The State of Play in the US Senate

[This commentary was just published in the May 31st New England Journal of Medicine.]

The acid test of any nation’s health care reform happens with a change in national administration. Only when a president or minister who instigated reform departs and a new regime assumes power can we judge the durability of any reform law or program. Like it or not, now is that moment for the Affordable Care Act (ACA) in the era of President Donald Trump. Over the coming months, U.S. society will decide, through the Congress, which of President Barack Obama’s reforms will survive and which will not.

On May 4, the U.S. House of Representatives, by a 217-to-213 vote, approved the American Health Care Act (AHCA), legislation formulated to make far-reaching changes to the ACA and Medicaid.1 The AHCA would largely undo the ACA’s Medicaid expansion and subsidies for private health insurance, restructure Medicaid’s financing, permit state governments to waive popular ACA insurance-market reforms, and repeal ACA tax increases, among other changes. The Congressional Budget Office (CBO), in its May 24 analysis of the final House bill,2 estimated that, if enacted into law, it would result in 14 million Americans losing health insurance by 2018 and 23 million by 2026, an $834 billion reduction between 2017 and 2026 in federal outlays for Medicaid, and 10-year deficit reduction of $119 billion.

The fate of the ACA and the AHCA now rest in the U.S. Senate, where prospects are uncertain. Almost certainly, any Senate legislation will differ substantially from the House bill. Although senators may take months or longer to devise and pass a bill, it is possible that members will move quickly or fail to find any compromise at all. As of late May, Senate leaders hope to have a bill approved by the Senate before their August recess and to send a final Senate–House plan to the President’s desk by the end of September.

Like their House counterparts, Senate Republican leaders are working hard to devise a bill negotiated only among the 52 GOP members, involving none of the chamber’s 48 Democratic caucus members. Senate Majority Leader Mitch McConnell (R-KY) empaneled himself and 12 of his white male colleagues to formulate a plan — and then expanded the group after being criticized for the gender imbalance.

Leaders intend to bypass standing committees in passing their plan — Senator Orrin Hatch (R-UT), chair of the Senate Finance Committee, said on May 9, “I don’t think it’s going to go through the committees.”3 In 2009, the Senate Health, Education, Labor, and Pensions Committee and the Senate Finance Committee each held numerous public hearings and monthlong markup sessions in preparing legislation that became the ACA, considering hundreds of Republican-filed amendments.

As in the House, Republican senators will use the budget reconciliation process to approve their bill, which allows it to pass with 51 votes and blocks filibusters that require 60 votes to overcome. Reconciliation rules limit provisions to matters with consequential impact on federal revenues and spending, forbidding extraneous provisions incidental to the federal budget, and placing at risk politically sensitive provisions included in the House-approved AHCA such as the ability of states to waive ACA insurance-market reforms. Republicans can lose only two votes from their 52 members, in which case Vice President Mike Pence may cast the deciding 51st vote; a loss of three or more would block passage if, as expected, all 48 Democrats unite against a Republican plan. Also, any Senate bill cannot reduce the federal deficit by less than the House version’s $119 billion.

Obtaining at least 50 Republican votes requires navigating a perilous set of policies advanced by the House. These address Medicaid, rules and premium subsidies for the private insurance market, tax cuts, and Planned Parenthood funding and abortion, among other issues. These are the essential pieces of the legislative puzzle that leaders must fit into place for any bill to pass.

Twenty Senate Republicans represent states that expanded their Medicaid programs to cover all low-income persons as permitted by the ACA, an expansion that the AHCA would erode substantially. The CBO estimated that 14 million Americans would lose Medicaid under the AHCA. Moreover, the AHCA would revolutionize Medicaid financing by establishing either capped per capita payments to states for each enrolled individual or block grants, ending Medicaid’s status as a federal entitlement. The CBO estimates the AHCA’s 10-year Medicaid spending reductions at $834 billion. Though not going as far as the House plan, Republican senators are exploring similar fundamental changes, outlined in a proposal advanced in March by four Republican governors organized by Ohio’s John Kasich.4

To satisfy conservatives in the House Freedom Caucus, House leaders amended the AHCA to permit states to waive popular ACA insurance-market reforms such as banning preexisting-condition exclusions and lifetime or annual benefit caps. States could also eliminate or downgrade the ACA’s 10 “essential health benefits” in ways that could degrade employer-sponsored insurance coverage as well. The AHCA would permit insurance companies to price older enrollees’ premiums at five times the rate for younger enrollees (the ACA allows up to 3:1 variation), mobilizing opposition from senior organizations such as AARP. Though experts on budget reconciliation question the viability of these changes under Senate rules, some senators advocate going further than the AHCA.

The AHCA also repeals ACA tax increases that finance the Medicaid and private-insurance expansions, including taxes affecting the insurance, pharmaceutical, and medical device industries and taxes on wealthy households making more than $200,000 annually (0.9% on earned income and 3.8% on unearned income). Trump and House Speaker Paul Ryan (R-WI) have emphasized links between repealing ACA taxes and their emerging tax-reform agenda. If Senate Republicans soften the House bill’s cuts in Medicaid coverage, private insurance coverage, or both, they may also need to lessen or delay the AHCA tax cuts to achieve the minimum budget-deficit savings required under Senate reconciliation rules. This trade-off highlights the essential tension in both the ACA and the AHCA between taxes and health insurance coverage.

The AHCA also bans all federal payments to Planned Parenthood for non–abortion-related services (payments for abortions are already prohibited) — a provision that, if included in a Senate bill, would cause Senators Susan Collins (R-ME) and Lisa Murkowski (R-AK) to vote no. The AHCA also prohibits subsidies for any health insurance policy that includes abortion coverage (federal payments for those services are prohibited under the ACA); this provision would prohibit any subsidies to otherwise eligible families in states such as New York and California, where abortion coverage is a mandated benefit. In 2010, disagreements among Democrats over abortion-related language nearly blocked the ACA’s passage.

Three conservative senators — Ted Cruz (R-TX), Mike Lee (R-UT), and Rand Paul (R-KY) — have declared their opposition to any Senate bill less conservative than the AHCA. Also, Senators Bill Cassidy (R-LA) and Maine’s Collins have four additional cosponsors for their Patient Freedom Act, which would allow states to retain the ACA or construct alternatives, and have been hosting health care reform conversations with moderate senators from both parties, including Senators Joe Manchin (D-WV) and Heidi Heitkamp (D-ND) and a bloc of Republicans including Shelley Moore Capito (R-WV), Murkowski, Rob Portman (R-OH), John McCain (R-AZ), and others who are especially concerned about the AHCA’s Medicaid cuts.

As this Senate drama unfolds, health insurers and consumers express worries about the Trump administration’s commitment to keeping the ACA’s insurance marketplaces functioning. Administration figures have offered varying statements regarding continuation of ACA “cost-sharing reduction” (CSR) payments to insurers that keep deductibles and coinsurance affordable for lower-middle-income families; on May 22, administration and House leaders agreed to postpone a hearing on a lawsuit brought by House Republicans to end CSR payments. Trump has stated repeatedly that ACA marketplaces are “failing,” despite counterindications from sources such as the CBO and Standard & Poor’s.5 With deliberate neglect of state individual insurance markets (ACA and private) covering approximately 20 million Americans, the prospects for massive instability are real and worrisome.

Some observers expect a drawn-out Senate process that could last into 2018 or beyond. Yet after the May 4 House passage of the AHCA, Republican senators began working quickly on alternatives, seeking less aggressive but still far-reaching changes to the ACA and Medicaid. After failed attempts to pass the AHCA in the House in March and April, many assumed the legislation was dead, only to see it reemerge suddenly in early May. Citizens and medical professionals should pay close attention to this urgent matter affecting American society.

References

    1. H.R. 1628, 115th Cong., American Health Care Act. (2017-2018) (https://www.congress.gov/bill/115th-congress/house-bill/1628).

      2.  Congressional Budget Office. Letter to House Speaker Paul Ryan. March 23, 2017 (https://www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/hr1628.pdf).

      3.  Hellman J. Hatch: Senate’s ObamaCare repeal unlikely to go through committees. The Hill. May 9, 2017 (http://thehill.com/policy/healthcare/332596-hatch-senates-obamacare-repeal-unlikely-to-go-through-committees).

      4.  Kasich J, Snyder M, Sandoval B, Hutchinson A. Letter to Sen. Mitch McConnell and Rep. Paul Ryan. March 16, 2017 (https://assets.documentcloud.org/documents/3519424/Governors-Letter-3-16-2017.pdf).

      5.  The U.S. ACA individual market showed progress in 2016, but still needs time to mature. S&P Global Market Intelligence. April 7, 2017 (https://www.globalcreditportal.com/ratingsdirect/renderArticle.do?articleId=1828594&SctArtId=421970&from=CM&nsl_code=LIME&sourceObjectId=10047007&sourceRevId=5&fee_ind=N&exp_date=20270408-00:16:31).

 

Posted in Uncategorized | Leave a comment

MayDay! The ACA Is Still Alive and Still in Danger

Today is May Day and the ACA is still alive.  Donald Trump’s campaign boast that he would sign a bill repealing the Affordable Care Act (ACA/ObamaCare) on his inauguration day is long gone and forgotten.  House Speaker Paul Ryan and Senate Majority Leader Mitch McConnell’s gamble that by April 28th the ACA would be effectively decimated using the expedited budget reconciliation process proved to be a sucker’s bet.

Undeterred, White House and House operatives are trying by Wednesday to line up 216 votes—not to pass the Republicans’ American Health Care Act (AHCA) but to feign signs of progress to dampen the white-hot anger of the Republican base at their Party leaders’ inability to enact the ACA repeal promised since the law’s signing on March 23, 2010.  They want to take a third run at it this week and perhaps succeed after two prior failures.  Senate Republicans, meanwhile, are crossing their fingers hoping that the House fails, sparing the upper chamber the funerary duties.  For the Senate to advance ACA repeal now, a new and wholly unimagined bill would need to be constructed.

The level of legislative malpractice evidenced by Speaker Ryan and his team since January is staggering and perplexing.  They designed a bill that the Congressional Budget Office estimated would cause 24 million Americans to lose health insurance.  They advanced a proposal that provoked public opposition from the American Hospital Association, the American Medical Association, the American Nurses Association, AARP, and hundreds of other national organizations representing Americans with serious stakes in our health care system.  They invented a plan that generated unprecedented grassroots support for the ACA and fierce opposition aimed at them. For the first time, Ryan’s plan turned most Americans into ACA supporters. His legislation generated support from only 17% of Americans, an unheard of level of non-support.

Why did they do this and why do they persist?

Trump and Ryan both showed their hands in recent public statements linking ACA repeal with their tax cut agenda; Trump’s tax plan was released in one-page outline form this past week.  To Republicans, the ACA’s poison is not the insurance expansion that bears remarkable resemblance to the two public health insurance programs they have always loved: Medicare Part C or Medicare Advantage, and Medicare Part D, the outpatient prescription drug benefit. Continue reading

Posted in Affordable Care Act, Health Policy, Health Politics, National Health Policy | Tagged , , , , , , | Leave a comment

A Republican Path to ACA Reform

[This commentary, written by me and Dr. William Seligman of the Harvard Chan School, was published today on the Commonwealth Magazine website.]

IF PRESIDENT DONALD TRUMP and Congressional Republicans were to decide that fixing rather than destroying the Affordable Care Act, especially its private health insurance marketplaces, was in their self-interest, could they do it?  And, could they do it in a way that aligns with Republican policy preferences?

The answer to both questions is “yes” – if Republicans heed lessons from their two favorite public health insurance programs. The programs are Medicare Part C, called Medicare Advantage, in which enrollees join private health insurance plans, and Medicare Part D, in which enrollees join private outpatient prescription drug plans.

While Republicans defend and brag about both of these reasonably successful programs, they may be surprised to learn that features of both point the way to successful stabilization and growth of the ACA’s private health insurance marketplaces.  Here’s how.

Medicare Advantage: From Bust to Boom

Consider these two quotes:

“People’s premiums are going up 35, 45, 55 percent … The market is disastrous, insurers are leaving day by day, it’s going to absolutely implode.”

“They’re anguished, upset, frustrated and angry by the demise of their plans. … They’re facing increasing premiums and…plans are leaving the market.”

The first quote is President Trump talking recently about the instability of the ACA’s marketplaces.  While most non-partisan observers disagree with the severity of his characterization, most – not all – of the federal, and some state, marketplaces are experiencing undeniable distress.

The second quote is from former congresswoman Nancy Johnson, a Connecticut Republican, talking in 2001 about the “Medicare + Choice” marketplace in which Medicare enrollees join a private health plan instead of participating in traditional fee-for-service Medicare (Parts A & B). Continue reading

Posted in Affordable Care Act, Health Policy, Health Politics, National Health Policy | Tagged , , , , , | Leave a comment

MassHealth Dives into Accountable Care

[I wrote this commentary for the Spring Issue of Commonwealth Magazine to profile Massachusetts’ new move into accountable care organizations, an experiment that deserves watching.  Dr. William Seligman co-wrote with me.]

IN A WILDLY uncertain national health care environment, something new, audacious, and risky is happening in MassHealth, the Medicaid program that provides health coverage to 1.9 million people who are poor, elderly, and persons with disabilities in Massachusetts. Gov. Charlie Baker’s administration is betting that an emerging health care delivery and payment model, called “accountable care organizations,” can restrain rising costs by keeping enrollees healthy and out of expensive settings, especially hospitals. Positive results will have big consequences for the state, for medical providers, and for hundreds of thousands of MassHealth enrollees who will become part of ACOs this year and into the future.

The ACO scheme is the major part of a massive new federal Medicaid waiver that Team Baker won from the outgoing Obama administration days before the November 8

MassHealth spending 17

election that put Donald Trump in the White House. The Obama administration liked the Baker plan because it fit with their mission to move US health care away from expensive fee-for-service payment and toward value-based financing that rewards quality and efficiency. Though no one knows for sure which way the Trump administration will move, right now it’s full speed ahead at MassHealth on the ACO agenda. Continue reading

Posted in Health Policy, Massachusetts Health Care, States, Uncategorized | Tagged , , , | Leave a comment

Health and Taxes and the Values at Stake in the ACA Debate

[This commentary was published this week on the website of the Milbank Quarterly.]

One of my favorite political scientists, Deborah Stone, wrote that much of the policy process involves debates about values masquerading as debates about numbers and facts.1 Although her construct is abundantly in evidence, it is being overlooked in the current debate over the future of the Affordable Care Act.

How much are premiums rising? How many plans are operating in the exchanges? How much money are accountable care organizations saving? What impact would a per capita cap financing scheme have on Medicaid? How much has the ACA restrained or propelled health cost growth? What do opinion polls show?

Each side furiously hurls data and anecdotes at each other as if by identifying the killer data point, the other side would throw up its hands in surrender and declare: “How could we have been so dumb?” Of course, this never happens in public policy debates. It never happens because numbers and anecdotes don’t motivate people on an issue as charged as the ACA. Values do. Continue reading

Posted in Affordable Care Act, Health Policy, Health Politics, National Health Policy | Tagged , , , , | Leave a comment

The State of Play Post-Trump/RyanCare

[This column is reprinted from the Commonwealth Magazine website.]

GLOBAL HEALTH EXPERT Michael Reich says that the acid test of any national health reform comes when a new national administration takes over. Only when a new president or prime minister assumes power can we judge the stability and staying power of any health system reform. In the US, that’s this moment. Since November 8, we’ve been learning what parts of the Affordable Care Act (ACA) have staying power, which do not, and what’s uncertain.

Right now, after Friday’s demise of the Republican repeal and replace plan, the American Health Care Act (AHCA), we know that Medicare, Medicaid, insurance market reforms such as guaranteed issue, and delivery system reforms such as accountable care organizations look TrumpCare3

safe. We know that the private insurance coverage reforms – insurance exchanges, premium and cost-sharing subsidies, the individual mandate – are at risk and in danger even though they dodged full repeal with the AHCA’s demise. And we don’t know the fate of the ACA’s many tax increases. Let’s view these systematically. Continue reading

Posted in Affordable Care Act, Health Policy, Health Politics, National Health Policy | Tagged , , , , , , , , | Leave a comment

Exploring the next phase of U.S. health reform

[This article was published on the website of the Harvard Chan School of Public Health in connection with an executive training program — Preparing for What’s Next in U.S. Health Reform — that I’m running May 31-June 2.]

by Lisa D. Ellis

These are uncertain times in American health care. The Republican Congress and President Trump have vowed to repeal and replace the Patient Protection and Affordable Care Act (ACA), commonly called Obamacare. They recently unveiled the American Health Care Act, the replacement plan, which has met with substantial resistance from all parts of the political spectrum. The current political and policy environment has left many health care leaders and other stakeholders wondering what to expect and how best to position their organizations for the next phase of health care reform.

The Potential Effects of Proposed Changes

House Republicans recently introduced legislation intended to create a new health plan, retaining some provisions of Obamacare and eliminating or scaling back others. While the exact details may continue to change in the coming weeks as the bill moves through Congress, there are some specific themes that can be expected in the final version that becomes law, according to John E. McDonough, DrPH, MPA, Program Director of Preparing for What’s Next in U.S. Health Reform and Director of the Center for Executive and Continuing Professional Education at the Harvard T.H. Chan School of Public Health. McDonough, who served as a Senior Advisor on National Health Reform to the U.S. Senate Committee on Health, Education, Labor, and Pensions, explains that there are two major components of the ACA that will be affected by whatever legislation is passed. These are access and value.

Two Main Themes: Access and Value

The first area, access, refers to insurance coverage for uninsured and underinsured Americans. While a significant impact of the ACA was that it expanded its Medicaid offerings to states to cover vulnerable residents, a number of Americans are now at risk of losing this support under whatever new plan is ultimately passed.

There are two major components of the ACA that will be affected by whatever legislation is passed. These are access and value.

“Many, many individuals have gotten health insurance coverage from ACA and [some of them] are quite concerned about whether they will still have coverage in three months, six months, or a year,” McDonough says.

The second area, value, refers to a focus started by the ACA to improve the quality, efficiency, and effectiveness of medical care in the United States. “The evidence shows Americans get care from our medical system that is not as high quality as we have a right to expect because of high costs,” McDonough says. The ACA established a number of initiatives to address this fact, including creating Accountable Care Organizations (ACOs), providing bundled payment plans, and imposing penalties on hospitals with very high rates of readmissions and hospital-acquired infections.

These types of efforts, which are part of a broader push to transform the health care delivery system to ensure a greater focus on value, are receiving widespread support from both Republicans and Democrats, which means that they should continue, and even grow, under any new health care law, McDonough stresses.

“There seems to be a growing sense in the health care community that [the move to value-based payment and population health management] pushed forward under ACA should continue and expand,” McDonough says, adding that this is one piece of good news in the sea of uncertainty that exists.

Preparing for New Developments

Ashish Jha, MD, MPH, Professor of International Health and Health Policy at the Harvard T.H. Chan School of Public Health, Director of the Harvard Global Health Institute, and a practicing general internist at the VA, agrees with this assessment. “The journey we began with ACA to move to value-based health care is going to continue,” he says. “But what form it will take, how we will do it, and how much is voluntary verses mandatory” remain to be seen moving forward.

He points out that this means that professionals need to know the range of options in order to be prepared for whatever way the field goes. “They need to ask, ‘What is the range and how do I prepare, so I will be in good shape?’’’ he explains.

Trends to Watch

Jha, who is also faculty on Preparing for What’s Next in U.S. Health Reform, points to a number of other changes also started under the ACA that, regardless of the final health plan passed, will continue to affect organizations over the next few years. For instance, people today are responsible for a growing portion of their own health care costs. This changes the way that organizations collect their money, meaning organizations need to find new ways of operating.

There will be many moral and ethical dilemmas for organizations as access shrinks and many patients lose coverage under the new plan.

“I think health care leaders are very used to a world where they provide services to patients and get paid by insurers, or the government/Medicare or Medicaid. But now they’re waking up to a new model where they are getting a larger chunk from patients. They’re not used to collecting money from patients themselves and that will change their relationships,” Jha says.

With customers footing more of the bill, they now have higher expectations from providers. “The customer is changing, and what will customers want in return now that they’re writing the check? That becomes a really important issue for providers to focus on. It’s part of patient-centered care. Now patients are in the driver’s seat,” he stresses.

Another issue worth paying attention to on the value side of the equation is that participation in some Medicare bundled payment programs will be voluntary for now, but is ultimately expected to become mandatory in the not-too-distant future. This raises some interesting questions for organizations, as they grapple with whether to use the voluntary program to get acclimated. Organizations that don’t participate now could end up having a lot of catching up to do in the future, which could “have very serious consequences three to five years down the road,” Jha says.

Issues to Watch

On the access side of things, Jha points out that there will also be many moral and ethical dilemmas for organizations as access shrinks and many patients lose coverage under the new plan. Five years ago, many people were uninsured and had no contact with the health care system. “Now, these people have been covered and have become part of the organizations [that serve them]. They have developed relationships with their doctors, so it’s a big difference now when they lose coverage,” he says. “Are organizations really going to walk away from these patients? [And if not], how will health systems manage the financial debt they will incur to care for the uninsured?”

Another important trend that will impact many health organizations moving forward revolves around consolidation. “Doctors are being bought out by big hospitals. We have no idea how the Trump Administration will feel about that. Consolidation is a strategy that provider organizations have used to survive, getting bigger. But that gravy train for providers is coming to an end. Now, with more people uninsured, and more focus on value, there are broader market issues around consolidation and integration that will be challenging for providers,” Jha says.

Other Trends Worth Following

Other trends that will continue to impact organizations include the growing push for providers to use interconnected Electronic Health Records (EHR). This is an important tool to help track and achieve key benchmarks of value-based care and improve coordination among providers for increased efficiency and better outcomes. “While everyone thinks this is a good thing, and most organizations have made the leap into EHRs, people, especially frontline doctors and nurses, are very frustrated with these systems.  How organizations will manage the transition between simply adopting the EHR and using it in ways that lead to meaningfully better care is the challenge ahead,” Jha says.

In addition, Jha says that the Trump Administration’s tougher restrictions on immigration may have a real effect on health systems that needs to be addressed up front. “Twenty-five percent of doctors in our country are foreign medical graduates, as are a large population of our nurses and other health professionals,” he says. “As immigration gets tighter, there’s a question as to whether we will have a harder time attracting the best and brightest in the world. So health care will have a hard time building their ranks” in the future. With an aging population, this means that health systems may have challenges creating a good workforce to care for them.

The Importance of Staying Up-to-Date

With so many fluctuations expected in how the health care system will do business in the coming months and years, both Jha and McDonough say that it is crucial for health care leaders to stay abreast of the latest developments as they progress.

One of the most important things is for health care leaders to stay in touch with what is happening out there and pay attention to the coverage in the media.

“One of the most important things is for health care leaders to stay in touch with what is happening out there and pay attention to the coverage in the media,” McDonough says. “If you work in a hospital, [you will need to] follow the national organizations, such as the American Hospital Association, and stay alert to the opinions of experts as to what might happen,” he says. But that alone will not be enough, says Jha. Understanding the nuances of policy changes will be critical for leaders to stay on top of the shifting requirements—and opportunities—that exist in the current environment so they can strategically position their organizations for success.


Harvard T.H. Chan School of Public Health offers Preparing for What’s Next in U.S. Health Reform, which offers key lessons involving health reform from the nation’s leading policy experts under the new federal administration. To learn more about this opportunity, click here.

Posted in Affordable Care Act, Health Policy, National Health Policy, Uncategorized | Tagged , , , , | Leave a comment

24 Million May Lose Health Insurance to Pay for Tax Cuts for Wealthy Americans

[This commentary, “GOP Cuts Are Moral Challenge for America,” was published on Commonwealth Magazine’s website on March 14.]

THE BIG NEWS IS, of course, Monday’s “score” from the Congressional Budget Office detailing that the House Republican bill to repeal and replace the Affordable Care Act/Obamacare will result in 14 million Americans losing health insurance by 2018 and 24 million by 2026.

Before that, something else caught my eye from the Bangor Daily News. It’s a blog post from a woman named Crystal Sands who writes about how the ACA enabled her and her young family to take a chance and find a new life as farmers. Her post, “The ACA makes a simpler farming life possible for our family,” says this:

“I’m a writer, an online professor, a farmer, a wife, and a mom. None of these jobs offer health insurance for me and my family, so our family purchases our health insurance through the Affordable Care Act. We work hard, but we try to work differently. If you read my blog, you know we’re learning to grow and raise our own food, and our health insurance through the ACA makes this possible.

“The ACA has helped me to become a better mom, a better wife, a better teacher because I am not so overworked, and it has made it so I can learn to be a farmer. I’m also just a better person. I’m not sick and overworked. I’m more patient and more kind and more helpful to everyone. And this is my story. There’s so much potential here to make lives better. There are many people, including many farmers, who depend on the ACA. I hope we don’t lose sight of that.

And now, CBO’s Cost Estimate of the American Health Care Act. Bottom line — $894 billion in tax cuts financed by $1.2 trillion in cuts to Medicaid and to subsidies/tax credits for private health insurance. Those cuts will produce an increase in numbers of uninsured Americans of 14 million by 2018, 21 million by 2020, and 24 million by 2026. Of the 24 million, 14 million will lose Medicaid and 10 million will lose private coverage, employer-sponsored and individual. Continue reading

Posted in Affordable Care Act, Health Policy, Health Politics, National Health Policy | Tagged , , , , , , , , , | Leave a comment

House Republicans Show Their Hand on ACA — and It’s Not Good

[This February 26 2017 commentary was published on the Commonwealth Magazine website.]

LATE LAST WEEK, Politico released a leaked 105-page draft bill defining the House Republican plan to repeal/replace/repair/re-whatever the Affordable Care Act/Obamacare. The draft legislation was dated February 10, so likely it’s already out of date, though it is the best indication yet of their rapidly evolving intentions and fits with many of their prior recent proposals. So a big GOP move is getting close, and it’s not good. What’s important?

First, the ACA’s generous coverage expansion (for many, not all) through Medicaid expansion and private insurance subsidies would be drastically curtailed, leaving most of the 22 million who got either form of coverage without an affordable option.

repeal-replace-720

Second, not only is the ACA Medicaid expansion repealed by 2019 (11 million people and counting), the plan would replace current Medicaid financing with a “per capita cap” by 2019, shrinking funding by hundreds of billions, perhaps more, over 10 years. Continue reading

Posted in Affordable Care Act, Health Policy, Health Politics, National Health Policy | Tagged , , , , , | Leave a comment

“It has saved my life.” Voices from Ohio on Medicaid Expansion

[This commentary was first published on February 15 on the Commonwealth Magazine website:]

OHIO IS ONE of 31 states that expanded Medicaid as permitted by the Affordable Care Act/Obamacare for nearly all low-income citizens. The state’s Republican governor, former presidential candidate John Kasich, has been among the most vocal proponents of the expansion on the Republican side and has taken a lot of grief for it from ACA opponents.

In early January, the state released an evaluation of the impact of the expansion, “Ohio Medicaid Group VIII Assessment: A Report to the Ohio General Assembly“. (Group VIII is the legal name for the ACA Medicaid expansion population.)

ohio-medicaid

The report has a host of quotes from interviews with individuals who benefited from the expansion, and I include a selection of these quotes below, along with a section from the report’s overall summary. This is what Medicaid expansion has meant to real Americans:

“It gives me peace of mind knowing that I don’t have to pay for the medical insurance, and it saves me money being able to afford food and utilities and everyday things you need in life.”

“It’s been a blessing and I thank God that I have Medicaid because I no longer have large payments and I can get my Medicaid medicines.”

“More freedom. Less worries. I was an addict for 3 years before getting Medicaid. Because of Medicaid I’m not an addict.” Continue reading

Posted in Affordable Care Act, Health Policy, Health Politics, States | Tagged , , , , | Leave a comment