money, up to 8.5 percent. Nobody would be asked to pay more than that.

The standard health insurance plan under Healthy America would cover 80 percent of medical costs. People with lower incomes would receive additional subsidies to reduce their out-of-pocket obligations, while consumers would also have the option to buy a plan with higher out-of-pocket costs but lower monthly premiums.

How is it paid for?

Bottom line: Most Democrats have focused their energy on figuring out what exactly an expanded Medicare program looks like. Legislators have given significantly less attention to how to pay for these expansions.

Bringing government health care to more Americans usually means finding more government revenue to pay for that expanded coverage. The Affordable Care Act, for example, expanded coverage to millions of people through a wide range of taxes that hit health insurers, medical device manufacturers, hospitals, wealthy Americans, and even tanning salons.

Right now, many of the details around financing remain murky. One reason for that is we don’t actually know how much these different plans would cost; the Congressional Budget Office hasn’t scored any of these plans yet (although there are a few independent estimates of how much the Sanders plan would cost). 

Medicare-for-all

Senate: Sanders’s office has released a list of financing options that generally impose higher taxes on the wealthiest Americans, such as increased income and estate taxes, establishing a new wealth tax on the top 0.1 percent, and imposing new fees on large banks. 

House: Over on the House side, aides say that while they are currently working on revisions to HR 676, that focuses mostly on updating the benefits package — and less on deciding how to pay for the package. They do not currently expect to release a financing plan in early 2019.

“Let’s get our policy straight first and then look for suggestions on financing,” says one Democratic House aide involved in the process. “It’s possible we might offer some ideas on financing, but that’s still under debate.”

Medicare/Medicaid buy-ins

Depending on how you look at it, financing is either one big advantage of the buy-in approach or it reveals the flaw in their design. These plans still charge people premiums, which would be calculated to cover the costs of covering people who buy the new public option plan as well as any administrative costs.

So there isn’t necessarily a need for a big new revenue source; the premiums are the revenue source. None of the Medicare buy-in plans included major new taxes or anything like you would see to pay for the Medicare-for-all single-payer plans. All three of them do set aside some money for startup costs, but it’s a marginal amount in the context of the federal budget. And the Medicaid buy-in plan does bump up certain doctor payment rates, which the legislators say would come from general revenue. 

The differences are so minor, they aren’t worth going through in detail. But it’s important to remember the trade-off: Medicare and Medicaid buy-ins don’t require a lot of new money because people will be asked to pay premiums — but that also means people will be asked to pay premiums, something the more ambitious versions of Medicare-for-all try to eliminate.

Think tank plans

Medicare Extra for All (Center for American Progress): Like the Sanders plan, Medicare Extra for All offers a menu of possible financing options that target the wealthy. Beyond that, Medicare Extra for All suggests one unique funding source: taxes on cigarettes and sugary beverages, as a way to raise revenue and improve public health outcomes.

Healthy America (Urban Institute): Because Healthy America combines Obamacare and most of Medicaid, the proposal is largely funded by repurposing the federal dollars that currently go to those programs. That would cover the bulk of the costs, but Urban does anticipate the need for new federal funding.

Like many of its peers, Urban isn’t yet set on a specific revenue stream, but it has floated a 1 percent increase on the Medicare payroll tax, split evenly between employers and employees. That would bring in about $820 billion over 10 years, which Urban thinks would be enough to cover most of the new costs needed to fund Healthy America

https://www.vox.com/2018/12/13/18103087/democrats-universal-health-care-sanders-jayapal

Importance of Aligning House and Senate Single-Payer Bills the Right Way

Aligning House And Senate Single-Payer Bills: Removing Medicare's Profiteering Incentives Is Key

By Steffie Woolhandler and David Himmelstein - Health Affairs Blog - November 19, 2018

Single-payer reform is in the news — and in the U.S. House and Senate. One hundred twenty-three Congresspeople have signed on as co-sponsors of H.R. 676, the single-payer legislation in House of Representatives, and 16 Senators have formally endorsed S.1804, the Senate version. (Disclosure: H.R. 676 was closely modeled on the Physicians for a National Health Program reform proposal published in JAMA, for which we served as lead authors).

While both bills would cover all Americans under a single, tax-funded insurance program, they prescribe different provider payment strategies. The Senate version largely adopts Medicare’s current payment mechanisms; the House bill’s is modeled on Canada’s single-payer program, also called “Medicare,” which pays hospitals global budgets (much as a fire department is paid in the U.S.) and sharply constrains opportunities for investor-owned care.

These differences haven’t attracted much attention from politicians or the press, and few patients are aware of, or deeply concerned about them. That’s not surprising, since both bills address the lay public’s most pressing payment-related concern: they would drastically shrink (S.1804) or completely eliminate (H.R. 676) out-of-pocket payments for needed care.

But these divergent payment strategies would create very different financial incentives for providers, shaping the culture of medicine and the financial viability of a single-payer reform. The Senate version would, like Medicare, pay hospitals and other institutional providers on a per-patient basis, intermixing payments for current operating expenses with funding for future capital investments and profits. As at present, hospitals’ success, and even survival, would depend on generating profits (“surpluses” in non-profit facilities). Hospitals with a favorable bottom line could invest and add new buildings and programs, while unprofitable ones couldn’t modernize or expand, risking a downward spiral toward takeover or closure.

It’s this profit imperative that drives hospitals’ financial gaming, e.g. upcoding, and concentration on the most lucrative services, such as elective cardiac and orthopedic services, rather than money losers like mental health. This payment mechanism (and S.1804 as a whole) also leaves the door open to investor-owned providers.

In contrast, the House bill would abolish per-patient billing by hospitals and other institutions, and its global budget payments would cover only operating costs; hospitals would be prohibited from retaining surpluses, and capital investments would be funded through separate government grants. The bill would also explicitly proscribe payments to investor-owned facilities, and it calls for their conversion to non-profit status financed by issuing bonds.

Implications For The Financial Viability Of Reform

Expanding and improving coverage, as both S.1804 and H.R. 676 would do, is expected to increase care utilization and hence clinical costs. Yet most analysts foresee savings on billing and administration (as well as on prescription drugs prices) that would offset these increases. Both bills would replace the current welter of private plans—with average overhead of about 12 percent of premiums—with a single public insurer whose overhead would likely be similar to the traditional Medicare program’s 2 percent, or the 1.6 percent in Canadian Medicare (National Health Expenditure Trends, 1975 to 2017: Data Tables — Series A).

But insurance overhead accounts for only 44 percent of the administrative savings that could be realized under a single-payer program; the rest comes from streamlining providers’ administrative work. For instance, U.S. hospitals’ administrative costs average 25.3 percent of their total revenues, versus only 12 percent in single-payer systems like Canada’s and Scotland’s that pay global operating budgets and minimize rewards for financial gaming.

Medicare’s payment approach requires hospitals to bill for and justify each hospitalization, a requirement that persists in value-based payment schemes like ACOs and would continue under S.1804. Hence, hospitals would have to maintain much of their current wasteful billing, documentation, and internal cost-tracking systems. Retaining the profit imperative would also continue to reward hospitals for financial gaming and tailoring services to profitability, driving up both administrative costs and wasteful spending on low-value care.

Instead of bundled payment arrangements tied to individual patients, the House version would substitute an institution-wide bundled payment, i.e., a global budget covering all operating costs. As noted above, that approach has streamlined hospital administration in other nations, which have been more effective than the United States at restraining overall costs. In contrast, ACOs have increased providers’ administrative costs by about $200 per patient annually, and have generated trivial or no savings after accounting for Medicare’s “shared savings” bonus payments. Similarly, Medicare’s (and other payers’) pay-for-performance initiatives impose substantial administrative costs on providers, with no evidence that they’ve improved patients’ outcomes in any setting.

In sum, the financial viability of a single-payer reform turns on cutting administrative costs and minimizing incentives for financial gaming. Maintaining Medicare’s current payment strategies, as under S.1804, would be substantially costlier than adopting the non-profit global-budgeting strategy used in several other nations.

Implications For Medical Culture

Differences in payment strategies also have implications for the work lives of doctors and other clinical personnel. Medicare’s turn to ACOs effectively forces providers to become insurers who bear the risk of their patients’ medical expenses, even those incurred in other venues. This strategy virtually banished small independent providers, triggering a wave of mergers and acquisitions. Community hospitals have been gobbled up, and a rapidly growing share of doctors have become employees.

The profit imperative imposed on hospitals and physician practices by Medicare’s payment incentives filters down to doctors. It manifests as morale-sapping productivity pressures; redundant documentation requirements; time wasted on mandatory upcoding classes; and the sense that clinical priorities have become subservient to financial ones. The length of doctors’ notes in EPIC’s electronic health record—larded with clinically useless templated and copied material, and four times as long in the U.S. as in other nations—gives one indication of how payment rules translate into burnout.

The Senate’s version risks maintaining these ACO-driven incentives, and even risks the reemergence of private insurance under the guise of vertically integrated, risk-bearing corporate ACOs.

The Future Of Investor-Owned Care

The House single-payer bill envisions a buyout of the investor-owned facilities needed to provide care under the single-payer system, while the Senate version would leave them in current hands.

Proponents of the House approach acknowledge that many non-profit health care organizations have drifted far from their charitable roots. However, they cite evidence that for-profit providers (including hospitals, dialysis centers, nursing homes, home care agencies, and hospices) provide inferior care at inflated prices (see, for instance here, here, here, here and here – use URL below to access live hyperlinks) and are more likely to bend care to profitability (see here, here, here and here). For-profit hospitals spend less on nurses and other clinical aspects of care, but more on administration and financial management; for-profit chains have often been cited for questionable business practices and have been repeatedly implicated in large scale fraud (see here, here, here and here).

According to CMS, for-profit nursing homes are cited for quality deficiencies 28 percent more often than non-profits, and for deficiencies that place residents in immediate jeopardy 53 percent more frequently. Investor-owned home care agencies cost Medicare $752 more per patient than non-profit agencies, while providing worse care.

Yet even some who would prefer to exclude investor-owned facilities from a single-payer system worry about the cost of a buyout. In conversations with Congressional aides, some have suggested that these costs could amount to $1 trillion or more, although none could cite a source for that figure. While it’s not clear exactly how to value the assets of investor-owned medical facilities, estimates of their current capital assets and of their stock market valuations provide some guidance.

In the detailed cost reports filed with Medicare covering fiscal year 2016 (the most recent year for which virtually all reports are available), all for-profit hospitals taken together reported total capital assets of $97.845 billion at the start of the year, and additional purchases totaling $7.453 billion (Himmelstein & Woolhandler, unpublished analysis of hospital cost reports). So the total capital stock of all for-profit hospitals – including not just acute care hospitals, but most other inpatient facilities besides stand-alone nursing homes – totaled $105.298 billion. (The comparable figure for non-profits is $718.628 billion).

Since most investor-owned providers also carry debt, it’s not surprising that the capital asset figures are considerably higher than the stock market value of the firms that own the facilities. As indicated in Exhibit 1 (use URL below to access exhibit), the market valuation of the five publicly-traded firms that account for the vast majority of for-profit hospitals totals $50.071 billion. While data on the market value of the (smaller) privately held for-profit hospital chains is not available, the value of the larger chains, and past sale prices for three of the privately-held firms, suggests that they’d add only several billion to the total.

Similarly, as Exhibit 1 shows, the total value of shares in publicly traded nursing home firms, rehab, dialysis, and home care and hospice providers is relatively modest: less than $50 billion. And these valuations (which fluctuate from day-to-day) include aspects of the businesses that would not be included in a buyout, e.g. the value of real estate devoted to senior living communities, or the roughly 15 percent of DaVita’s business that’s unrelated to dialysis and the 20 percent of Fresenius’ revenues attributable to sales of products such as dialysis supplies.

Overall, the fair market value of investor-owned facilities covered by a buyout, whether assessed by capital stock or stock prices, seems unlikely to exceed $150 billion. Purchasing these assets using Treasury Bill financing over 15 years at the current interest rate of 3 percent would cost about $12.75 billion annually, equivalent to about 1 percent of annual hospital costs. Moreover, even in the short term, some or all of these costs would be offset by savings on profits, which totaled more than $6 billion in 2017 for just three of these firms (HCA, DaVita and Fresenius).

Bottom line: A buyout of investor-owned facilities is affordable. Indeed, it might well lower costs.

Looking Forward

In the short run, the divergence between the House and Senate versions of single-payer reform is of little consequence. No bill will be enacted under the current administration. Yet with support for single payer blossoming among Democratic leaders and the public, the prospect of legislative action is increasing, and with it the push for convergence. Indeed, Pramila Jayapal, the leader of the House Single-Payer Caucus, has indicated her intent to move the two bills closer together.

In aligning the bills, House members should, in our view, adopt some aspects of the Senate’s bill, notably its repeal of the Hyde Amendment that forbids using federal funds for abortion, as well as its greater specificity. But Senators should adopt the House bill’s payment strategies and commitment to non-profit ownership of health care providers.

http://pnhp.org/news/importance-of-aligning-house-and-senate-single-payer-bills-the-right-way/

If you want Medicare-for-all, prepare for a long and bloody fight

by Paul Waldman - The Washington Post - December 12, 2018

Over the last two years, the idea of government-guaranteed universal health coverage, often shorthanded as Medicare-for-all (I’ll refer to it as M4A from here) has grown from a minority belief within the Democratic Party to a majority belief, and one that is on its way to becoming consensus. We are now entering a period of debate within the party about what universal coverage should look like and how to transition from the system we have now to the system we want.

This is an extremely complicated policy challenge, but it’s an even more difficult political challenge. And to be honest, I worry that many of the M4A advocates — whose basic principles I share — may not fully appreciate what they’re going to be up against.

Let’s look at this report from Politico’s Adam Cancryn on the forces gearing up to prevent M4A from ever happening, many of which were also staunchly opposed to the Republican effort to repeal the Affordable Care Act:

More than a dozen groups intend to press their point next year through The Partnership for America’s Health Care Future, a vehicle to combat an expanded government role in health care.

America’s Health Insurance Plans and the BlueCross BlueShield Association helped found the coalition alongside the Federation of American Hospitals, the big drug lobby PhRMA and the American Medical Association.

Since then, it’s added another 13 organizations — most representing companies with much to lose under a system that shrinks or in some cases eliminates private health care. [. . .]

The Partnership, some of whose members began discussions within weeks of Senate Republicans’ failed Obamacare repeal vote in July 2017, is planning to launch a campaign featuring ads, polling and white papers playing up the private sector’s role and warning against further disruptions to the health system, people involved with the group said. Avalere, a consulting firm Democrats often leaned on to highlight the dangers of GOP repeal bills, is producing research for the coalition.

That’s the tip of the iceberg. It doesn’t mean universal coverage shouldn’t be a critical goal, but it does mean that it’s going to be a struggle, and advocates need a plan to overcome the opposition from people with almost limitless resources and an intense interest in making sure M4A never comes to pass.

It is difficult to formulate such a plan at this stage because the internal policy debate is still ongoing. There are some on the left who say they will settle for nothing less than a full single-payer system with no role at all for private insurers. (Many of those people have a habit of lashing out at anyone who deviates even slightly from this vision as a neo-liberal shill and corporate sellout, but the people who do that are often those with the least understanding of the complexities of this issue.) Others are devising plans that retain some role for private insurers but boost the government’s role as a guarantor of coverage (here’s an example). My own preference is for a hybrid system like they have in France, where there is a basic universal system that covers everyone, and then people are free to buy additional private supplemental insurance to get more comprehensive benefits.

But Medicare-for-all is easy to understand, and benefits from the fact that so many people love Medicare. That branding will likely stick to whatever Democrats settle on, for better or worse. But no matter what we wind up calling it, the opposition is going to be fierce. And there a few things we need to understand about what will happen if there’s a time when a Democratic president and a Democrat-controlled Congress actually try to accomplish universal coverage.

Obviously, the opposition will be far, far better funded than the supporters are, simply because the ones who stand to benefit will be the public at large, while the ones who stand to lose will be a bunch of highly profitable industries. President Barack Obama managed to co-opt many of these opponents in 2009 and 2010 (though the cooperation was always tenuous), which helped make it possible to pass the ACA. But if we’re talking about M4A, there will be no co-opting. Insurers, doctors, pharmaceutical companies — they’re going to fight against it.

Some of the arguments they make will be legitimate, and some won’t. But the public will find it impossible to distinguish between the two when it is faced with a torrent of propaganda, all aided by the Republican Party. Last time we had “death panels”; who knows what we’ll have next time.

And supporters will be fighting against powerful status quo bias, no matter how many people tell pollsters right now that M4A sounds like a great idea. Consider what happened in November: A good deal of the success Democrats had in last month’s elections came because of the health care issue, but it was narrowly focused, in many cases on the single issue of preexisting conditions. But Democrats had the benefit of arguing against change — people have protections now, and Republicans wanted to take them away.

Arguing for change, especially radical change, is always more difficult. Even if people are unhappy with the status quo, they will be receptive to the argument that change will make things worse and cause them to lose what they do have.

I wish I had a magical solution to these political problems. But the first step is understanding that actually passing a universal system will take a huge amount of work, extremely friendly historical circumstances, and no small measure of luck. It will take years at least, and success is anything but assured. The fact that it’s right and necessary, or that the current system is still a nightmare in so many ways, doesn’t make it inevitable. No one should delude themselves into thinking otherwise.

http://healthoverprofit.org/2018/12/12/if-you-want-medicare-for-all-prepare-for-a-long-and-bloody-fight/

The impossibility of bipartisan health-care compromise

by Ryan Cooper - The Week - December 12, 2018

If there's one thing political centrists claim to value, it's compromise. It's "the way Washington is supposed to work," writes Third Way's Bill Schneider. "Centrists, or moderates, are really people who are willing to compromise," The Moderate Voice's Robert Levine tells Vice.

What does this mean when it comes to health care and the developing lefty push for Medicare-for-all? The fresh new centrist health-care organization, the Partnership for America's Health Care Future (PAHCF), says it is a "diverse, patient-focused coalition committed to pragmatic solutions to strengthen our nation's health-care system." In keeping with the moderate #brand, PAHCF may not support Medicare-for-all. But perhaps they might support a quarter-measure compromise, like allowing people under 65 to buy into Medicare?

Haha, of course not. Their offer is this: nothing.

Valuing compromise in itself in politics is actually a rather strange notion. It would make a lot more sense to determine the optimal policy structure through some kind of moral reasoning, and then work to obtain an outcome as close as possible to that. Compromise is necessary because of the anachronistic (and visibly malfunctioning) American constitutional system, but it is only goodinsofar as it avoids a breakdown of democratic functioning that would be even worse.

However, "moderation" is routinely not even that, but instead a cynical veneer over raw privilege and self-interest. The American health-care system, as I have written on many occasions, is a titanic maelstrom of waste, fraud, and outright predation — ripping off the American people to the tune of $1 trillion annually.

And so, Adam Cancryn reports on the centrist Democrats plotting with Big Medical to strangle the Medicare-for-all effort:

Deep-pocketed hospital, insurance, and other lobbies are plotting to crush progressives' hopes of expanding the government's role in health care once they take control of the House. The private-sector interests, backed in some cases by key Obama administration and Hillary Clinton campaign alumni, are now focused on beating back another prospective health-care overhaul, including plans that would allow people under 65 to buy into Medicare. [Politico]

Behind the preposterously named "PAHCF" stands a huge complex of institutions that benefit from the wretched status quo. This includes the PhRMA drug lobby (Americans spend twice what comparable countries do on drugs, almost entirely because of price-gouging), the Federation of American Hospitals (Americans overpay on almost every medical procedure by roughly 2- to 10-fold), the American Medical Association (U.S. doctors, especially specialists, make far more than in comparable nations), America's Health Insurance Plans, and BlueCross BlueShield (the cost of average employer-provided insurance for a family of four has increased by almost $5,000 since 2014, to $28,166).

The human carnage inflicted by this bloody quagmire of corruption and waste is nigh unimaginable. Perhaps 30,000 people die annually from lack of insurance, and 250,000 annually from medical error. America is a country where insurance can cost $24,000 before it covers anything, where doctors can conspire to attend each other's surgeries so they can send pointless six-figure balance bills, where hospitals can charge the uninsured 10 times the actual cost of care, where gangster drug companies can buy up old patents and jack up the price by 57,500 percent, and on and on.

One might think this is all a bit risky. Wouldn't it be more prudent to accept some sensible reforms, so these institutions don't get completely driven out of business?

But wealthy elites almost never behave this way. John Kenneth Galbraith, explaining the French Revolution, once outlined one of the firmer rules of history: "People of privilege almost always prefer to risk total destruction rather than surrender any part of their privileges." One reason is "the invariable feeling that privilege, however egregious, is a basic right. The sensitivity of the poor to injustice is a small thing as compared with that of the rich."

And so we see with the Big Medical lobby. The vast ziggurat of corpses piled up every year from horrific health-care dysfunction is just a minor side issue compared to the similar-sized piles of profits these companies accumulate — which they will fight like crazed badgers to preserve.

As Paul Waldman points out, this means a big resistance to the prospect of doing anything at all, let alone Medicare-for-all. However, the political implication is clear. If compromise is impossible, then liberals and leftists who want to improve the quality and justice of American health care should write off the corrupt pseudo-centrists, and go for broke. Democrats should write a health-care reform bill so aggressive that it drastically weakens the profitability of Big Medical, and drives many of them out of business entirely. If you cannot join them, beat them.

https://theweek.com/articles/811962/impossibility-bipartisan-healthcare-compromise

Editor's Note:

The following hot-link is to a video of a discussion of the economic study of the Bernie Sanders "Medicare-for-All" legislation, now pending in the US Senate. It is well worth taking the time to watch. It answers a lot of questions about the economic feasibility of the Sanders approach. 

https://www.facebook.com/sandersinstitute/videos/1263137220491181/

-SPC

Texas Judge Strikes Down Obama’s Affordable Care Act as Unconstitutional

by Abby Goodnough and Robert Pear - NYT - December 15, 2018

WASHINGTON — A federal judge in Texas struck down the entire Affordable Care Act on Friday on the grounds that its mandate requiring people to buy health insurance is unconstitutional and the rest of the law cannot stand without it.

The ruling was over a lawsuit filed this year by a group of Republican governors and state attorneys general. A group of intervening states led by Democrats promised to appeal the decision, which will most likely not have any immediate effect. But it will almost certainly make its way to the Supreme Court, threatening the survival of the landmark health law and, with it, health coverage for millions of Americans, protections for people with pre-existing conditions and much more.

In his ruling, Judge Reed O’Connor of the Federal District Court in Fort Worth said that the individual mandate requiring people to have health insurance “can no longer be sustained as an exercise of Congress’s tax power.”

Accordingly, Judge O’Connor, a George W. Bush appointee, said that “the individual mandate is unconstitutional” and the remaining provisions of the Affordable Care Act are invalid.

At issue was whether the health law’s insurance mandate still compelled people to buy coverage after Congress reduced the penalty to zero dollars as part of the tax overhaul that President Trump signed last December.

When the Supreme Court upheld the mandate as constitutional in 2012, it was based on Congress’s taxing power. Congress, the court said, could legally impose a tax penalty on people who do not have health insurance.

But in the new case, the 20 plaintiff states, led by Texas, argued that with the penalty zeroed out, the individual mandate had become unconstitutional — and that the rest of the law could not be severed from it.

The Justice Department’s response to the case was highly unusual: though it disagreed with the plaintiffs that the entire law should be struck down, it declined this year to defend not just the individual mandate, but the law’s provisions that protect people with pre-existing conditions. That prompted a coalition of 16 states and the District of Columbia, led by California, to intervene and defend the law.

On Friday night, a spokeswoman for Xavier Becerra, the California attorney general, said California and the other defendant states would challenge the ruling with an appeal in the United States Court of Appeals for the Fifth Circuit in New Orleans.

“Today’s ruling is an assault on 133 million Americans with pre-existing conditions, on the 20 million Americans who rely on the A.C.A.’s consumer protections for health care, on America’s faithful progress toward affordable health care for all Americans,” Mr. Becerra said in a statement. “The A.C.A. has already survived more than 70 unsuccessful repeal attempts and withstood scrutiny in the Supreme Court.”

Attorney General Ken Paxton of Texas, who initiated the lawsuit, applauded the decision, saying in a statement, “Today’s ruling enjoining Obamacare halts an unconstitutional exertion of federal power over the American health care system.”

He added, “Our lawsuit seeks to effectively repeal Obamacare, which will give President Trump and Congress the opportunity to replace the failed social experiment with a plan that ensures Texans and all Americans will again have greater choice about what health coverage they need and who will be their doctor.”

Mr. Trump, who has consistently sought the law’s repeal and has weakened it through regulatory changes, posted a response to the ruling on Twitter late Friday night: “As I predicted all along, Obamacare has been struck down as an UNCONSTITUTIONAL disaster! Now Congress must pass a STRONG law that provides GREAT healthcare and protects pre-existing conditions.”

The White House, in a separate statement late Friday, said: “We expect this ruling will be appealed to the Supreme Court. Pending the appeal process, the law remains in place.”

If Judge O’Connor’s decision ultimately stands, about 17 million Americans will lose their health insurance, according to the Urban Institute, a left-leaning think tank. That includes millions who gained coverage through the law’s expansion of Medicaid, and millions more who receive subsidized private insurance through the law’s online marketplaces.

Insurers will also no longer have to cover young adults up to age 26 under their parents’ plans; annual and lifetime limits on coverage will again be permitted; and there will be no cap on out-of-pocket costs.

Also gone will be the law’s popular protections for people with pre-existing conditions, which became a major talking point in the November midterm elections, as Democratic candidates constantly reminded voters that congressional Republicans had tried to repeal the law last year.

Many Democrats successfully centered their midterm campaigns on protecting the Affordable Care Act’s insurance mandates for pre-existing conditions.

Senator Joe Manchin III of West Virginia, one of the few Democratic senators to save his seat in a heavily Trump-friendly state, excoriated his opponent, West Virginia’s attorney general, Patrick Morrisey, for joining the lawsuit decided in favor of the Republicans on Friday.

Democrats in Wisconsin campaigned on a pledge to withdraw the state from the suit, and after they won, that state’s Republican Legislature passed legislation blocking the newly elected Democrats from withdrawing. That legislation was signed into law on Friday by Gov. Scott Walker, who lost his bid for re-election in November.

But most Republican candidates insisted during the campaign that they did not want to withdraw protections for pre-existing conditions, and most were silent after Friday’s ruling.

Without those protections, insurers could return to denying coverage to such people or to charging them more. They could also return to charging people more based on their age, gender or profession.

The Kaiser Family Foundation, a nonpartisan research organization, estimates that 52 million adults from 18 to 64, or 27 percent of that population, would be rejected for coverage under the practices that were in effect in most states before the Affordable Care Act.

“If this Texas decision on the ACA is upheld, it would throw the individual insurance market and the whole health care system into complete chaos,” Larry Levitt, a senior vice president of the Kaiser Family Foundation, wrote on Twitter. “But, the case still has a long legal road to travel before that’s an immediate threat.”

Democrats immediately attacked the ruling as absurd. Representative Nancy Pelosi of California said that when the party took control of the House next month, with her as speaker, it would “move swiftly to formally intervene in the appeals process to uphold the lifesaving protections for people with pre-existing conditions and reject Republicans’ effort to destroy the Affordable Care Act.”

In his ruling, Judge O’Connor agreed with the plaintiffs that the individual mandate could not be severed from the rest of the Affordable Care Act because it was “the keystone” of the law, essential to its regulation of the health insurance market.

“The individual mandate is inseverable from the entire A.C.A.,” he declared.

The judge said he would not “parse the A.C.A.’s provisions one by one,” but had to invalidate the whole law, including the expansion of Medicaid and the requirement for employers to offer coverage to workers. “The Medicaid-expansion provisions were designed to serve and assist fulfillment of the individual mandate,” he wrote.

At oral arguments before Judge O’Connor in September, California and the other intervening states had argued that the mandate could not be unconstitutional if it was not forcing people to pay penalties anymore. But even if Judge O’Connor threw it out, they said, the rest of the law could legally be severed from it and survive.

The ruling came a day before the end of the fifth open enrollment season for Affordable Care Act coverage in most states, one in which sign-ups for “Obamacare,” as the coverage sold through the law’s marketplaces is known, have declined so far by about 12 percent compared with last year.

https://www.nytimes.com/2018/12/14/health/obamacare-unconstitutional-texas-judge.html

A Partisan Ruling on Obamacare

A decision by a judge in Texas striking down the totality of the Affordable Care Act has little basis in law.

by Christian Farias - NYT - December 15, 2018

After sitting on a ruling for months, a federal judge in Texas has given the Trump administration and a group of Republican-led states exactly what they asked for, and then some: the invalidation of the entire Affordable Care Act.

Don't panic. The ruling, issued late on Friday and only one day before the end of the law’s annual open enrollment period, is not a model of constitutional or statutory analysis. It’s instead a predictable exercise in motivated reasoning — drafted by a jurist with a history of ruling against policies and laws advanced by President Barack Obama. 

The reason the judge, Reed O’Connor, gets these cases isn’t a mystery: Texas and its allied states know the game and shop these lawsuits right into Judge O’Connor’s courtroom. 

Another thing that isn’t a mystery? The genesis of this latest attack on Obamacare. Disenchanted that a Republican-controlled federal government wouldn’t repeal every word of the law, Texas and a coalition of states tried a sleight of hand: They leaned on President Trump’s 2017 tax bill, known officially as the Tax Cuts and Jobs Act — which zeroed out the tax penalty of the health care law’s individual mandate — and argued that the mandate itself was unconstitutional.

That argument has a certain flair to it, but the states didn’t stop there. Their lawyers suggested that, because the individual mandate is a linchpin of the A.C.A. as a whole — in fact, the one thing that holds the law together — the law cannot stand without it. If the mandate falls, the logic went, the entire statute falls with it.

Shocking even conservative legal experts, the Trump administration fell for this spurious argument and lent its support to the Texas lawsuit — which, if successful, would render all of the marquee provisions of Obamacare, like protections for patients with pre-existing conditions, null.

This all-out assault on health care is one reason Democrats did so well in the midterm elections, as voters rejected anti-Obamacare candidates at the polls. They included several lawmakers who had gleefully voted for Mr. Trump’s tax bill less than a year earlier.

Except the tax bill did not invalidate the Affordable Care Act — it did away only with the penalty for not being insured. Congress left the rest of the law intact.

Instead of respecting that legislative choice, Judge O’Connor proceeded to find all the operative provisions of the A.C.A. “inseverable” from the hollowed-out individual mandate. The whole law must fall. He gave the Texas-led challengers precisely what they wanted.

This partisan, activist ruling cannot stand. If it’s not reversed by the conservative United States Court of Appeals for the Fifth Circuit, then it’s off to the Supreme Court, where all five justices who, in 2012, already determined that the Affordable Care Act was constitutional will still be there.

One of them is Chief Justice John Roberts, who made a splash last month when he appeared to rebuke Mr. Trump’s criticism of judges who don’t rule as the president likes. The president this time around is rejoicing over Obamacare’s apparent demise — and is heaping praise on the “highly respected judge” who was itching to do Republicans’ bidding. (The White House, in a modicum of decency, has said the law will stay put as the appeal moves through the courts.)

But as Chief Justice Roberts said when he cast the decisive vote that upheld Obamacare, “It is not our job to protect the people from the consequences of their political choices.” Here the American people, through their elected representatives, made their choice, both in 2010 and 2017: Obamacare is the law of the land. It will remain that way.

https://www.nytimes.com/2018/12/15/opinion/obamacare-unconstitutional-texas-judge.html

With ACA in peril, Republicans get to show if they really want to protect people with preexisting conditions

by Colby Itkowitz - Washington Post - December 15, 2108

From the moment the White House decided it would defend no part of the Affordable Care Act in a federal lawsuit brought by 20 red state governors and attorneys general, Democrats pounced on the real-world implications.

The lawsuit claimed Congress' removal of the individual mandate penalty requiring everyone have health insurance nullified the entire law and made it unconstitutional. The Trump administration’s refusal to stand up for any part of the law meant that if a judge ruled against the law then the whole thing would come crashing down, including the popular parts, namely coverage protections for Americans with preexisting health conditions.

Leading up to the midterm elections, Democrats were unrelenting in their attacks on Republicans over the future of the ACA’s preexisting conditions policy. It became such a focal point of their campaigns that Republicans had to start talking about it too, promising voters they would save the protections. Even one of the attorneys general on the lawsuit, Missouri’s Josh Hawley, cut an ad where he talked about his sick son and the importance of covering people with current or past health issues.

President Trump, in campaign rallies around the country, started declaring himself and the Republican Party the best on the issue of preexisting conditions.

Late Friday night, on the last night of open enrollment, a Texas judge ruled in the lawsuit that the ACA was unconstitutional and the whole law should be overturned Nothing happens to the law yet, this decision will be appealed and likely end up before the Supreme Court, but it certainly puts President Obama’s signature policy accomplishment in the perilous situation.

The big question facing Republicans tonight is whether they will support legislation ensuring people with preexisting conditions continue to receive equitable health insurance coverage. Throughout the campaign, Democrats pointed out the hypocrisy of Republicans supporting the lawsuit while also telling voters preexisting conditions protections would be preserved. The problem with that promise is that Congress has not put in place any safeguards or contingencies for those protections in the event the law gets overturned.

Several Republicans in the weeks leading up to the election, introduced legislation forbidding insurance companies to discriminate against the 133 million Americans with health issues. But some of those proposals left loopholes that would have allowed companies to deny coverage or charge more based on gender or age. Moreover, there’s risk in requiring companies cover sick people if the rest of the law isn’t in place. To work, the law needed younger, healthy people to balance out the insurance pool. But without a mandate or subsidized plans those people are less likely to buy coverage, leaving insurance companies with a sicker, and thus expensive, consumer base.

Politically it’s a nightmare for Republicans. Democrats, who after eight years on the defensive when it came to the Affordable Care Act, have found themselves with the upper hand. Recent polling by the Kaiser Family Foundation found 65 percent of Americans believe it’s “very important” that insurers can’t deny people coverage based on their health. Republicans have yet to pass a replacement for the ACA, something they’ve been promising for years.

After the news of the judge’s decision broke, presumptive incoming Speaker of the House Nancy Pelosi immediately declared her intention to protect people with preexisting conditions. The onus would then be on Senate Majority Leader Mitch McConnell and his Republican caucus to do the same.

Trump, who tweeted about the ruling, said Congress must pass a law that protects preexisting conditions. But this is health policy in divided government (remember: “Nobody knew health care could be so complicated”) and it’s not going to be so easy to replace the ACA if the Supreme Court ultimately strikes it down.

✔

As I predicted all along, Obamacare has been struck down as an UNCONSTITUTIONAL disaster! Now Congress must pass a STRONG law that provides GREAT healthcare and protects pre-existing conditions. Mitch and Nancy, get it done!

94.9K

9:07 PM - Dec 14, 2018

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https://www.washingtonpost.com/politics/2018/12/15/with-aca-peril-republicans-get-show-if-they-really-want-protect-people-with-preexisting-conditions/?utm_term=.776bc7bc9325