Americans Need Health Care. It Can’t Be Tied to Their Jobs.
The dual crises of mass unemployment and the coronavirus have laid bare a central flaw of the U.S. health care system.
by Jeneen Interlandi - NYT - June 29, 2020
In the
early months of 2020, Americans were engaged in the perennial
election-year debate over how best to reform the nation’s health care
system. As usual, the electorate was torn and confused. Polling
indicated that a small majority
of likely voters favored a new universal system that would cover
everyone. But that support evaporated when it was made clear that any
such overhaul would involve abolishing the private insurance market. At
the time, nearly 160 million
Americans received their health benefits through an employer, and the
vast majority of them liked that coverage just fine — maybe not enough
to sing about it, but enough to be wary of a potential replacement.
Then came the pandemic of the century. And the highest level of unemployment since the Great Recession. And the most concentrated wave of job loss in the nation’s history — more than 40 million Americans filed new unemployment claims between mid-March and late May. It will take time to ascertain the full impact of those losses on the nation’s health insurance rate, but an early survey from the Commonwealth Fund is not encouraging: 41 percent of those who lost a job (or whose spouse lost a job) because of the pandemic relied on that job for health insurance; 20 percent of those people have not managed to secure alternative coverage.
Nothing illuminates the problems with an employer-based health care system quite like massive unemployment in the middle of a highly contagious and potentially deadly disease outbreak. For one thing, uninsured people are less likely to seek medical care, making this coronavirus that much more difficult to contain. Also, people with chronic or immune-compromising medical conditions are particularly susceptible to this new contagion — which means the people most in need of employer-sponsored health benefits are the same ones who can least afford to return to work at the moment.
“The pandemic has amplified all the vulnerabilities in our health care system,” says Drew Altman, president of the nonpartisan Kaiser Family Foundation, including “the uninsured, racial disparities, the crisis of unmanaged chronic conditions and the general lack of national planning.”
Then came the pandemic of the century. And the highest level of unemployment since the Great Recession. And the most concentrated wave of job loss in the nation’s history — more than 40 million Americans filed new unemployment claims between mid-March and late May. It will take time to ascertain the full impact of those losses on the nation’s health insurance rate, but an early survey from the Commonwealth Fund is not encouraging: 41 percent of those who lost a job (or whose spouse lost a job) because of the pandemic relied on that job for health insurance; 20 percent of those people have not managed to secure alternative coverage.
Nothing illuminates the problems with an employer-based health care system quite like massive unemployment in the middle of a highly contagious and potentially deadly disease outbreak. For one thing, uninsured people are less likely to seek medical care, making this coronavirus that much more difficult to contain. Also, people with chronic or immune-compromising medical conditions are particularly susceptible to this new contagion — which means the people most in need of employer-sponsored health benefits are the same ones who can least afford to return to work at the moment.
“The pandemic has amplified all the vulnerabilities in our health care system,” says Drew Altman, president of the nonpartisan Kaiser Family Foundation, including “the uninsured, racial disparities, the crisis of unmanaged chronic conditions and the general lack of national planning.”
As
dire as the crisis is, though, it’s also an opportunity to look at
health care reform with fresh eyes — and to maybe, finally, rebuild the
nation’s health care system in a way that works for all Americans, not
just the wealthy and the well employed.
The first step will be acknowledging the problems of our current system. If American health care were its own country, it would be the fourth largest in the world by gross domestic product. The nation spends an average of $3.5 trillion per year on health care — more than Japan, Germany, France, China, the United Kingdom, Italy, Canada, Brazil, Spain and Australia combined — and still loses more people to preventable and treatable medical conditions than any of those countries do.
In other words, America has created the most expensive, least effective health care system in the modern world, and the most vulnerable Americans have been paying for that failure with their lives since long before the coronavirus came to town.
In many ways, of course, that system is no system at all. It’s a patchwork in which access to care depends on a roster of factors, including age, employment status and state of residence. It’s a free-for-all in which the prices of life-or-death essentials like insulin and heart surgery are set at whatever the market will bear, and efforts to check those prices are routinely bludgeoned by interest groups that hold enormous sway over lawmakers. It’s a labyrinth in which consultants, billing clerks and administrators vastly outnumber medical professionals. And it’s a voracious beast that feeds American households with well-paying jobs, then devours them with insurmountable medical bills — often at their weakest moments.
The story of how this nonsystem came to be begins during World War II, when a trifecta of policy choices permanently altered the health care landscape. First, President Franklin D. Roosevelt froze wages to prevent the nation’s massive shortage of able-bodied men from sending labor costs through the roof. Then, the National War Labor Board, a federal agency created to resolve labor disputes during wartime, ruled that health insurance would not count as wages; this allowed employers trying to compete for workers in a tight market to offer health insurance to prospective hires without violating the wage regulations. And finally, the Internal Revenue Service determined that such insurance benefits would not be taxed.
The first step will be acknowledging the problems of our current system. If American health care were its own country, it would be the fourth largest in the world by gross domestic product. The nation spends an average of $3.5 trillion per year on health care — more than Japan, Germany, France, China, the United Kingdom, Italy, Canada, Brazil, Spain and Australia combined — and still loses more people to preventable and treatable medical conditions than any of those countries do.
In other words, America has created the most expensive, least effective health care system in the modern world, and the most vulnerable Americans have been paying for that failure with their lives since long before the coronavirus came to town.
In many ways, of course, that system is no system at all. It’s a patchwork in which access to care depends on a roster of factors, including age, employment status and state of residence. It’s a free-for-all in which the prices of life-or-death essentials like insulin and heart surgery are set at whatever the market will bear, and efforts to check those prices are routinely bludgeoned by interest groups that hold enormous sway over lawmakers. It’s a labyrinth in which consultants, billing clerks and administrators vastly outnumber medical professionals. And it’s a voracious beast that feeds American households with well-paying jobs, then devours them with insurmountable medical bills — often at their weakest moments.
The story of how this nonsystem came to be begins during World War II, when a trifecta of policy choices permanently altered the health care landscape. First, President Franklin D. Roosevelt froze wages to prevent the nation’s massive shortage of able-bodied men from sending labor costs through the roof. Then, the National War Labor Board, a federal agency created to resolve labor disputes during wartime, ruled that health insurance would not count as wages; this allowed employers trying to compete for workers in a tight market to offer health insurance to prospective hires without violating the wage regulations. And finally, the Internal Revenue Service determined that such insurance benefits would not be taxed.
The
inequities of this arrangement were clear from the start. It excluded
elderly and disabled Americans because they couldn’t work, and low-wage
workers and racial minorities, because they couldn’t secure the kinds of
jobs that offered health insurance. But employer-based insurance was
popular — employers had better bargaining power than individuals, and it
was easier to have them handle the logistics — and elected officials
faced little pressure to create a more robust alternative. In the
decades that followed, even as officials fortified public schools,
transit systems and utilities, they left health care to the private
markets. Eventually, Medicare, Medicaid and the Affordable Care Act
filled some of the gaps created by employer-based insurance, but no
program ever filled all of them.
By 1960, roughly two-thirds of all Americans were insured by their employers, by 1970 health insurance had become big business, and by the 1980s health care costs were soaring. Some of that increase can be attributed to advances in technology that made care more expensive. But a great deal of the spike resulted from what economists refer to as “price insensitivity” and what the rest of us might call obliviousness. “If the insurer is paying, nobody looks at the bill,” says Zack Cooper, a health economist at the Yale School of Medicine. “So you can raise prices as much as you want, and you can create a much more luxurious system overall, to justify it.”
Unencumbered by the demands of a cost-conscious clientele, hospitals ramped up equipment purchases, expanded hospital wings and workforces, created specialty clinics — and then increased their reimbursement rates to pay for it all. Rather than scrutinize those price hikes, which were passed from hospitals to insurers to customers, employers simply accepted them. And why wouldn’t they? The more generous the insurance package and the nicer the hospitals and clinics, the bigger the tax break for the companies paying the tab. “For employers, it’s essentially the house’s money,” Mr. Cooper says. “But then, for anyone not on that raft of good coverage, it’s enormous costs or nothing.”
That calculus is especially brutal for un- or underemployed Americans, but it’s a bad deal for all workers. Economists tend to agree that health benefits sap wages — meaning that employers recoup at least some of the cost of insuring their employees by paying them less money than they otherwise might. At least some unions say that they spend so much of their bargaining power securing these benefits for their members that they have little left for other crucial fights, like retirement. Lower-skilled workers have long been squeezed out of better paying jobs because, as the economists Anne Case and Angus Deaton note, a labor market skewed by pricey health benefits tends to favor those whose talents can more easily justify the expense.
Perhaps worst of all, employees of every ilk frequently find themselves trapped: changing jobs, foregoing employment or taking professional risks (like starting a business) all involve changes in health insurance and, in the worst case scenario, a loss of coverage. The end result is a medical underclass whose horizons are contracted by the sheer logistics of hanging on to health care.
To change this system, Americans will have to change their thinking. There is a tendency among workers with good health insurance to see those benefits as something that’s purely earned, through work. But employer-based insurance is heavily subsidized by the federal government. Those subsidies are not much different than the ones granted to low-income Americans through Medicaid and the Affordable Care Act, but through the lens of American politics the latter are frequently derided as an outrageous form of welfare, while the former are accepted as par for the course.
That thinking may already be evolving. According to a 2019 poll, nearly 60 percent of Americans agree that health care is a human right and that the government should be responsible for ensuring that as many people as possible can access it when they need to. But to truly realize this ideal, the country will have to stop making employers the sole source of health care for so many people. America must create either a new health care system or offer significantly more options within the current one.
By 1960, roughly two-thirds of all Americans were insured by their employers, by 1970 health insurance had become big business, and by the 1980s health care costs were soaring. Some of that increase can be attributed to advances in technology that made care more expensive. But a great deal of the spike resulted from what economists refer to as “price insensitivity” and what the rest of us might call obliviousness. “If the insurer is paying, nobody looks at the bill,” says Zack Cooper, a health economist at the Yale School of Medicine. “So you can raise prices as much as you want, and you can create a much more luxurious system overall, to justify it.”
Unencumbered by the demands of a cost-conscious clientele, hospitals ramped up equipment purchases, expanded hospital wings and workforces, created specialty clinics — and then increased their reimbursement rates to pay for it all. Rather than scrutinize those price hikes, which were passed from hospitals to insurers to customers, employers simply accepted them. And why wouldn’t they? The more generous the insurance package and the nicer the hospitals and clinics, the bigger the tax break for the companies paying the tab. “For employers, it’s essentially the house’s money,” Mr. Cooper says. “But then, for anyone not on that raft of good coverage, it’s enormous costs or nothing.”
That calculus is especially brutal for un- or underemployed Americans, but it’s a bad deal for all workers. Economists tend to agree that health benefits sap wages — meaning that employers recoup at least some of the cost of insuring their employees by paying them less money than they otherwise might. At least some unions say that they spend so much of their bargaining power securing these benefits for their members that they have little left for other crucial fights, like retirement. Lower-skilled workers have long been squeezed out of better paying jobs because, as the economists Anne Case and Angus Deaton note, a labor market skewed by pricey health benefits tends to favor those whose talents can more easily justify the expense.
Perhaps worst of all, employees of every ilk frequently find themselves trapped: changing jobs, foregoing employment or taking professional risks (like starting a business) all involve changes in health insurance and, in the worst case scenario, a loss of coverage. The end result is a medical underclass whose horizons are contracted by the sheer logistics of hanging on to health care.
To change this system, Americans will have to change their thinking. There is a tendency among workers with good health insurance to see those benefits as something that’s purely earned, through work. But employer-based insurance is heavily subsidized by the federal government. Those subsidies are not much different than the ones granted to low-income Americans through Medicaid and the Affordable Care Act, but through the lens of American politics the latter are frequently derided as an outrageous form of welfare, while the former are accepted as par for the course.
That thinking may already be evolving. According to a 2019 poll, nearly 60 percent of Americans agree that health care is a human right and that the government should be responsible for ensuring that as many people as possible can access it when they need to. But to truly realize this ideal, the country will have to stop making employers the sole source of health care for so many people. America must create either a new health care system or offer significantly more options within the current one.
There’s no shortage of ideas
for how to accomplish this goal. A single-payer system in which one
entity (usually the federal government) covers every citizen regardless
of age or employment status, could work. So could a new “public option”
that makes federally guaranteed health insurance available to many more
people. Any such choice will involve trade-offs and will need to be
accompanied by other aggressive reforms, including price controls and
checks on the influence of special interests over legislation.
Any of these reforms will be politically difficult. Even in the midst of a global pandemic, Republicans are still trying to gut the Affordable Care Act, and Democrats are still divided over how best to respond to that threat. But if there were ever a time to take bold steps — or to finally undo the mistakes of the past — it’s now.
https://www.nytimes.com/2020/06/29/opinion/coronavirus-medicare-for-all.html?action=click&module=Opinion&pgtype=Homepage
Any of these reforms will be politically difficult. Even in the midst of a global pandemic, Republicans are still trying to gut the Affordable Care Act, and Democrats are still divided over how best to respond to that threat. But if there were ever a time to take bold steps — or to finally undo the mistakes of the past — it’s now.
https://www.nytimes.com/2020/06/29/opinion/coronavirus-medicare-for-all.html?action=click&module=Opinion&pgtype=Homepage
Trump Administration Asks Supreme Court to Strike Down Affordable Care Act
If
successful, the move would permanently end the health insurance program
popularly known as Obamacare and wipe out coverage for as many as 23
million Americans.
by Sheryl Gay Stolberg - NYT - June 26, 2020
WASHINGTON
— The Trump administration asked the Supreme Court late Thursday to
overturn the Affordable Care Act — a move that, if successful, would
bring a permanent end to the health insurance program popularly known as
Obamacare and wipe out coverage for as many as 23 million Americans.
In an 82-page brief submitted an hour before a midnight deadline, the administration joined Republican officials in Texas and 17 other states in arguing that in 2017, Congress, then controlled by Republicans, had rendered the law unconstitutional when it zeroed out the tax penalty for not buying insurance — the so-called individual mandate.
The administration’s argument, coming in the thick of an election season — as well as a pandemic that has devastated the economy and left millions of unemployed Americans without health coverage — is sure to reignite Washington’s bitter political debate over health care.
In an 82-page brief submitted an hour before a midnight deadline, the administration joined Republican officials in Texas and 17 other states in arguing that in 2017, Congress, then controlled by Republicans, had rendered the law unconstitutional when it zeroed out the tax penalty for not buying insurance — the so-called individual mandate.
The administration’s argument, coming in the thick of an election season — as well as a pandemic that has devastated the economy and left millions of unemployed Americans without health coverage — is sure to reignite Washington’s bitter political debate over health care.
In
his brief, Solicitor General Noel J. Francisco argued that the health
law’s two remaining central provisions are now invalid because Congress
intended that all three work together.
“Nothing
the 2017 Congress did demonstrates it would have intended the rest of
the A.C.A. to continue to operate in the absence of these three integral
provisions,” the brief said, using the abbreviation for the name of the
health care law. “The entire A.C.A. thus must fall with the individual
mandate.”
The Texas case is by far the most serious challenge to date for the 10-year-old health care law, President Barack Obama’s signature domestic achievement. The Supreme Court has already ruled on two legal challenges to the act, and both times it has left most of the law in place.
The court has not said when it will hear oral arguments, but they are most likely to take place in the fall, just as Americans are preparing to go to the polls in November.
Republicans have long said their goal is to “repeal and replace” the Affordable Care Act but have yet to agree on an alternative. They are bracing for the possibility that the effort to overturn the health law will cost them. Joel White, a Republican strategist, said in a recent interview that he considered it “pretty dumb to be talking about how we need to repeal Obamacare in the middle of a pandemic.”
The Texas case is by far the most serious challenge to date for the 10-year-old health care law, President Barack Obama’s signature domestic achievement. The Supreme Court has already ruled on two legal challenges to the act, and both times it has left most of the law in place.
The court has not said when it will hear oral arguments, but they are most likely to take place in the fall, just as Americans are preparing to go to the polls in November.
Republicans have long said their goal is to “repeal and replace” the Affordable Care Act but have yet to agree on an alternative. They are bracing for the possibility that the effort to overturn the health law will cost them. Joel White, a Republican strategist, said in a recent interview that he considered it “pretty dumb to be talking about how we need to repeal Obamacare in the middle of a pandemic.”
Democrats, who view health care a winning issue and who reclaimed the House majority
in 2018 on their promise to expand access and bring down costs, are
trying to use the Supreme Court case to press their advantage. Speaker
Nancy Pelosi has scheduled a vote for Monday on a measure to expand the
health care law, in an effort to draw a sharp contrast between Democrats
and Republicans.
“President Trump and the Republicans’ campaign to rip away the protections and benefits of the Affordable Care Act in the middle of the coronavirus crisis is an act of unfathomable cruelty,” Ms. Pelosi said in a statement late Thursday night, after the administration’s brief was filed.
“If President Trump gets his way,” she added, “130 million Americans with pre-existing conditions will lose the A.C.A.’s lifesaving protections and 23 million Americans will lose their health coverage entirely.”
The case the court will hear grows out of a lawsuit that Republican officials in 20 states, led by Texas, filed against the Department of Health and Human Services in February 2018, seeking to have the health law struck down. After Democratic victories in the 2018 midterm elections, two states, Wisconsin and Maine, withdrew.
When the case was argued in the trial court, the Trump administration, though a defendant, did not defend the law, siding instead with the plaintiffs. But unlike Texas and the other states, the administration argued at the time that only the law’s protections for people with pre-existing conditions should be struck down, but that the rest of the law, including its expansion of Medicaid, should survive.
Last year, however, the administration expanded its opposition, telling a federal appeals court that the entire law should be invalidated. In the meantime, another 17 states, led by California, intervened to defend the law, as did the House, now controlled by Democrats.
“Now is not the time to rip away our best tool to address very real and very deadly health disparities in our communities,” Attorney General Xavier Becerra of California said in a statement on Thursday, adding: “This fight comes at the most crucial time. The death toll from the coronavirus today is greater than the death toll of the Vietnam War.”
“President Trump and the Republicans’ campaign to rip away the protections and benefits of the Affordable Care Act in the middle of the coronavirus crisis is an act of unfathomable cruelty,” Ms. Pelosi said in a statement late Thursday night, after the administration’s brief was filed.
“If President Trump gets his way,” she added, “130 million Americans with pre-existing conditions will lose the A.C.A.’s lifesaving protections and 23 million Americans will lose their health coverage entirely.”
The case the court will hear grows out of a lawsuit that Republican officials in 20 states, led by Texas, filed against the Department of Health and Human Services in February 2018, seeking to have the health law struck down. After Democratic victories in the 2018 midterm elections, two states, Wisconsin and Maine, withdrew.
When the case was argued in the trial court, the Trump administration, though a defendant, did not defend the law, siding instead with the plaintiffs. But unlike Texas and the other states, the administration argued at the time that only the law’s protections for people with pre-existing conditions should be struck down, but that the rest of the law, including its expansion of Medicaid, should survive.
Last year, however, the administration expanded its opposition, telling a federal appeals court that the entire law should be invalidated. In the meantime, another 17 states, led by California, intervened to defend the law, as did the House, now controlled by Democrats.
“Now is not the time to rip away our best tool to address very real and very deadly health disparities in our communities,” Attorney General Xavier Becerra of California said in a statement on Thursday, adding: “This fight comes at the most crucial time. The death toll from the coronavirus today is greater than the death toll of the Vietnam War.”
The
Supreme Court has agreed to consider three legal questions in the case:
whether Texas and two individual plaintiffs who have joined the suit
have standing; whether Congress rendered the individual mandate
unconstitutional; and, if it did, whether the rest of the law must fall
with it.
If the court strikes down only the mandate, not much will change, according to an analysis by the Kaiser Family Foundation, which wrote that the “practical result will be essentially the same as the A.C.A. exists today, without an enforceable mandate.” But if the court decides that all or part of the law must be overturned, it would affect “nearly every American in some way,” the foundation wrote.
The Texas suit has created great uncertainty for the roughly 20 million people covered by the law, as well as for millions of others who have lost their jobs and health coverage during the coronavirus pandemic. A recent analysis by the liberal-leaning Center for American Progress estimated that 23 million people would lose coverage if the Affordable Care Act is abolished — including nearly two million in Texas and more than four million in California.
The lawsuit has also drawn opposition from hospitals and doctors, including the American Medical Association. In a friend of the court brief filed last month, it wrote that striking down the law “at a time when the system is struggling to respond to a pandemic that has infected nearly 1.4 million Americans and killed more than 80,000 at the time of this writing would be a self-inflicted wound that could take decades to heal.”
https://www.nytimes.com/2020/06/26/us/politics/obamacare-trump-administration-supreme-court.html?
If the court strikes down only the mandate, not much will change, according to an analysis by the Kaiser Family Foundation, which wrote that the “practical result will be essentially the same as the A.C.A. exists today, without an enforceable mandate.” But if the court decides that all or part of the law must be overturned, it would affect “nearly every American in some way,” the foundation wrote.
The Texas suit has created great uncertainty for the roughly 20 million people covered by the law, as well as for millions of others who have lost their jobs and health coverage during the coronavirus pandemic. A recent analysis by the liberal-leaning Center for American Progress estimated that 23 million people would lose coverage if the Affordable Care Act is abolished — including nearly two million in Texas and more than four million in California.
The lawsuit has also drawn opposition from hospitals and doctors, including the American Medical Association. In a friend of the court brief filed last month, it wrote that striking down the law “at a time when the system is struggling to respond to a pandemic that has infected nearly 1.4 million Americans and killed more than 80,000 at the time of this writing would be a self-inflicted wound that could take decades to heal.”
https://www.nytimes.com/2020/06/26/us/politics/obamacare-trump-administration-supreme-court.html?
'Unfathomable Cruelty': Trump Files Legal Brief Aiming to Kick 20 Million Off Health Insurance in Middle of Pandemic
"We need to be guaranteeing healthcare for all, not gutting it from millions."
by
The Trump administration late Thursday night filed a legal brief
asking the Supreme Court to invalidate the entirety of the Affordable
Care Act, a move that would strip health insurance from more than 20
million people in the middle of a pandemic and slash taxes for the richest Americans.
The brief (pdf), submitted by the Justice Department in support of a Republican lawsuit, argues that Congress' 2017 repeal of the individual mandate rendered the ACA unconstitutional.
"The entire ACA thus must fall with the individual mandate," writes Solicitor General Noel Francisco.
Rep. Pramila Jayapal (D-Wash.), co-chair of the Congressional Progressive Caucus and lead sponsor of the House Medicare for All Act of 2019, said in response to the Trump administration's latest attack on the ACA that "we need to be guaranteeing healthcare for all, not gutting it from millions."
The brief comes at a time when millions of Americans are newly uninsured due to the coronavirus pandemic, which caused calamitous job losses nationwide and kicked many people off their employer-provided coverage. Government data released Thursday shows that nearly half a million Americans turned to the federal ACA exchanges in April and May after losing their health insurance due to the Covid-19 crisis.
If successful, the effort by Republican state attorneys general and the Trump administration to tear down the ACA would add around 23 million Americans to the ranks of the uninsured and end protections for more than 100 million people with pre-existing conditions.
"It wouldn't only end coverage for the 11.4 million people who signed up for insurance for this year, but also halt the expansion of Medicaid that covers more than 12 million people," the Wall Street Journal reports. "Insurers would again be able to deny people health coverage or charge higher premiums to consumers with pre-existing conditions."
Full repeal of the ACA would also deliver massive tax cuts to the richest Americans and big corporations, according to a report released this week by the Center on Budget and Policy Priorities.
"The highest-income 0.1 percent (1 in 1,000) households would receive tax cuts averaging about $198,000 per year," the think tank notes. "Households with annual incomes over $1 million would receive tax cuts averaging about $42,000 per year... Striking down the ACA would thus transfer billions of dollars each year from low- and moderate-income people (who would lose subsidized health coverage) to high-income households and corporations (which would receive large tax cuts)."
California Attorney General Xavier Becerra, a member of the coalition of Democratic state attorneys general fighting the GOP lawsuit in court, said Thursday that his side "intends to win this."
"In the middle of a pandemic, the Trump administration's fighting to destroy the ACA," Becerra tweeted. "Tonight before SCOTUS they showed how far they're willing to go."
Ahead of the Trump administration's anticipated legal filing, House Democrats on Wednesday introduced legislation that would bolster the ACA but stop well short of progressive calls to expand Medicare to cover the uninsured.
Titled the Patient Protection and Affordable Care Enhancement Act, the bill aims to make the ACA more affordable by boosting federal premium subsidies.
In a statement Thursday night, House Speaker Nancy Pelosi (D-Calif.) said "Trump and the Republicans' campaign to rip away the protections and benefits of the Affordable Care Act in the middle of the coronavirus crisis is an act of unfathomable cruelty."
"If President Trump gets his way, 130 million Americans with pre-existing conditions will lose the ACA's lifesaving protections and 23 million Americans will lose their health coverage entirely," said Pelosi. "There is no legal justification and no moral excuse for the Trump administration's disastrous efforts to take away Americans' healthcare.
https://www.commondreams.org/news/2020/06/26/unfathomable-cruelty-trump-files-legal-brief-aiming-kick-20-million-health-insurance?The brief (pdf), submitted by the Justice Department in support of a Republican lawsuit, argues that Congress' 2017 repeal of the individual mandate rendered the ACA unconstitutional.
"The entire ACA thus must fall with the individual mandate," writes Solicitor General Noel Francisco.
Rep. Pramila Jayapal (D-Wash.), co-chair of the Congressional Progressive Caucus and lead sponsor of the House Medicare for All Act of 2019, said in response to the Trump administration's latest attack on the ACA that "we need to be guaranteeing healthcare for all, not gutting it from millions."
The brief comes at a time when millions of Americans are newly uninsured due to the coronavirus pandemic, which caused calamitous job losses nationwide and kicked many people off their employer-provided coverage. Government data released Thursday shows that nearly half a million Americans turned to the federal ACA exchanges in April and May after losing their health insurance due to the Covid-19 crisis.
If successful, the effort by Republican state attorneys general and the Trump administration to tear down the ACA would add around 23 million Americans to the ranks of the uninsured and end protections for more than 100 million people with pre-existing conditions.
"It wouldn't only end coverage for the 11.4 million people who signed up for insurance for this year, but also halt the expansion of Medicaid that covers more than 12 million people," the Wall Street Journal reports. "Insurers would again be able to deny people health coverage or charge higher premiums to consumers with pre-existing conditions."
Full repeal of the ACA would also deliver massive tax cuts to the richest Americans and big corporations, according to a report released this week by the Center on Budget and Policy Priorities.
"The highest-income 0.1 percent (1 in 1,000) households would receive tax cuts averaging about $198,000 per year," the think tank notes. "Households with annual incomes over $1 million would receive tax cuts averaging about $42,000 per year... Striking down the ACA would thus transfer billions of dollars each year from low- and moderate-income people (who would lose subsidized health coverage) to high-income households and corporations (which would receive large tax cuts)."
California Attorney General Xavier Becerra, a member of the coalition of Democratic state attorneys general fighting the GOP lawsuit in court, said Thursday that his side "intends to win this."
"In the middle of a pandemic, the Trump administration's fighting to destroy the ACA," Becerra tweeted. "Tonight before SCOTUS they showed how far they're willing to go."
Ahead of the Trump administration's anticipated legal filing, House Democrats on Wednesday introduced legislation that would bolster the ACA but stop well short of progressive calls to expand Medicare to cover the uninsured.
Titled the Patient Protection and Affordable Care Enhancement Act, the bill aims to make the ACA more affordable by boosting federal premium subsidies.
In a statement Thursday night, House Speaker Nancy Pelosi (D-Calif.) said "Trump and the Republicans' campaign to rip away the protections and benefits of the Affordable Care Act in the middle of the coronavirus crisis is an act of unfathomable cruelty."
"If President Trump gets his way, 130 million Americans with pre-existing conditions will lose the ACA's lifesaving protections and 23 million Americans will lose their health coverage entirely," said Pelosi. "There is no legal justification and no moral excuse for the Trump administration's disastrous efforts to take away Americans' healthcare.
Obamacare Faces Unprecedented Test as Economy Sinks
The
battles over the health law have played out during a decade of
continuous economic growth. How it performs as a safety net now may help
determine its future.
By Abby Goodnough and - NYT - June 27, 2020
The Affordable Care Act, the landmark health law that has
been a subject of caustic debate for more than a decade, is being tested
as never before, as millions of Americans lose their jobs and medical
coverage in the midst of the nation’s gravest health crisis in a
century.
The law is offering a vast majority of newly unemployed people a path to stopgap health coverage, providing a cushion that did not exist during the last crushing recession — or ever before. But the crisis has also highlighted fundamental weaknesses with its patchwork system — ones magnified by Republican efforts to undermine and dismantle it, but also seized on by some Democrats pushing for a sweeping overhaul.
On Thursday, as the coronavirus pandemic surged and the country reported a daily record in new virus cases, the Trump administration continued the Republican Party’s push to abolish the law. Shortly before midnight, the Justice Department filed a brief asking the Supreme Court to overturn the law, in a case brought by a group of Republican attorneys general.
The case is likely to be argued this fall during the closing stages of a bitter presidential election in which health care is certain to be a galvanizing issue. Joseph R. Biden Jr., the presumptive Democratic nominee, continues to support improving and expanding the A.C.A. with an option to buy a public plan, rather than replacing it with a “Medicare for all” system preferred by many in the left wing of the party.
The law is offering a vast majority of newly unemployed people a path to stopgap health coverage, providing a cushion that did not exist during the last crushing recession — or ever before. But the crisis has also highlighted fundamental weaknesses with its patchwork system — ones magnified by Republican efforts to undermine and dismantle it, but also seized on by some Democrats pushing for a sweeping overhaul.
On Thursday, as the coronavirus pandemic surged and the country reported a daily record in new virus cases, the Trump administration continued the Republican Party’s push to abolish the law. Shortly before midnight, the Justice Department filed a brief asking the Supreme Court to overturn the law, in a case brought by a group of Republican attorneys general.
The case is likely to be argued this fall during the closing stages of a bitter presidential election in which health care is certain to be a galvanizing issue. Joseph R. Biden Jr., the presumptive Democratic nominee, continues to support improving and expanding the A.C.A. with an option to buy a public plan, rather than replacing it with a “Medicare for all” system preferred by many in the left wing of the party.
As
those political and legal battles play out, how the law actually works
in the coming months of intense need could go a long way toward
determining its durability and future.
“This is the first test of the A.C.A. in an economic downturn,” said Peter V. Lee, the executive director of Covered California, the state’s insurance marketplace created under the law. “But it’s not just a test — it’s a national study of what happens in states that implemented the A.C.A. as opposed to those that didn’t.”
Four out of every five people who have lost employer-provided health insurance during the coronavirus pandemic are eligible for free coverage through expanded Medicaid programs or government-subsidized private insurance, according to the Kaiser Family Foundation, a nonpartisan health research group. And many jobless 20-somethings have been able to join their parents’ plans. All three options were made possible by the law.
Yet others have fallen through the holes in the law’s safety net. Nearly three million low-income people are ineligible for assistance in the 14 states that have declined to expand Medicaid under the law, including Texas, Florida and others, mostly in the South, where coronavirus cases are now spiking. Many people who have qualified for government subsidies to buy private plans still face unaffordable co-pays and deductibles.
David Exum, of Kannapolis, N.C., has experienced both the benefits and the shortcomings of the law. He lost his health coverage when he was laid off from his job as a web content coordinator in March. He is now paying just $1 a month for a subsidized plan.
“This is the first test of the A.C.A. in an economic downturn,” said Peter V. Lee, the executive director of Covered California, the state’s insurance marketplace created under the law. “But it’s not just a test — it’s a national study of what happens in states that implemented the A.C.A. as opposed to those that didn’t.”
Four out of every five people who have lost employer-provided health insurance during the coronavirus pandemic are eligible for free coverage through expanded Medicaid programs or government-subsidized private insurance, according to the Kaiser Family Foundation, a nonpartisan health research group. And many jobless 20-somethings have been able to join their parents’ plans. All three options were made possible by the law.
Yet others have fallen through the holes in the law’s safety net. Nearly three million low-income people are ineligible for assistance in the 14 states that have declined to expand Medicaid under the law, including Texas, Florida and others, mostly in the South, where coronavirus cases are now spiking. Many people who have qualified for government subsidies to buy private plans still face unaffordable co-pays and deductibles.
David Exum, of Kannapolis, N.C., has experienced both the benefits and the shortcomings of the law. He lost his health coverage when he was laid off from his job as a web content coordinator in March. He is now paying just $1 a month for a subsidized plan.
It
is a big improvement from the last recession, he said, when he became
uninsured for several years after losing his job and getting divorced.
But for Mr. Exum, 53, the law is imperfect.
His plan is cheap because it has a high deductible — $6,900 a year. Worse, if his unemployment benefits expire before he finds a new job, and his income drops below the poverty line, he will lose his premium subsidies and will no longer be able to afford the plan. But because of a quirk in the law, he would not be eligible for Medicaid in that situation, because North Carolina has not expanded the program to cover many low-income men.
“I know there are millions in the same boat,” said Mr. Exum, who has been walking a mile or two a day to stay healthy during the pandemic. “It’s just really scary.”
The strange glitch exists because the law originally required all states to expand Medicaid, and thus did not set up a system of subsidies for the poorest Americans to buy private coverage. The Supreme Court ultimately ruled that states could opt out of expanding Medicaid, but Congress, bitterly divided over the law, never fixed the glitch.
“The pandemic has exposed some of the glaring weaknesses in the A.C.A.,” said Paul Starr, a professor of sociology and public affairs at Princeton who served as a health policy adviser to the Clinton administration. “When millions of workers lose their jobs, most of them also lose their health coverage, and the A.C.A. does not provide for any automatic backup or means of transferring coverage to a publicly subsidized alternative.”
“To be sure, we are better off with the A.C.A. than without it,” Mr. Starr added, “but we ought to be prepared to go beyond it and create a system that doesn’t leave so many Americans in the lurch.”
The A.C.A. brought the country’s uninsured rate down to record lows several years after it was enacted in 2010, but even before the pandemic some 28 million people had no coverage. Still, an analysis by the Kaiser Family Foundation estimated that 27 million Americans could have lost job-based health coverage between March and May, and that a vast majority of them — 79 percent — are eligible for new coverage from Medicaid or subsidized private plans.
His plan is cheap because it has a high deductible — $6,900 a year. Worse, if his unemployment benefits expire before he finds a new job, and his income drops below the poverty line, he will lose his premium subsidies and will no longer be able to afford the plan. But because of a quirk in the law, he would not be eligible for Medicaid in that situation, because North Carolina has not expanded the program to cover many low-income men.
“I know there are millions in the same boat,” said Mr. Exum, who has been walking a mile or two a day to stay healthy during the pandemic. “It’s just really scary.”
The strange glitch exists because the law originally required all states to expand Medicaid, and thus did not set up a system of subsidies for the poorest Americans to buy private coverage. The Supreme Court ultimately ruled that states could opt out of expanding Medicaid, but Congress, bitterly divided over the law, never fixed the glitch.
“The pandemic has exposed some of the glaring weaknesses in the A.C.A.,” said Paul Starr, a professor of sociology and public affairs at Princeton who served as a health policy adviser to the Clinton administration. “When millions of workers lose their jobs, most of them also lose their health coverage, and the A.C.A. does not provide for any automatic backup or means of transferring coverage to a publicly subsidized alternative.”
“To be sure, we are better off with the A.C.A. than without it,” Mr. Starr added, “but we ought to be prepared to go beyond it and create a system that doesn’t leave so many Americans in the lurch.”
The A.C.A. brought the country’s uninsured rate down to record lows several years after it was enacted in 2010, but even before the pandemic some 28 million people had no coverage. Still, an analysis by the Kaiser Family Foundation estimated that 27 million Americans could have lost job-based health coverage between March and May, and that a vast majority of them — 79 percent — are eligible for new coverage from Medicaid or subsidized private plans.
In
the 36 states that expanded Medicaid, the Kaiser analysis predicted
that 14 million people would qualify for the free program and another
3.5 million would qualify for subsidized A.C.A. plans.
Some states are already seeing spikes in Medicaid enrollment — in May alone, enrollment jumped by 8.4 percent in Minnesota and by 8.2 percent in Kentucky, according to the Georgetown Center for Children and Families — and experts anticipate bigger jumps, straining state budgets, in the coming months. So far, during the pandemic, nearly 800,000 people have signed up for new private plans through the law’s marketplaces.
In Boise, Idaho, Jeremy Bratsman was laid off from his job as a regional manager in January, and was still searching for work when the economy started shutting down in March. Mr. Bratsman, 43, has Type 1 diabetes; a few years ago, he paid $15,000 for insulin and other supplies over the course of a year while uninsured. Now, though, he qualifies for Medicaid with his wife and four sons because Idaho expanded the program in January.
“I’ve talked to other uninsured diabetics,” his wife, Rebecca Bratsman, said. “And when they are in one of those states that hasn’t expanded, I just tell them to move. They don’t have any option.”
In states that do not run their own A.C.A. marketplaces, Republican efforts to weaken the law have made enrollment in new private plans during the pandemic more challenging. For example, the Trump administration all but eliminated funding for outreach in those states, including grants to nonprofit organizations that help people enroll in new coverage. Anyone who becomes uninsured after losing a job is eligible to sign up for a marketplace plan for 60 days afterward, but the administration has done little to raise awareness.
https://www.nytimes.com/2020/06/27/health/coronavirus-obamacare-unemployment-health-coverage.html?action=click&module=Well&pgtype=Homepage§ion=Health
Some states are already seeing spikes in Medicaid enrollment — in May alone, enrollment jumped by 8.4 percent in Minnesota and by 8.2 percent in Kentucky, according to the Georgetown Center for Children and Families — and experts anticipate bigger jumps, straining state budgets, in the coming months. So far, during the pandemic, nearly 800,000 people have signed up for new private plans through the law’s marketplaces.
In Boise, Idaho, Jeremy Bratsman was laid off from his job as a regional manager in January, and was still searching for work when the economy started shutting down in March. Mr. Bratsman, 43, has Type 1 diabetes; a few years ago, he paid $15,000 for insulin and other supplies over the course of a year while uninsured. Now, though, he qualifies for Medicaid with his wife and four sons because Idaho expanded the program in January.
“I’ve talked to other uninsured diabetics,” his wife, Rebecca Bratsman, said. “And when they are in one of those states that hasn’t expanded, I just tell them to move. They don’t have any option.”
In states that do not run their own A.C.A. marketplaces, Republican efforts to weaken the law have made enrollment in new private plans during the pandemic more challenging. For example, the Trump administration all but eliminated funding for outreach in those states, including grants to nonprofit organizations that help people enroll in new coverage. Anyone who becomes uninsured after losing a job is eligible to sign up for a marketplace plan for 60 days afterward, but the administration has done little to raise awareness.
https://www.nytimes.com/2020/06/27/health/coronavirus-obamacare-unemployment-health-coverage.html?action=click&module=Well&pgtype=Homepage§ion=Health
Maine Hospitals Seek Millions In Assistance To Make Up For Losses Tied To Pandemic
by Irwin Gratz - Maine Public - June 25, 2020
Maine Hospitals and physicians are the latest to warn that they will need financial help because of losses tied to the coronavirus pandemic. Hospitals are asking the state for $100 million in assistance, while independent physicians are seeking $20 million.As Maine Hospital Association Vice President Jeffrey Austin told Maine Public's Irwin Gratz, the pandemic has hit hospital revenues on an number of fronts:
Ed. note: this interview has been edited for length and clarity
Austin: In March, when everyone realized that this was a big pandemic and something that's going to affect life, both the President and the Governor directed hospitals to cease elective procedures. And elective procedures kind of get a bad name, it sort of implies it's not necessary, but it's really the scheduling that's elective. That led to a drop in hospital activity and, accordingly, hospital revenue of about 50%. So literally overnight, the workload and the revenue coming in dropped by 50%, the idea being that no one knew how many people were going to get COVID and, more importantly, how many were going to get hospitalized. So one of the goals was to sort of clear capacity.
The second thing was some of the equipment necessary that we've all heard about, the PPE, masks and so forth, needed to be preserved. So not using them for elective surgeries, and instead preserving them for COVID. Thankfully, we didn't have the feared surge like New York City or Italy. But the work was still done, or the work was still delayed and not done, as the case may be, and revenues plummeted at hospitals and private medical practices across the state.
Gratz: All right, as you know, not all hospitals are the same. Was there a particular kind, big or small, urban or rural, which has had a greater need?
Oddly, no, it's been one of the stories of this pandemic that, not only within Maine — there has been a range of hospitals large and small, urban and rural, as you said — but across the country, as we talk to our colleagues, the revenue picture was the same. It was about half everywhere. And where COVID was active was not consistent across the country or across the state. So Maine Medical Center in Portland has absorbed a lot of the cases in Maine and hospitals in New York and so on and so forth. But, in terms of the drop in electives or the drop the non-emergent surgeries and workload, that was really consistent across the state and across the country at around 50%.
Where do you think the state might get the money that you're seeking?
One, the Medicaid program has seen a lighter caseload and lighter expenditures. So they've actually saved some money from people not going to the hospital. It's not just Medicaid, obviously, private payers and all the like, but to the extent that the workload was not coming in, and we weren't receiving revenues, payers were not paying revenues. So we think there is some excess Medicaid capacity in the budget. The federal government increased its share of what it pays for Medicaid. That's one of the ways they provided relief. So in a few different ways, the Medicaid program should have some money to provide some relief.
But then the other issue will be the $1.25 billion that the feds have provided to the state. Would that be available for some of these hospitals? We think it will. And if it's not clear now, we're hopeful that in the next federal package, though, they'll make that clear that it can be used in this way.
So the hospitals are seeking — I just want to also be straight — the hospitals are asking for about $100 million?
Correct. And then the independent physicians who are not employed with hospitals — many are right now but some are not — they're also seeking about $20 million, because they've had a similar experience.
What could happen if the hospitals can't get access to this extra money?
I appreciate you asking that. In any given year, out of Maine's 36 hospitals, a little over half are losing money. They're in the red. And several hospitals, I think eight, have been in the red for at least five consecutive years. Two are already trying to restructure in bankruptcy. So we need this relief to make sure that that does not grow.
https://www.mainepublic.org/post/maine-hospitals-seek-millions-assistance-make-losses-tied-pandemic
I’m a Health Care Worker. You Need to Know How Close We Are to Breaking.
Now it’s hospital staff in Arizona who are being challenged by the coronavirus, and that didn’t have to be.
By
Now it’s hospital staff in Arizona who are being challenged by the coronavirus, and that didn’t have to be.
Dr.
Dreifuss is director of rural and global emergency medicine programs at
the University of Arizona College of Medicine at Tucson.
Emergency medical and critical-care
team members are canaries in the coal mine. When we are understaffed
and overworked, when there is no staff to triage patients, when more and
more patients are piling up at the emergency department door, the
system breaks down, then people break down. You can borrow ventilators
(until you can’t) and make more personal protective equipment (we hope).
You cannot magically produce more nurses, respiratory therapists,
physicians or other professionals.
My colleagues and I witnessed the physical and emotional devastation of the health care work force in Wuhan, China; in Italy; in New York. Health care workers were catching the coronavirus on the front lines, getting sick, getting their families sick, dying. We saw them suffer the lasting scars of feeling helpless in the face of this new coronavirus, unable to save their patients or themselves. We did what we could to prepare ourselves for when the pandemic would hit our community, knowing it was just a matter of time.
A group of us from a variety of backgrounds began building a coalition called HCW Hosted to help local health care workers find quarantine housing to isolate from our families. We have since added other services: health-status monitoring, emotional-health support and psychological first aid. These support services have helped fill some of the gaps our employers and government infrastructure have failed to address. But even if every city and town had an organization like HCW Hosted, that would still be only part of what is needed to mitigate the impact of Covid-19.
I get angry when I see people refuse to wear a mask or physically distance from others or stay home when they could because it is inconvenient — or as a political statement. If you do not wear a mask and physically distance, you are putting yourself and others in harm’s way. You are putting us in harm’s way. Then you will expect us to risk our lives to save you. And it’s not just we whom you ask to risk our lives, but our families as well. What you are saying to people like me and my team is, “Your life and the lives of your loved ones do not matter to us; you are disposable.”
I am willing to sacrifice for the greater good of the public. I took an oath to that effect when I became a physician. But the public has to sacrifice some too if we want to get through this as safely as possible — social scientists call this “health citizenship.” It means contacting your elected representatives and imploring them to follow public health science when they set policy — and voting out those who won’t. It means demanding the health care systems protect the well-being of staffs. And yes, it means wearing a mask, staying home when possible and practicing physical distancing so that our hospitals and care facilities are not swamped and we are not overwhelmed.
Your sacrifices of comfort and convenience make a difference — for your family, your neighbors, your health care workers and your access to quality health care in the future if you need it. I hope you don’t visit me or my team in the hospital anytime soon, but should you need to come see us, we want to be available and able to provide you the best possible care.
To do that, we need you to be part of our team.
https://www.nytimes.com/2020/06/26/opinion/coronavirus-arizona-hospitals.html
GOVERNMENT PUBLIC health officials in normal times are
entrusted with thankless duties — tracking down the source of food
poisoning, monitoring the spread of influenza, keeping tabs on water
quality. Now, the coronavirus pandemic, and President Trump’s perverse response to it, have thrown these public servants into a vortex of fury, exposing them to threats from an angry population and pressure from political leaders. They deserve better.
Opponents
of a mask order recently came to the house of Chris Farnitano, a public
health officer in Contra Costa County, across the bay from
San Francisco. On the sidewalk, they drew an arrow pointing to his
residence, according to the Los Angeles Times.
“Tyranny is not the answer,” someone wrote in chalk. In Orange County,
in Southern California, late last month, an angry group spoke out at a
county supervisors meeting against an order requiring face coverings.
“One person suggested that the order might make it necessary to invoke
Second Amendment rights to bear arms, while another read aloud the home
address of the order’s author — the county’s chief health officer, Dr.
Nichole Quick,” according to a report
by Kaiser Health News. She was later given personal protection from the
sheriff, and then, after another meeting that included criticism from
the board of supervisors, resigned. Seven senior public health officials
in California have quit since the pandemic began.
Amy Acton, the Ohio health director, drew widespread praise for her calm demeanor and her participation in Republican Gov. Mike DeWine’s decisive and rapid response to the pandemic. But as the lockdown stretched on, protesters demonstrated in front of her house. Outside the statehouse, a protester held up a sign saying, “Dr. Amy is Killing Ohio!” Ms. Acton resigned on June 11 but remains an adviser to Mr. DeWine.
It is difficult to maintain public trust in the teeth of widespread anxiety, harder when circumstances call for unpopular measures. But these inevitable challenges have been compounded by Mr. Trump’s instinct to politicize the pandemic response and drag it into the culture wars. The president eggs on anti-lockdown demonstrators with calls to “liberate” their states; he refuses to wear a mask; he spouts nonsense about the virus fading away; he endorses therapies that are useless or worse. The resulting hostility and disrespect for science and medicine is corrosive and counterproductive. The nation can ill afford to lose public health expertise. It needs the best advice that public health professionals can muster at this moment of extreme duress.
https://www.washingtonpost.com/opinions/theres-a-war-raging-against-health-officials-we-cant-afford-to-lose-their-expertise/2020/06/26/8d8f4580-b7d8-11ea-aca5-ebb63d27e1ff_story.html
It
seems like ages ago now, but just a few months ago Democrats were
engaged in an intense and often bitter argument about precisely what
kind of health-care reform the federal government should undertake if a
Democratic president and Congress are elected this November. Lately most
Americans have been far too consumed with the pandemic and the
recession to think about reform that might or might happen in the future
— which is just fine with Republicans.
But
they won’t be able to keep the issue out of people’s minds for long.
Two things will put it back on the agenda. First, as we approach
November, Democrats all over the country will be airing ads and sending
out mailers about health care, most of which will focus not on the
nuances of reform but on the villainy of the GOP.
And second, the issue could come back to the Supreme Court just before the election, casting a new light on the destruction Republicans are trying to bring down on the American health-care system.
This is, to put mildly, not an opportune time for a party to be arguing for tossing 20 million or so people off their health coverage, eliminating protections for preexisting conditions, and throwing the entire health-care system into chaos.
But that is what the GOP advocates: The latest of Republicans' many lawsuits against the Affordable Care Act seeks to have the entire law struck down, which would not only obliterate an entire regulatory structure with nothing to replace it but would also snatch coverage away from all those who benefited from the expansion of Medicaid and take away subsidies that help those on the individual market afford private coverage.
And incredibly, a decade after they made “repeal and replace” their health-care mantra, Republicans still have no replacement plan.
As the New York Times reports, the issue is poised to come back onto the agenda, which is just about the last thing vulnerable Republicans want:
Back in May,
Attorney General William Barr, showing a brief flash of political
pragmatism, advised the president that the administration might want to
modify its support for the lawsuit, brought by a group of Republican
states, that seeks to have the ACA torn out root and branch. President
Trump said no, insisting that full repeal must be the administration’s
position.
That lawsuit will be heard by the Supreme Court sometime in the fall. Although the decision probably won’t come until next year, shortly before the election we could have dramatic oral arguments in which Republicans publicly defend their plan to eviscerate the health-care system and throw millions off their coverage, while Democrats argue for maintaining the somewhat shaky protections Americans now enjoy.
You can see why Republicans are getting worried.
Even before the pandemic hit, the administration was working to take away as many people’s health coverage as possible, by undercutting Medicaid, trying to scare immigrants away from signing up for benefits they’re eligible for, and any number of other little-noticed policy changes. In a move that was unusually cruel even for this cruelest of administrations, officials even sought to make it easier to discriminate against transgender Americans in health care.
And now, the pandemic has underscored how vulnerable so many Americans are. In May, the Kaiser Family Foundation estimated that 27 million Americans could lose employer-based coverage as a consequence of the pandemic and the suspension of economic activity; while many were able to scramble to find alternative coverage, anxiety around health care is as high as it has ever been.
I would argue that this moment creates an opportunity for real reform, even of some kinds that weren’t being widely discussed when Democratic candidates were having this debate during the primaries. In particular, the fact that most of us get coverage through our employers is an accident of history that we could and should do away with, since it makes us so much more vulnerable to sudden shocks, whether personal (losing your job) or national (a pandemic).
The truth is that Democrats have long been skittish about ambitious health-care reform — they’d like to do it, but they’re always worried that it will be too difficult and the voters will punish them for it. I’m sure Joe Biden feels that way. Nevertheless, the plan he put out last July is radically progressive compared with the ACA itself, even if, as he often does, he was simply finding the center point within the Democratic Party. It’s just that that center point had moved left, so he was proposing something that sounded moderate.
While there’s no question Biden will set health-care reform in motion if he becomes president, we have no idea how hard he’s willing to fight or where he’ll compromise. But right now, nobody is talking about the details of his plan.
The reality is that from now until November, there will be a stark contrast: Republicans are trying to take away people’s health care, and Democrats aren’t. The president may spit up the occasional hairball of an attack about how Democrats are trying to create “socialism,” but he can’t divert attention from that simple binary.
It might have been different if Trump had told his allies to drop the lawsuit, or even come up with an alternative for reform. But it’s clear that he and his party were never going to be capable of doing something constructive on health care. And now they’re going to pay the price.
https://www.washingtonpost.com/opinions/2020/06/23/political-disaster-is-looming-republicans-health-care/
In
other words, Republicans’ insistence that they have a superior
alternative to Obamacare is a zombie lie — a claim that should be dead
after having been proved false again and again, but it is still
shambling along, eating people’s brains.
But why can’t Republicans come up with a better alternative to Obamacare? Are they just incompetent? Possibly — but even if they did know what they were doing, they couldn’t produce a superior plan, because no such plan is possible. In particular, unless you’re willing to move left instead of right, by going for single payer, the only way to guarantee coverage for Americans with pre-existing conditions is a system that looks a lot like Obamacare.
The logic here has been clear from the beginning. To ensure coverage of people with pre-existing conditions, you have to prohibit insurers from discriminating based on medical history. But that’s not enough: To provide a decent risk pool, you also have to induce healthy people to sign up, preferably with both subsidies and a penalty for being uninsured. In other words, you need a system that is basically Obamacare.
The 2017 tax cut, which did away with the individual mandate — the penalty for noninsurance — weakened the system; you can see this by the fact that states, like New Jersey, that imposed their own mandates saw a drop in insurance premiums. But the design of the subsidies, which insulated most people from rising premiums, contained the damage: The percentage of Americans without health insurance, which fell sharply as a result of Obamacare, remains near record lows.
So is there any alternative to Obamacare? Of course there is. We could go back to being a country in which people with pre-existing conditions and/or low incomes can’t get health insurance, where for a large fraction of the population illness either goes untreated or leads to bankruptcy. That would, in part, mean becoming a country in which Americans who caught Covid-19 during the pandemic would be uninsurable for the rest of their lives.
Indeed, turning us back into that kind of country is the G.O.P.’s true goal, and is what will happen if the party gets its way either as a result of the current lawsuit or through legislation during a second Trump term.
But Republicans can’t admit that this is their goal. The public overwhelmingly supports protection for Americans with pre-existing conditions, so right-wing politicians have to pretend they can provide that while dismantling the regulations and subsidies such protection requires. And they have to hope that voters won’t remember that they have been promising a plan, but never delivering, for more than a decade.
Let’s hope voters are smarter than that. Fool me once, shame on you. Fool me 70 times and counting, shame on me.
https://www.nytimes.com/2020/06/29/opinion/obamacare-coronavirus-republicans.html?
The
Trump administration has taken steps to limit patients’ out-of-pocket
costs for coronavirus testing and treatment, using relief funds to reimburse providers
for uninsured patients’ bills. Insurers are required to cover patients’
coronavirus tests with no cost-sharing or co-payments. Alex Azar, the
health and human services secretary, reiterated that commitment in a Sunday interview on CNN, saying, “If you are uninsured, it will be covered by us.”
The testing experience of the Texas group suggests that it doesn’t always work out that way. Some emergency rooms charge cash prices and tack on testing fees that insurers are not required to cover. In this case, the patient who paid cash actually got the best deal. Mr. Harvey has health insurance but felt it would be a “hassle” to use it for the coronavirus test. So he paid for his test with two $100 bills after receiving the nasal swab, and was on his way.
https://www.nytimes.com/2020/06/29/upshot/coronavirus-tests-unpredictable-prices.html?r
TUCSON, Ariz. — As I write this, I have just finished my
ninth consecutive overnight shift as an emergency medicine physician
here. At the end of each shift I go to an Airbnb, where I have been
living alone for two and a half months, away from my wife and
10-year-old daughter so that I am less likely to pass the coronavirus on
to them.
In a medical crisis, my job is to manage a clinical team, problem-solve and be in control. It is hard to admit that I feel vulnerable and scared when I think of the Covid-19 surge we are facing now and the combined Covid-19 and influenza tsunami expected later this year. But I am admitting it because you need to know how close health care workers are to breaking.
My colleagues and I watched what happened this spring in New York with horror and hoped we could avoid the same from happening in our state. But our federal and state governments abandoned their duty and let the virus terrorize our vulnerable communities, spreading rampantly. Now we are beginning to experience what hospitals in the Northeast went through months ago.
When Arizona and other states started to open back up in May, public health experts predicted a surge of Covid-19 cases. That surge is just beginning. We see a steady increase in patients arriving at the emergency department with Covid-19 symptoms. Every day Arizona sets a record high for daily cases. As of today, over twice as many Arizonans are hospitalized for Covid-19 symptoms as were on June 1.
In a medical crisis, my job is to manage a clinical team, problem-solve and be in control. It is hard to admit that I feel vulnerable and scared when I think of the Covid-19 surge we are facing now and the combined Covid-19 and influenza tsunami expected later this year. But I am admitting it because you need to know how close health care workers are to breaking.
My colleagues and I watched what happened this spring in New York with horror and hoped we could avoid the same from happening in our state. But our federal and state governments abandoned their duty and let the virus terrorize our vulnerable communities, spreading rampantly. Now we are beginning to experience what hospitals in the Northeast went through months ago.
When Arizona and other states started to open back up in May, public health experts predicted a surge of Covid-19 cases. That surge is just beginning. We see a steady increase in patients arriving at the emergency department with Covid-19 symptoms. Every day Arizona sets a record high for daily cases. As of today, over twice as many Arizonans are hospitalized for Covid-19 symptoms as were on June 1.
Patients
are evaluated, stabilized and admitted to an inpatient medical team.
But many admitted patients remain in the emergency department,
“boarding” while awaiting transfer to the hospital wards because there
are no more intensive-care beds available in the hospital or there is insufficient staff to care for them in the beds that are available.
Because of that, far fewer emergency department beds are available for people with non-Covid-19 health conditions and medical emergencies. So sick people wait for an emergency department bed to become available. The surge in cases night after night shows no sign of slowing and it is terrifying.
The media has reported how few hospital beds are available in the state. But even if we had enough beds, it wouldn’t matter if our staff wasn’t physically and emotionally well enough to attend to the people occupying those beds. Many hospital systems have chosen to furlough staff and tighten belts even as health care teams were beginning to feel the psychological strain of the pandemic. Physicians are a small part of our clinical care teams. We are profoundly limited in what we can do without the support of nurses, paramedics, emergency and intensive-care technicians, respiratory therapists, radiology technicians, environmental services workers, social workers, case managers, unit coordinators, clinical pharmacists and others.
Health care workers are exhausted. Staffing shortages and increasing fatigue are the new normal for emergency departments, intensive-care units and Covid-19 units, and across hospital wards. Staffing levels are being set with an emphasis on “productivity” as determined by financial calculations rather than clinical severity or the complex needs of our patients and the community we serve.
Staff members call in sick or feel so emotionally drained that they need a mental health day to face another shift on the front lines. Staffing shortages are being made even worse by the furloughs of some of our most experienced team members. Inexperienced new nurses remain and plunge into caring for increasingly ill patients with less mentorship and support.
Because of that, far fewer emergency department beds are available for people with non-Covid-19 health conditions and medical emergencies. So sick people wait for an emergency department bed to become available. The surge in cases night after night shows no sign of slowing and it is terrifying.
The media has reported how few hospital beds are available in the state. But even if we had enough beds, it wouldn’t matter if our staff wasn’t physically and emotionally well enough to attend to the people occupying those beds. Many hospital systems have chosen to furlough staff and tighten belts even as health care teams were beginning to feel the psychological strain of the pandemic. Physicians are a small part of our clinical care teams. We are profoundly limited in what we can do without the support of nurses, paramedics, emergency and intensive-care technicians, respiratory therapists, radiology technicians, environmental services workers, social workers, case managers, unit coordinators, clinical pharmacists and others.
Health care workers are exhausted. Staffing shortages and increasing fatigue are the new normal for emergency departments, intensive-care units and Covid-19 units, and across hospital wards. Staffing levels are being set with an emphasis on “productivity” as determined by financial calculations rather than clinical severity or the complex needs of our patients and the community we serve.
Staff members call in sick or feel so emotionally drained that they need a mental health day to face another shift on the front lines. Staffing shortages are being made even worse by the furloughs of some of our most experienced team members. Inexperienced new nurses remain and plunge into caring for increasingly ill patients with less mentorship and support.
My colleagues and I witnessed the physical and emotional devastation of the health care work force in Wuhan, China; in Italy; in New York. Health care workers were catching the coronavirus on the front lines, getting sick, getting their families sick, dying. We saw them suffer the lasting scars of feeling helpless in the face of this new coronavirus, unable to save their patients or themselves. We did what we could to prepare ourselves for when the pandemic would hit our community, knowing it was just a matter of time.
A group of us from a variety of backgrounds began building a coalition called HCW Hosted to help local health care workers find quarantine housing to isolate from our families. We have since added other services: health-status monitoring, emotional-health support and psychological first aid. These support services have helped fill some of the gaps our employers and government infrastructure have failed to address. But even if every city and town had an organization like HCW Hosted, that would still be only part of what is needed to mitigate the impact of Covid-19.
I get angry when I see people refuse to wear a mask or physically distance from others or stay home when they could because it is inconvenient — or as a political statement. If you do not wear a mask and physically distance, you are putting yourself and others in harm’s way. You are putting us in harm’s way. Then you will expect us to risk our lives to save you. And it’s not just we whom you ask to risk our lives, but our families as well. What you are saying to people like me and my team is, “Your life and the lives of your loved ones do not matter to us; you are disposable.”
I am willing to sacrifice for the greater good of the public. I took an oath to that effect when I became a physician. But the public has to sacrifice some too if we want to get through this as safely as possible — social scientists call this “health citizenship.” It means contacting your elected representatives and imploring them to follow public health science when they set policy — and voting out those who won’t. It means demanding the health care systems protect the well-being of staffs. And yes, it means wearing a mask, staying home when possible and practicing physical distancing so that our hospitals and care facilities are not swamped and we are not overwhelmed.
Your sacrifices of comfort and convenience make a difference — for your family, your neighbors, your health care workers and your access to quality health care in the future if you need it. I hope you don’t visit me or my team in the hospital anytime soon, but should you need to come see us, we want to be available and able to provide you the best possible care.
To do that, we need you to be part of our team.
https://www.nytimes.com/2020/06/26/opinion/coronavirus-arizona-hospitals.html
Trump’s perverse pandemic response has thrown health officials into a vortex of fury
by The Editorial Board - The Washington Post - June 27, 2020
Amy Acton, the Ohio health director, drew widespread praise for her calm demeanor and her participation in Republican Gov. Mike DeWine’s decisive and rapid response to the pandemic. But as the lockdown stretched on, protesters demonstrated in front of her house. Outside the statehouse, a protester held up a sign saying, “Dr. Amy is Killing Ohio!” Ms. Acton resigned on June 11 but remains an adviser to Mr. DeWine.
As states reopen and more tests are conducted, coronavirus cases
continue to ravage the U.S. The Post spoke with experts to determine
what wave we’re in. (Video: Adriana Usero, Allie Caren/Photo: Sarah
Hashemi/The Washington Post)
Ms. Acton’s experience is being repeated over and over
across the country, even as the virus surges out of control in some
places. Responsibility for public health falls predominantly on states
and counties, and they have borne the brunt of frustration and confusion
over the pandemic. At least 27 state and local health leaders have
resigned, retired or been fired since April across 13 states, a review by
Kaiser Health News and the Associated Press showed. Others have faced
ugly death threats and been forced to ask for security protection.It is difficult to maintain public trust in the teeth of widespread anxiety, harder when circumstances call for unpopular measures. But these inevitable challenges have been compounded by Mr. Trump’s instinct to politicize the pandemic response and drag it into the culture wars. The president eggs on anti-lockdown demonstrators with calls to “liberate” their states; he refuses to wear a mask; he spouts nonsense about the virus fading away; he endorses therapies that are useless or worse. The resulting hostility and disrespect for science and medicine is corrosive and counterproductive. The nation can ill afford to lose public health expertise. It needs the best advice that public health professionals can muster at this moment of extreme duress.
https://www.washingtonpost.com/opinions/theres-a-war-raging-against-health-officials-we-cant-afford-to-lose-their-expertise/2020/06/26/8d8f4580-b7d8-11ea-aca5-ebb63d27e1ff_story.html
A political disaster is looming for Republicans on health care
by Paul Waldman - The Washington Post - June 23, 2020
And second, the issue could come back to the Supreme Court just before the election, casting a new light on the destruction Republicans are trying to bring down on the American health-care system.
This is, to put mildly, not an opportune time for a party to be arguing for tossing 20 million or so people off their health coverage, eliminating protections for preexisting conditions, and throwing the entire health-care system into chaos.
But that is what the GOP advocates: The latest of Republicans' many lawsuits against the Affordable Care Act seeks to have the entire law struck down, which would not only obliterate an entire regulatory structure with nothing to replace it but would also snatch coverage away from all those who benefited from the expansion of Medicaid and take away subsidies that help those on the individual market afford private coverage.
And incredibly, a decade after they made “repeal and replace” their health-care mantra, Republicans still have no replacement plan.
As the New York Times reports, the issue is poised to come back onto the agenda, which is just about the last thing vulnerable Republicans want:
Republicans are increasingly worried that their decade-long push to repeal the Affordable Care Act will hurt them in the November elections, as coronavirus cases spike around the country and millions of Americans who have lost jobs during the pandemic lose their health coverage as well.
The issue will come into sharp focus this week, when the White House is expected to file legal briefs asking the Supreme Court to put an end to the program, popularly known as Obamacare. Speaker Nancy Pelosi, seizing on the moment, will unveil a Democratic bill to lower the cost of health care, with a vote scheduled for next week in the House.
That lawsuit will be heard by the Supreme Court sometime in the fall. Although the decision probably won’t come until next year, shortly before the election we could have dramatic oral arguments in which Republicans publicly defend their plan to eviscerate the health-care system and throw millions off their coverage, while Democrats argue for maintaining the somewhat shaky protections Americans now enjoy.
You can see why Republicans are getting worried.
Even before the pandemic hit, the administration was working to take away as many people’s health coverage as possible, by undercutting Medicaid, trying to scare immigrants away from signing up for benefits they’re eligible for, and any number of other little-noticed policy changes. In a move that was unusually cruel even for this cruelest of administrations, officials even sought to make it easier to discriminate against transgender Americans in health care.
And now, the pandemic has underscored how vulnerable so many Americans are. In May, the Kaiser Family Foundation estimated that 27 million Americans could lose employer-based coverage as a consequence of the pandemic and the suspension of economic activity; while many were able to scramble to find alternative coverage, anxiety around health care is as high as it has ever been.
I would argue that this moment creates an opportunity for real reform, even of some kinds that weren’t being widely discussed when Democratic candidates were having this debate during the primaries. In particular, the fact that most of us get coverage through our employers is an accident of history that we could and should do away with, since it makes us so much more vulnerable to sudden shocks, whether personal (losing your job) or national (a pandemic).
The truth is that Democrats have long been skittish about ambitious health-care reform — they’d like to do it, but they’re always worried that it will be too difficult and the voters will punish them for it. I’m sure Joe Biden feels that way. Nevertheless, the plan he put out last July is radically progressive compared with the ACA itself, even if, as he often does, he was simply finding the center point within the Democratic Party. It’s just that that center point had moved left, so he was proposing something that sounded moderate.
While there’s no question Biden will set health-care reform in motion if he becomes president, we have no idea how hard he’s willing to fight or where he’ll compromise. But right now, nobody is talking about the details of his plan.
The reality is that from now until November, there will be a stark contrast: Republicans are trying to take away people’s health care, and Democrats aren’t. The president may spit up the occasional hairball of an attack about how Democrats are trying to create “socialism,” but he can’t divert attention from that simple binary.
It might have been different if Trump had told his allies to drop the lawsuit, or even come up with an alternative for reform. But it’s clear that he and his party were never going to be capable of doing something constructive on health care. And now they’re going to pay the price.
https://www.washingtonpost.com/opinions/2020/06/23/political-disaster-is-looming-republicans-health-care/
Obamacare Versus the G.O.P. Zombies
Ten years of failed promises to come up with something better.
by Paul Krugman - NYT - June 29, 2020
Covid-19 cases are surging in states that took Donald
Trump’s advice and reopened for business too soon. This new surge — is
it OK now to call it a second wave? — is, on average, hitting people younger
than the initial surge in the Northeast did. Perhaps as a result,
rising infections haven’t been reflected in a comparable rise in deaths,
although that may be only a matter of time.
There is, however, growing evidence that even those who survive Covid-19 can suffer long-term adverse effects: scarred lungs, damaged hearts and perhaps neurological disorders.
And if the Trump administration gets its way, there may be another source of long-term damage: permanent inability to get health insurance.
Remarkably, last week the administration reaffirmed its support for a lawsuit seeking to overturn the Affordable Care Act, which would, among other things, eliminate protection for Americans with pre-existing medical conditions. If the suit were to succeed, having had Covid-19 would surely be one of the pre-existing conditions making health insurance hard, perhaps impossible, to get.
There is, however, growing evidence that even those who survive Covid-19 can suffer long-term adverse effects: scarred lungs, damaged hearts and perhaps neurological disorders.
And if the Trump administration gets its way, there may be another source of long-term damage: permanent inability to get health insurance.
Remarkably, last week the administration reaffirmed its support for a lawsuit seeking to overturn the Affordable Care Act, which would, among other things, eliminate protection for Americans with pre-existing medical conditions. If the suit were to succeed, having had Covid-19 would surely be one of the pre-existing conditions making health insurance hard, perhaps impossible, to get.
Now, the legal argument
behind the case is beyond flimsy: The lawsuit claims that the 2017 tax
cut effectively invalidated the act, even though that was no part of
Congress’s intention. But with a conservative majority on the Supreme
Court, nobody knows what will happen. And Trump’s support for the suit
makes it clear that if re-elected he will do all he can to destroy
Obamacare.
Not
to worry, says the president. In tweets over the weekend he insisted
that he would come up with an alternative to Obamacare that would be
“FAR BETTER AND MUCH LESS EXPENSIVE” while protecting Americans with
pre-existing conditions.
But he’s been claiming to have a much better alternative to Obamacare since he took office. Republicans in Congress, who voted to repeal Obamacare 70 times during the Obama years, have been making the same claim for more than a decade.
Yet somehow the great alternative to the Affordable Care Act has never materialized. In 2017, when the G.O.P. finally came close to repealing the act — failing thanks only to a last-minute change of heart on the part of Senator John McCain — the plan on offer would have stripped away protection for pre-existing conditions and added 23 million Americans to the ranks of the uninsured.
Paul Krugman’s Newsletter: Get a better understanding of the economy — and an even deeper look at what’s on Paul’s mind.
But he’s been claiming to have a much better alternative to Obamacare since he took office. Republicans in Congress, who voted to repeal Obamacare 70 times during the Obama years, have been making the same claim for more than a decade.
Yet somehow the great alternative to the Affordable Care Act has never materialized. In 2017, when the G.O.P. finally came close to repealing the act — failing thanks only to a last-minute change of heart on the part of Senator John McCain — the plan on offer would have stripped away protection for pre-existing conditions and added 23 million Americans to the ranks of the uninsured.
But why can’t Republicans come up with a better alternative to Obamacare? Are they just incompetent? Possibly — but even if they did know what they were doing, they couldn’t produce a superior plan, because no such plan is possible. In particular, unless you’re willing to move left instead of right, by going for single payer, the only way to guarantee coverage for Americans with pre-existing conditions is a system that looks a lot like Obamacare.
The logic here has been clear from the beginning. To ensure coverage of people with pre-existing conditions, you have to prohibit insurers from discriminating based on medical history. But that’s not enough: To provide a decent risk pool, you also have to induce healthy people to sign up, preferably with both subsidies and a penalty for being uninsured. In other words, you need a system that is basically Obamacare.
The 2017 tax cut, which did away with the individual mandate — the penalty for noninsurance — weakened the system; you can see this by the fact that states, like New Jersey, that imposed their own mandates saw a drop in insurance premiums. But the design of the subsidies, which insulated most people from rising premiums, contained the damage: The percentage of Americans without health insurance, which fell sharply as a result of Obamacare, remains near record lows.
So is there any alternative to Obamacare? Of course there is. We could go back to being a country in which people with pre-existing conditions and/or low incomes can’t get health insurance, where for a large fraction of the population illness either goes untreated or leads to bankruptcy. That would, in part, mean becoming a country in which Americans who caught Covid-19 during the pandemic would be uninsurable for the rest of their lives.
Indeed, turning us back into that kind of country is the G.O.P.’s true goal, and is what will happen if the party gets its way either as a result of the current lawsuit or through legislation during a second Trump term.
But Republicans can’t admit that this is their goal. The public overwhelmingly supports protection for Americans with pre-existing conditions, so right-wing politicians have to pretend they can provide that while dismantling the regulations and subsidies such protection requires. And they have to hope that voters won’t remember that they have been promising a plan, but never delivering, for more than a decade.
Let’s hope voters are smarter than that. Fool me once, shame on you. Fool me 70 times and counting, shame on me.
https://www.nytimes.com/2020/06/29/opinion/obamacare-coronavirus-republicans.html?
Two Friends in Texas Were Tested for Coronavirus. One Bill Was $199. The Other? $6,408.
It’s an example of the unpredictable way health prices can vary for patients who receive identical care.
by Sarah Kliff - NYT - June 29, 2020
Before a camping and kayaking trip along the Texas Coast,
Pam LeBlanc and Jimmy Harvey decided to get coronavirus tests. They
wanted a bit more peace of mind before spending 13 days in close
quarters along with three friends.
The two got drive-through tests at Austin Emergency Center in Austin. The center advertises a “minimally invasive” testing experience in a state now battling one of the country’s worst coronavirus outbreaks. Texas recorded 5,799 new cases Sunday, and recently reversed some if its reopening policies.
They both recalled how uncomfortable it was to have the long nasal swab pushed up their noses. Ms. LeBlanc’s eyes started to tear up; Mr. Harvey felt as if the swab “was in my brain.”
Their tests came back with the same result — negative, allowing the trip to go ahead — but the accompanying bills were quite different.
The two got drive-through tests at Austin Emergency Center in Austin. The center advertises a “minimally invasive” testing experience in a state now battling one of the country’s worst coronavirus outbreaks. Texas recorded 5,799 new cases Sunday, and recently reversed some if its reopening policies.
They both recalled how uncomfortable it was to have the long nasal swab pushed up their noses. Ms. LeBlanc’s eyes started to tear up; Mr. Harvey felt as if the swab “was in my brain.”
Their tests came back with the same result — negative, allowing the trip to go ahead — but the accompanying bills were quite different.
The emergency room charged Mr. Harvey $199 in cash. Ms. LeBlanc, who paid with insurance, was charged $6,408.
“I assumed, like an idiot, it would be cheaper to use my insurance than pay cash right there,” Ms. LeBlanc said. “This is 32 times the cost of what my friend paid for the exact same thing.”
Ms. LeBlanc’s health insurer negotiated the total bill down to $1,128. The plan said she was responsible for $928 of that.
During the pandemic, there has been wide variation between what providers bill for the same basic diagnostic test, with some charging $27, others $2,315. It turns out there is also significant variation in how much a test can cost two patients at the same location.
Mr. Harvey and Ms. LeBlanc were among four New York Times readers who shared bills they received from the same chain of emergency rooms in Austin. Their experiences offer a rare window into the unpredictable way health prices vary for patients who receive seemingly identical care.
“I assumed, like an idiot, it would be cheaper to use my insurance than pay cash right there,” Ms. LeBlanc said. “This is 32 times the cost of what my friend paid for the exact same thing.”
Ms. LeBlanc’s health insurer negotiated the total bill down to $1,128. The plan said she was responsible for $928 of that.
During the pandemic, there has been wide variation between what providers bill for the same basic diagnostic test, with some charging $27, others $2,315. It turns out there is also significant variation in how much a test can cost two patients at the same location.
Mr. Harvey and Ms. LeBlanc were among four New York Times readers who shared bills they received from the same chain of emergency rooms in Austin. Their experiences offer a rare window into the unpredictable way health prices vary for patients who receive seemingly identical care.
Three paid with
insurance, and one with cash. Even after negotiations between insurers
and the emergency room, the total that patients and their insurers ended
up paying varied by 2,700 percent.
Such discrepancies arise from a fundamental fact about the American health care system: The government does not regulate health care prices.
Some academic research confirms that prices can vary within the same hospital. One 2015 paper found substantial within-hospital price differences for basic procedures, such as M.R.I. scans, depending on the health insurer.
The researchers say these differences aren’t about quality. In all likelihood, the expensive M.R.I.s and the cheap M.R.I.s are done on the same machine. Instead, they reflect different insurers’ market clout. A large insurer with many members can demand lower prices, while small insurers have less negotiating leverage.
Because health prices in the United States are so opaque, some researchers have turned to their own medical bills to understand this type of price variation. Two health researchers who gave birth at the same hospital with the same insurance compared notes afterward. They found that one received a surprise $1,600 bill while the other one didn’t.
The difference? One woman happened to give birth while an out-of-network anesthesiologist was staffing the maternity ward; the other received her epidural from an in-network provider.
“The additional out-of-pocket charge on top of the other labor and delivery expenses was left entirely up to chance,” the co-authors Erin Taylor and Layla Parast wrote in a blog post summarizing the experience. Ms. Parast, who received the surprise bill, ultimately got it reversed but not until her baby was nearly a year old.
Such discrepancies arise from a fundamental fact about the American health care system: The government does not regulate health care prices.
Some academic research confirms that prices can vary within the same hospital. One 2015 paper found substantial within-hospital price differences for basic procedures, such as M.R.I. scans, depending on the health insurer.
The researchers say these differences aren’t about quality. In all likelihood, the expensive M.R.I.s and the cheap M.R.I.s are done on the same machine. Instead, they reflect different insurers’ market clout. A large insurer with many members can demand lower prices, while small insurers have less negotiating leverage.
Because health prices in the United States are so opaque, some researchers have turned to their own medical bills to understand this type of price variation. Two health researchers who gave birth at the same hospital with the same insurance compared notes afterward. They found that one received a surprise $1,600 bill while the other one didn’t.
The difference? One woman happened to give birth while an out-of-network anesthesiologist was staffing the maternity ward; the other received her epidural from an in-network provider.
“The additional out-of-pocket charge on top of the other labor and delivery expenses was left entirely up to chance,” the co-authors Erin Taylor and Layla Parast wrote in a blog post summarizing the experience. Ms. Parast, who received the surprise bill, ultimately got it reversed but not until her baby was nearly a year old.
The testing experience of the Texas group suggests that it doesn’t always work out that way. Some emergency rooms charge cash prices and tack on testing fees that insurers are not required to cover. In this case, the patient who paid cash actually got the best deal. Mr. Harvey has health insurance but felt it would be a “hassle” to use it for the coronavirus test. So he paid for his test with two $100 bills after receiving the nasal swab, and was on his way.
https://www.nytimes.com/2020/06/29/upshot/coronavirus-tests-unpredictable-prices.html?r
An Economic Perspective
on the Affordable Care Act:
Expectations and Reality
by Sayeh Nikpay, India Pungarcher and Austin Frakt - Journal of Health Policy, politics and Law - June 19, 2020
by Sayeh Nikpay, India Pungarcher and Austin Frakt - Journal of Health Policy, politics and Law - June 19, 2020
The Affordable Care Act (ACA) was enacted in 2010 to address both high
uninsured rates and rising health care spending through insurance expansion reforms
and efforts to reduce waste. It was expected to have a variety of impacts in areas within
the purview of economics, including effects on health care coverage, access to care,
financial security, labor market decisions, health, and health care spending. To varying
degrees, legislative, executive, and judicial actions have altered its implementation,
affecting the extent to which expectations in each of these dimensions have been
realized. We review the ACA’s reforms, the subsequent actions that countered them, and
the expected and realized effects on coverage, access to care, financial security, health,
labor market decisions, and health care spending.
Keywords Affordable Care Act, economics, health policy
Through the 2000s, high health care spending and growing numbers of uninsured were widely viewed as public policy crises (Gruber, Newquist, and Schreiber 2011; Blendon et al. 2006). The Affordable Care Act (ACA) attempts to address both. At the time of its passage, the ACA’s expanded coverage options were expected to have a significant positive impact on the economic conditions of US households through lower spending on pre- miums and out-of-pocket payments, greater financial security, improved job mobility, and improved health. The ACA was also expected to reduce the growth rate of health care spending. Ten years after its passage, we compare expected and realized effects of the ACA on its key economic outcomes: coverage, access to care, financial security, labor market deci- sions, health, and health care spending.
Journal of Health Politics, Policy and Law, Vol. 45, No. 5, October 2020 DOI 10.1215/03616878-8543340 Ó 2020 by Duke University Press
Downloaded from https://read.dukeupress.edu/jhppl/article-pdf/doi/10.1215/03616878-8543340/810284/8543340.pdf by guest
Keywords Affordable Care Act, economics, health policy
Through the 2000s, high health care spending and growing numbers of uninsured were widely viewed as public policy crises (Gruber, Newquist, and Schreiber 2011; Blendon et al. 2006). The Affordable Care Act (ACA) attempts to address both. At the time of its passage, the ACA’s expanded coverage options were expected to have a significant positive impact on the economic conditions of US households through lower spending on pre- miums and out-of-pocket payments, greater financial security, improved job mobility, and improved health. The ACA was also expected to reduce the growth rate of health care spending. Ten years after its passage, we compare expected and realized effects of the ACA on its key economic outcomes: coverage, access to care, financial security, labor market deci- sions, health, and health care spending.
Journal of Health Politics, Policy and Law, Vol. 45, No. 5, October 2020 DOI 10.1215/03616878-8543340 Ó 2020 by Duke University Press
Downloaded from https://read.dukeupress.edu/jhppl/article-pdf/doi/10.1215/03616878-8543340/810284/8543340.pdf by guest
Abstract
890 Journal of Health Politics, Policy and Law
Expected Effects of the ACA on Economic Outcomes
as Enacted
A goal of the ACA was to achieve near-universal coverage through con- sumer protective regulation of private health insurance, an individual health insurance mandate, and subsidies in the form of Medicaid expansion for low-income households and tax credits for middle-income households. The Congressional Budget Office (CBO) and other organizations and scholars estimated the consequences of the ACA on coverage, spending, the labor market, and health.
According to the CBO, the ACA’s reforms were expected to increase coverage by 32 million Americans by 2019 (CBO 2010), enhancing financial security through protection from catastrophic health spending while reducing out-of-pocket costs. By improving the quality and afford- ability of alternatives to employer-sponsored insurance (ESI), the ACA’s coverage gains were also expected to alleviate “job lock,” wherein indi- viduals are discouraged from leaving their job for fear of losing (or paying more for) coverage. The CBO (2014) estimated that the ACA would encourage 2.5 million Americans to leave the labor force by 2023, likely to retire or become self-employed. Despite debate among economists over the causal effect of insurance on health (Frakt 2011), some expected the ACA’s coverage provisions could improve it (Sommers, Gawande, and Baicker 2017).
The second goal of the ACA was to reduce the nation’s health spending growth rate (Cutler 2010). The law, as enacted, attempted to reduce health care spending by various means: increased insurer competition, reduced federal tax subsidies for generous ESI plans (the “Cadillac tax,” subse- quently repealed), and a host of Medicare and Medicaid payment reforms and reimbursement cuts. Reimbursement cuts were focused mainly on hospitals and Medicare Advantage plans, cuts in the growth rate of pay- ments to providers, and “delivery system reforms” (DSRs), which tie payment to quality and/or spending goals. The ACA also included an Independent Medicare Advisory Board, which was charged with cutting reimbursements in the Medicare program should spending exceed a target. However, the CBO never expected the Independent Medicare Advisory Board to produce much in the way of Medicare savings, and the board, which faced daunting political challenges, was ultimately repealed by Congress without ever having been constituted (Oberlander and Spivack 2018).
The CBO estimated that the ACA would lower federal deficits by $198 billion, and that cost-control provisions would reduce federal spending by
Downloaded from https://read.dukeupress.edu/jhppl/article-pdf/doi/10.1215/03616878-8543340/810284/8543340.pdf by guest
Expected Effects of the ACA on Economic Outcomes
as Enacted
A goal of the ACA was to achieve near-universal coverage through con- sumer protective regulation of private health insurance, an individual health insurance mandate, and subsidies in the form of Medicaid expansion for low-income households and tax credits for middle-income households. The Congressional Budget Office (CBO) and other organizations and scholars estimated the consequences of the ACA on coverage, spending, the labor market, and health.
According to the CBO, the ACA’s reforms were expected to increase coverage by 32 million Americans by 2019 (CBO 2010), enhancing financial security through protection from catastrophic health spending while reducing out-of-pocket costs. By improving the quality and afford- ability of alternatives to employer-sponsored insurance (ESI), the ACA’s coverage gains were also expected to alleviate “job lock,” wherein indi- viduals are discouraged from leaving their job for fear of losing (or paying more for) coverage. The CBO (2014) estimated that the ACA would encourage 2.5 million Americans to leave the labor force by 2023, likely to retire or become self-employed. Despite debate among economists over the causal effect of insurance on health (Frakt 2011), some expected the ACA’s coverage provisions could improve it (Sommers, Gawande, and Baicker 2017).
The second goal of the ACA was to reduce the nation’s health spending growth rate (Cutler 2010). The law, as enacted, attempted to reduce health care spending by various means: increased insurer competition, reduced federal tax subsidies for generous ESI plans (the “Cadillac tax,” subse- quently repealed), and a host of Medicare and Medicaid payment reforms and reimbursement cuts. Reimbursement cuts were focused mainly on hospitals and Medicare Advantage plans, cuts in the growth rate of pay- ments to providers, and “delivery system reforms” (DSRs), which tie payment to quality and/or spending goals. The ACA also included an Independent Medicare Advisory Board, which was charged with cutting reimbursements in the Medicare program should spending exceed a target. However, the CBO never expected the Independent Medicare Advisory Board to produce much in the way of Medicare savings, and the board, which faced daunting political challenges, was ultimately repealed by Congress without ever having been constituted (Oberlander and Spivack 2018).
The CBO estimated that the ACA would lower federal deficits by $198 billion, and that cost-control provisions would reduce federal spending by
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Nikpay, Pungarcher, and Frakt - An Economic Perspective on the ACA 891
approximately $416 billion over 10 years, relative to the status quo (CBO
2010; Cutler, Davis, and Stremikis 2010). Economists expected that many
of these mostly federally focused cost-control measures would have
spillover effects on private health spending (Zuckerman and Holahan
2012). Some economists therefore suggested that reforms like those in the
ACA could reduce national health spending by $590 billion over 10 years
relative to the estimated total national health spending over that period
without the ACA, and slow the growth rate of spending by about 10%
(Cutler, Davis, and Stremikis 2010).
Realized Economic Effects of the ACA
Because predicting the future is always uncertain, few estimates about any law’s effects are perfectly accurate. In the case of the ACA in particular, legislative, executive, and judicial actions subsequent to passage had substantial impacts on the realized economic effects, summarized below.
Coverage
Between 2009 and 2018, the uninsured rate decreased from 15.1% to 8.9%, with the largest decrease occurring after implementation of the ACA’s coverage provisions (see table 1). Between 2013 and 2014, the uninsured rate fell from 13.3% of Americans (41.8 million) in 2013 to 7.9% of Americans (25.6 million) in 2014 (Smith and Medalia 2015) (table 1). While slightly larger, this number was similar to the CBO’s projected number of uninsured Americans by 2019 (23 million) (CBO 2010). The number of Americans with coverage in the individual market increased over this period from 11.4% (35.8 million) to 14.1% (46.1 million), while Medicaid enrollment increased from 17.5% (54.9 million) to 19.5% (61.7 million) (Smith and Medalia 2015).
Importantly, the ACA’s coverage gains were not due to the erosion of ESI. The probability of losing ESI changed by less than 1% while rates of gaining nongroup and public coverage among the uninsured increased by 3% and 5%, respectively (Graves and Nikpay 2017). Other work shows that the ACA’s dependent coverage mandate—which allowed dependent children to stay on their parents’ insurance through age 26 — increased ESI by 10% and resulted in 938,000 fewer uninsured young adults (Akosa Antwi, Moriya, and Simon 2013).
Nevertheless, coverage gains have fallen short of CBO estimates. Most of the discrepancy can be attributed to post-ACA legislative, executive, and
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Realized Economic Effects of the ACA
Because predicting the future is always uncertain, few estimates about any law’s effects are perfectly accurate. In the case of the ACA in particular, legislative, executive, and judicial actions subsequent to passage had substantial impacts on the realized economic effects, summarized below.
Coverage
Between 2009 and 2018, the uninsured rate decreased from 15.1% to 8.9%, with the largest decrease occurring after implementation of the ACA’s coverage provisions (see table 1). Between 2013 and 2014, the uninsured rate fell from 13.3% of Americans (41.8 million) in 2013 to 7.9% of Americans (25.6 million) in 2014 (Smith and Medalia 2015) (table 1). While slightly larger, this number was similar to the CBO’s projected number of uninsured Americans by 2019 (23 million) (CBO 2010). The number of Americans with coverage in the individual market increased over this period from 11.4% (35.8 million) to 14.1% (46.1 million), while Medicaid enrollment increased from 17.5% (54.9 million) to 19.5% (61.7 million) (Smith and Medalia 2015).
Importantly, the ACA’s coverage gains were not due to the erosion of ESI. The probability of losing ESI changed by less than 1% while rates of gaining nongroup and public coverage among the uninsured increased by 3% and 5%, respectively (Graves and Nikpay 2017). Other work shows that the ACA’s dependent coverage mandate—which allowed dependent children to stay on their parents’ insurance through age 26 — increased ESI by 10% and resulted in 938,000 fewer uninsured young adults (Akosa Antwi, Moriya, and Simon 2013).
Nevertheless, coverage gains have fallen short of CBO estimates. Most of the discrepancy can be attributed to post-ACA legislative, executive, and
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892 Journal of Health Politics, Policy and Law
Table 1 Affordable Care Act Economic Indicators
Indicator
Fraction of the US population that has { No coverage
Medicaid coverage
Individual market coverage Employer-sponsored coverage
Total US health care spending{ Per capita health care spending { Annual spending growth {
Total health care Medicare Medicaid Private
Monthly benchmark plan premium* Average employer-sponsored
insurance premiums# Family coverage Single coverage
Fraction of individuals in a high-deductible plan#
Average employer-sponsored deductibles#
Fraction of the US population that has { No coverage
Medicaid coverage
Individual market coverage Employer-sponsored coverage
Total US health care spending{ Per capita health care spending { Annual spending growth {
Total health care Medicare Medicaid Private
Monthly benchmark plan premium* Average employer-sponsored
insurance premiums# Family coverage Single coverage
Fraction of individuals in a high-deductible plan#
Average employer-sponsored deductibles#
2009
15.1% 16.2% 13.1% 56.6%
$2.5 trillion $8,131
4.0%
6.8%
8.8%
3.5%
$273 (2014)
$13,375 $4,824 8.0%
$825
15.1% 16.2% 13.1% 56.6%
$2.5 trillion $8,131
4.0%
6.8%
8.8%
3.5%
$273 (2014)
$13,375 $4,824 8.0%
$825
2018
8.9% 20.5% 13.4% 55.2%
$3.6 trillion $11,172
4.6% 6.4% 3.0% 5.8% $481
$19,616 $6,896 29.0%
$1573
8.9% 20.5% 13.4% 55.2%
$3.6 trillion $11,172
4.6% 6.4% 3.0% 5.8% $481
$19,616 $6,896 29.0%
$1573
Change
6.2%
-4.3% -1.2% 1.4%
$1.1 trillion $3,041
—
—
—
—
$6,241 $2,072
$748
-4.3% -1.2% 1.4%
$1.1 trillion $3,041
—
—
—
—
$6,241 $2,072
$748
Notes: All dollar figures are expressed in nominal dollars.
{Census Bureau estimates of health insurance coverage estimates in the United States, 2009
(Denavas-walt, Proctor, and Smith 2010) and 2018 (Berchick, Barnett, and Upton 2019).
{Historical national health expenditure accounts (2019).
*Kaiser Family Foundation average benchmark plan (2019).
$The benchmark plan is the second-lowest cost “silver plan” to which the value of health
insurance subsidies in the ACA marketplaces is pegged.
#Kaiser Family Foundation Employer Health Benefits Annual Survey, 2019 (2019c).
judicial actions. Because some states did not expand Medicaid coverage — made optional by a 2012 Supreme Court ruling—2.3 million Americans are without affordable coverage options, too wealthy to qualify for (non- expanded) Medicaid but too poor to qualify for marketplace subsidies (Garfield, Orgera, and Damico 2020). Elimination of the individual man- date by Congress (Tax Cuts and Jobs Act of 2017, H.R. 1, 115th Cong.), elevation of nonregulated coverage options by executive order (Trump 2017), and regulations that increase barriers to marketplace enrollment such as shortened enrollment periods (DHHS 2017) have further eroded coverage gains. Although the number of individuals enrolled in the ACA’s marketplaces remained relatively stable, falling from 12.2 million to 11.8 million between 2017 and 2018 (KFF 2019b), the uninsured rate did
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{Historical national health expenditure accounts (2019).
*Kaiser Family Foundation average benchmark plan (2019).
$The benchmark plan is the second-lowest cost “silver plan” to which the value of health
insurance subsidies in the ACA marketplaces is pegged.
#Kaiser Family Foundation Employer Health Benefits Annual Survey, 2019 (2019c).
judicial actions. Because some states did not expand Medicaid coverage — made optional by a 2012 Supreme Court ruling—2.3 million Americans are without affordable coverage options, too wealthy to qualify for (non- expanded) Medicaid but too poor to qualify for marketplace subsidies (Garfield, Orgera, and Damico 2020). Elimination of the individual man- date by Congress (Tax Cuts and Jobs Act of 2017, H.R. 1, 115th Cong.), elevation of nonregulated coverage options by executive order (Trump 2017), and regulations that increase barriers to marketplace enrollment such as shortened enrollment periods (DHHS 2017) have further eroded coverage gains. Although the number of individuals enrolled in the ACA’s marketplaces remained relatively stable, falling from 12.2 million to 11.8 million between 2017 and 2018 (KFF 2019b), the uninsured rate did
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Nikpay, Pungarcher, and Frakt - An Economic Perspective on the ACA 893
increase 0.5 percentage points, leaving an additional 1.86 million Ameri-
cans uninsured (Berchick, Barnett, and Upton 2019).
Financial Security and Access to Care
The ACA makes health insurance more affordable to many Americans— especially those with high-cost medical conditions. Acknowledging that such individuals often could not obtain coverage before the ACA, the premium for the average plan in the individual market increased slightly by about 9% between 2009 and 2014 when the ACA’s coverage provisions took effect (Adler and Ginsburg 2016). The cost of a standardized plan used to calculate health insurance subsidies in the marketplace, the benchmark plan premium, has increased from an average of $273 in 2014 to $476 in 2019 (KFF 2019a). Importantly, because marketplace premium subsidies are based on the household’s income and increase when benchmark pre- miums rise, those who purchased marketplace coverage with subsidies should not have paid more for health insurance coverage as a result of rising premiums in the marketplace. However, in theory, elimination of the individual mandate and elevation of nonregulated alternatives to the mar- ketplace plans should have made these new health insurance markets more expensive and less stable. Although estimates of coverage in 2019 — the first year without the individual mandate—are not yet available, multiple studies suggest that the removal of the individual mandate alone should raise the number of uninsured Americans (Fiedler 2020).
With coverage expansion came reduced out-of-pocket spending and increased access to care. Relative to those in nonexpansion states, indi- viduals in Medicaid expansion states are 11% more likely to have no out- of-pocket medical or premium expenditures (Abramowitz 2020), have about $1,000 less in past-due debts (Hu et al. 2016), are 11% less likely to use payday loans (Allen et al. 2017), are 2.8% less likely to file for bank- ruptcy (Caswell and Waidmann 2019), and have greater improvement in credit scores (Brevoort, Grodzicki, and Hackmann 2017). Gaining cover- age increases office-based primary care visits by 24.1% (Biener, Zuvekas, and Hill 2018), prescription drug use by 19% (Ghosh, Simon, and Sommers 2019), and use of certain high-value medical screenings by 9.9–11.6% (Sommers et al. 2017; Guth et al. 2020).
While out-of-pocket spending declined for Americans who gained coverage, per-capita out-of-pocket spending actually increased over all Americans by $3,041 between 2009 and 2018 (table 1). This increase likely results from higher prevalence of high-deductible health insurance plans,
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cans uninsured (Berchick, Barnett, and Upton 2019).
Financial Security and Access to Care
The ACA makes health insurance more affordable to many Americans— especially those with high-cost medical conditions. Acknowledging that such individuals often could not obtain coverage before the ACA, the premium for the average plan in the individual market increased slightly by about 9% between 2009 and 2014 when the ACA’s coverage provisions took effect (Adler and Ginsburg 2016). The cost of a standardized plan used to calculate health insurance subsidies in the marketplace, the benchmark plan premium, has increased from an average of $273 in 2014 to $476 in 2019 (KFF 2019a). Importantly, because marketplace premium subsidies are based on the household’s income and increase when benchmark pre- miums rise, those who purchased marketplace coverage with subsidies should not have paid more for health insurance coverage as a result of rising premiums in the marketplace. However, in theory, elimination of the individual mandate and elevation of nonregulated alternatives to the mar- ketplace plans should have made these new health insurance markets more expensive and less stable. Although estimates of coverage in 2019 — the first year without the individual mandate—are not yet available, multiple studies suggest that the removal of the individual mandate alone should raise the number of uninsured Americans (Fiedler 2020).
With coverage expansion came reduced out-of-pocket spending and increased access to care. Relative to those in nonexpansion states, indi- viduals in Medicaid expansion states are 11% more likely to have no out- of-pocket medical or premium expenditures (Abramowitz 2020), have about $1,000 less in past-due debts (Hu et al. 2016), are 11% less likely to use payday loans (Allen et al. 2017), are 2.8% less likely to file for bank- ruptcy (Caswell and Waidmann 2019), and have greater improvement in credit scores (Brevoort, Grodzicki, and Hackmann 2017). Gaining cover- age increases office-based primary care visits by 24.1% (Biener, Zuvekas, and Hill 2018), prescription drug use by 19% (Ghosh, Simon, and Sommers 2019), and use of certain high-value medical screenings by 9.9–11.6% (Sommers et al. 2017; Guth et al. 2020).
While out-of-pocket spending declined for Americans who gained coverage, per-capita out-of-pocket spending actually increased over all Americans by $3,041 between 2009 and 2018 (table 1). This increase likely results from higher prevalence of high-deductible health insurance plans,
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894 Journal of Health Politics, Policy and Law
including among those with ESI. The fraction of employees enrolled in a
high-deductible plan increased from 8% to 29% between 2009 and 2018.
At the same time, the deductible for an average single plan increased by
$748 (KFF 2019c).
Labor Market Decisions
Although several studies and the CBO predicted large increases in self- employment and retirement (Nikpay 2020; Blumberg, Corlette, and Lucia 2013; CBO 2010), there is little evidence they materialized. Older adults in Medicaid expansion states are no less likely to work full-time than similar adults in nonexpansion states (Levy, Buchmueller, and Nikpay 2018). The ACA’s dependent coverage provisions also did not lead to changes in labor market decisions (Heim, Lurie, and Simon 2015). Other than the broad inference that new coverage options under the law may not be sufficiently attractive to draw people out of the labor force (despite predictions to the contrary), it is not clear specifically why. One possibility is that the near- continuous attacks on and erosion of the law’s provisions raised doubts about the durability of its protections.
Health
The preponderance of evidence suggests that health insurance improves health. Therefore, it is not surprising that those who gained coverage through the ACA’s Medicaid expansion (Burns and Wolfe 2016; Graves et al. 2020) or extension of employer-sponsored coverage to young adults (Barbaresco, Courtemanche, and Qi 2015) saw gains in self-reported health. Two recent studies showed that the ACA’s coverage provisions reduce mortality. Linking mortality and survey data on Americans who were the targets of the ACA Medicaid expansion, Miller and colleagues (2019) found that the Medicaid expansion averted 19,200 deaths over its first four years. Goldin, Lurie, and McCubbin (2019) used a randomized field trial to compare uninsured individuals who signed up for marketplace coverage to those who did not and found a large 2.4% reduction in mortality for each month of coverage gained.
Health Care Spending
The ACA was expected to modestly reduce the growth of health spending. Federal Medicare spending growth has slowed from 6.8% in 2009 to 6.4%
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Labor Market Decisions
Although several studies and the CBO predicted large increases in self- employment and retirement (Nikpay 2020; Blumberg, Corlette, and Lucia 2013; CBO 2010), there is little evidence they materialized. Older adults in Medicaid expansion states are no less likely to work full-time than similar adults in nonexpansion states (Levy, Buchmueller, and Nikpay 2018). The ACA’s dependent coverage provisions also did not lead to changes in labor market decisions (Heim, Lurie, and Simon 2015). Other than the broad inference that new coverage options under the law may not be sufficiently attractive to draw people out of the labor force (despite predictions to the contrary), it is not clear specifically why. One possibility is that the near- continuous attacks on and erosion of the law’s provisions raised doubts about the durability of its protections.
Health
The preponderance of evidence suggests that health insurance improves health. Therefore, it is not surprising that those who gained coverage through the ACA’s Medicaid expansion (Burns and Wolfe 2016; Graves et al. 2020) or extension of employer-sponsored coverage to young adults (Barbaresco, Courtemanche, and Qi 2015) saw gains in self-reported health. Two recent studies showed that the ACA’s coverage provisions reduce mortality. Linking mortality and survey data on Americans who were the targets of the ACA Medicaid expansion, Miller and colleagues (2019) found that the Medicaid expansion averted 19,200 deaths over its first four years. Goldin, Lurie, and McCubbin (2019) used a randomized field trial to compare uninsured individuals who signed up for marketplace coverage to those who did not and found a large 2.4% reduction in mortality for each month of coverage gained.
Health Care Spending
The ACA was expected to modestly reduce the growth of health spending. Federal Medicare spending growth has slowed from 6.8% in 2009 to 6.4%
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Nikpay, Pungarcher, and Frakt - An Economic Perspective on the ACA 895
in 2018, and Medicaid spending growth has slowed from 8.8% to 3.0%,
over the same time. However, private spending on health care has increased
from 3.5% to 5.8% between 2009 and 2018, and out-of-pocket expendi-
tures have also increased. As a result, national health care spending growth
increased from 4% to 4.6% (see table 1) (CMS 2019), with spikes in
spending growth corresponding to insurance expansions in 2014 (Hartman
et al. 2019). While a slowing of expenditure growth in Medicare and
Medicaid was too small to reduce the overall national trend, actual
spending growth over the ACA’s first decade is lower than was originally
predicted by the Centers for Medicare and Medicaid Services (Holahan
et al. 2017). However, federal health spending growth reductions may not
be fully attributable to the ACA and may reflect changes in underlying
health care use among the Medicare-eligible population (Cutler et al.
2019).
In fact, studies suggest that many of the ACA’s delivery system reforms have had only modest effects on spending. ACOs appear to have resulted in a few percentage points of savings to Medicare (McWilliams, Landon, and Chernew 2013), but the extent to which these are attributable to the pro- gram is debated (Markovitz et al. 2019). The evidence on savings from Medicare Bundled Payments is also mixed (Joynt Maddox et al. 2018; Navathe et al. 2017; Lewin Group 2016; Yee, Pizer, and Frakt forthcom- ing). Although the Center for Medicare and Medicaid Innovation has launched 37 new payment models (Twomey 2018), the effects on spending are unknown.
There are several reasons that the ACA’s DSRs had a modest impact on spending at best. First, the ACA was implemented at the same time as a wave of provider consolidation. Since the law’s passage, there have been 1,792 mergers between hospitals as well as growing consolidation between hospitals and physician groups (Gee and Gurwitz 2018; Nikpay, Richards, and Penson 2018). The consequence is higher commercial market prices (Cooper et al. 2019; Capps, Dranove, and Ody 2018). In an effort to improve coordination, the ACA’s DSRs may encourage consolidation, although the evidence is mixed (Kanter, Polsky, and Werner 2019; Neprash, Chernew, and McWilliams 2017). Lack of Medicaid expansion may also increase consolidation by hastening hospital closures among poorly performing hospitals in rural areas (Lindrooth et al. 2018). Second, DSRs relied on provider incentives that may have been underpowered. In other words, the incentive to reduce costs was small relative to the wider health care system’s incentives for volume over value (Frakt and Jha 2018). Additionally, these reforms were often voluntary, meaning that if the
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In fact, studies suggest that many of the ACA’s delivery system reforms have had only modest effects on spending. ACOs appear to have resulted in a few percentage points of savings to Medicare (McWilliams, Landon, and Chernew 2013), but the extent to which these are attributable to the pro- gram is debated (Markovitz et al. 2019). The evidence on savings from Medicare Bundled Payments is also mixed (Joynt Maddox et al. 2018; Navathe et al. 2017; Lewin Group 2016; Yee, Pizer, and Frakt forthcom- ing). Although the Center for Medicare and Medicaid Innovation has launched 37 new payment models (Twomey 2018), the effects on spending are unknown.
There are several reasons that the ACA’s DSRs had a modest impact on spending at best. First, the ACA was implemented at the same time as a wave of provider consolidation. Since the law’s passage, there have been 1,792 mergers between hospitals as well as growing consolidation between hospitals and physician groups (Gee and Gurwitz 2018; Nikpay, Richards, and Penson 2018). The consequence is higher commercial market prices (Cooper et al. 2019; Capps, Dranove, and Ody 2018). In an effort to improve coordination, the ACA’s DSRs may encourage consolidation, although the evidence is mixed (Kanter, Polsky, and Werner 2019; Neprash, Chernew, and McWilliams 2017). Lack of Medicaid expansion may also increase consolidation by hastening hospital closures among poorly performing hospitals in rural areas (Lindrooth et al. 2018). Second, DSRs relied on provider incentives that may have been underpowered. In other words, the incentive to reduce costs was small relative to the wider health care system’s incentives for volume over value (Frakt and Jha 2018). Additionally, these reforms were often voluntary, meaning that if the
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896 Journal of Health Politics, Policy and Law
targets for savings are too aggressive, nobody will participate. Finally, the
cost of implementing the DSRs may have eaten away at modest DSR
savings. One recent analysis found that, after factoring in the costs of
implementing DSRs, the net savings amount to only $1 billion (Buntin and
Graves 2020).
The expected effects of the ACA’s cost-control measures were also altered by policy actions taken after its passage. Legislation in 2020 repealed the Cadillac tax on generous employer-sponsored coverage (Further Consolidated Appropriations Act of 2020, H.R. 1865, 116th Congress), which was expected to lower health spending and raise payroll tax revenue by $204 billion between 2020 and 2025 (Drake et al. 2017). Legislative actions have also repeatedly delayed the implementation of Medicaid cuts to hospitals, which were expected to reduce federal spending by $4 billion. Finally, administrative actions have eliminated the imple- mentation of several planned DSRs, although the specific impact of costs is unknown (CMS 2017). In total, these actions are expected to increase health spending by $225 billion from 2019 to 2023 above what it would have otherwise been (CBO 2017a, 2019).
Discussion
The architects of the ACA sought to increase coverage and reduce costs and the law was expected by economists to increase access to care, financial security, and job mobility. Although legislative, executive, and judicial actions subsequent to the law’s passage have weakened it in a variety of ways, gains in coverage, access to care, financial security, and health have been surprisingly durable. Yet, these benefits are not evenly shared. For some low-income individuals in Medicaid nonexpansion states, there is little change in these outcomes from the pre-ACA period. For others, even subsidized marketplace coverage comes with high deductibles and cost sharing that impose significant financial burdens (Cohen and Zammitti 2017).
While economists anticipated many of the ACA’s effects, one prominent surprise is the role of the individual mandate. Economists believed it was necessary to maintain low premiums in the individual market. Though it was effectively removed for 2019 by the reduction of the penalty to $0, marketplaces remained stable (CBO 2017b; Tax Cuts and Jobs Act of 2017). Perhaps the mandate was needed to create stable individual markets but is not needed to maintain them.
https://read.dukeupress.edu/jhppl/article-pdf/doi/10.1215/03616878-8543340/810284/8543340.pdf
The expected effects of the ACA’s cost-control measures were also altered by policy actions taken after its passage. Legislation in 2020 repealed the Cadillac tax on generous employer-sponsored coverage (Further Consolidated Appropriations Act of 2020, H.R. 1865, 116th Congress), which was expected to lower health spending and raise payroll tax revenue by $204 billion between 2020 and 2025 (Drake et al. 2017). Legislative actions have also repeatedly delayed the implementation of Medicaid cuts to hospitals, which were expected to reduce federal spending by $4 billion. Finally, administrative actions have eliminated the imple- mentation of several planned DSRs, although the specific impact of costs is unknown (CMS 2017). In total, these actions are expected to increase health spending by $225 billion from 2019 to 2023 above what it would have otherwise been (CBO 2017a, 2019).
Discussion
The architects of the ACA sought to increase coverage and reduce costs and the law was expected by economists to increase access to care, financial security, and job mobility. Although legislative, executive, and judicial actions subsequent to the law’s passage have weakened it in a variety of ways, gains in coverage, access to care, financial security, and health have been surprisingly durable. Yet, these benefits are not evenly shared. For some low-income individuals in Medicaid nonexpansion states, there is little change in these outcomes from the pre-ACA period. For others, even subsidized marketplace coverage comes with high deductibles and cost sharing that impose significant financial burdens (Cohen and Zammitti 2017).
While economists anticipated many of the ACA’s effects, one prominent surprise is the role of the individual mandate. Economists believed it was necessary to maintain low premiums in the individual market. Though it was effectively removed for 2019 by the reduction of the penalty to $0, marketplaces remained stable (CBO 2017b; Tax Cuts and Jobs Act of 2017). Perhaps the mandate was needed to create stable individual markets but is not needed to maintain them.
https://read.dukeupress.edu/jhppl/article-pdf/doi/10.1215/03616878-8543340/810284/8543340.pdf
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