National Health Policy – Page 4

The Future of Public Health under President Trump

[The Q&A below was published in Harvard media this past week.]

How might the election of Donald Trump as the next U.S. president impact public health over the next four years? John McDonough, professor of the practice of public health at Harvard Chan School, who worked in the Senate on the passage of the Affordable Care Act (ACA), offers his perspective in this Q&A.

Many are worried that Obamacare will be in deep trouble—and likely be repealed—once Donald Trump is in the White House, working with Republican majorities in both the House of Representatives and the Senate. A week after the election, Trump appears to be hedging on his prior pledge to completely do away with the health reform law. What do you think will happen to the ACA—and to the millions of people who gained health insurance because of it?

The likelihood for total 100% repeal of the ACA is unlikely for two reasons: One is that this would have to be accomplished through regular legislative order in the U.S. Senate and Republicans would not be able to attract the necessary eight votes needed from Democratic senators to do this. Of course, if Republicans choose to abolish the filibuster, that would change. A second reason that repeal is unlikely is that many Republicans appreciate many non-controversial provisions in the ACA and repealing them would be backward steps they would not want to make happen.

Instead, and for now at least, Republicans appear to be moving toward a two-track process of “repeal and replace.” Repeal of the ACA’s essential health insurance coverage provisions, as well as the new taxes that financed the ACA’s expansions, could be achieved through the special “budget reconciliation process,” which only requires 51 votes for passage and cannot be filibustered. This would take some months to achieve, and is doable as long as 50 of the 52 Republican senators are willing to vote to eliminate coverage for as many as 22 million Americans—the number newly insured under the ACA—and their willingness to do that is not yet certain. Republicans did vote to repeal the most important parts of Obamacare in January of this year, but they did it knowing that President Obama would veto the measure. It would be a different vote knowing that President Trump would sign it.

Replacing the ACA with some other sort of health care law would be far more difficult because that legislation would need to proceed through regular legislative order and could and would be filibustered by Democrats, thus blocking the legislation. So it is conceivable that repeal could happen and replace might not follow, which would leave the up-to-22 million most at risk in a most difficult situation.

It’s been reported in the media that President-elect Trump may consider keeping some of the ACA’s more popular provisions, such as the requirement that insurance companies not deny coverage to people with pre-existing medical conditions, or that children up to age 26 can be covered under a family’s health plan. How do you think this might play out?

House Speaker Paul Ryan and House Republican leaders, in their “Better Way” document on repeal and replace last summer, indicated that they would continue the ACA’s “guaranteed issue” provisions—those making it illegal for insurers to deny anyone coverage because of health status, age, gender, or other factors—though only for those who are able to maintain “continuous coverage” with no or only short-term coverage breaks. For the millions of Americans who find themselves unable to afford coverage for some period of time, Republicans would, by their own words, return pre-existing condition exclusions and medical underwriting—charging the sick higher prices than the healthy. The provision for children up to age 26 being able to stay on parent’s health insurance policies is most likely not to be repealed.

How might the new president’s policies impact women’s health? He has said he would nominate a conservative Supreme Court justice who would be in favor of a pro-life agenda. Could this lead to Roe v. Wade being overturned? What other ways might women’s health be impacted under the Trump administration?

Even with a Trump appointment to the U.S. Supreme Court, there are five current votes, including Justice Anthony Kennedy, opposed to a Roe v. Wade repeal. So President Trump would need at least one additional replacement of those five to have a chance at repeal.

Other aspects of women’s health coverage are at risk because of Republican plans to repeal large portions of the ACA. Republicans want to return all discretion over required benefits to states, including the ACA’s mandates on benefits such as birth control, mammography, prescription drugs, behavioral health, and much more. So it’s possible that women could lose coverage for services that are currently free, such as contraception, mammograms, folic acid supplements during pregnancy, and screenings for gestational diabetes, sexually transmitted diseases, and cervical cancer.

Trump broke with conservative orthodoxy when he said that he’s in favor of Medicare being able to negotiate drug prices. He also has said that he would take on the Big Pharma lobby in order to reduce high prescription drug costs. Do you think he’ll be able to follow through on these pledges?

President Trump’s administration would only be able to negotiate drug prices or make other significant changes in pharmaceutical policies with the consent of Congress, which is most unlikely to provide that authority to him. Also, though the health policy section on his campaign website included drug-related proposals, the health policy section on his presidential transition website includes no mentions of these.

There were a number of health-related ballot initiatives across the nation. Three states, including Massachusetts, voted to legalize recreational marijuana and another three voted in favor of medicinal pot; voters in California, Washington, and Nevada approved various gun control measures; Californians raised cigarette taxes; and four cities voted to tax sugar-sweetened beverages. Also, Colorado rejected the establishment of a single-payer health insurance system in that state. How are these ballot initiatives changing the public health landscape?

On recreational marijuana, the tide of public opinion is changing the national landscape in spite of bipartisan opposition to this liberalization from elected officials all over the nation. It feels somewhat like the fast-changing tide a few years ago on gay marriage. And it feels unstoppable.

Taxes on sugar-sweetened beverages, at least on the local level, seem to be approaching the level of public acceptance we have seen in prior years with relation to tobacco taxes. The public seems supportive, at least in cities, especially when the revenues raised are clearly defined in terms of spending targets, such as public education. We have yet to see this approach pushed at a state initiative level, which would be a much more challenging proposition.

Regarding the vote against single-payer health insurance in Colorado, it seems that the U.S. sees one of these single-payer ballot initiatives every decade or so, and in each case, they start with some robust public support and then lose in a landslide: California in 1994, 73% to 27% no; Oregon in 2002, 77% to 23% no, and now Colorado in 2016, 80% to 20% no. It has always been a difficult sell and the Colorado results demonstrate that it still is.

— Karen Feldscher

Explaining our Health Care Dilemma to the World

I co-wrote the article below for the British Medical Journal with John Park, a Kennedy Scholar at the Harvard TH Chan School of Public Health:

America’s HealthCare Dilemma

The insurance of at least 22 million Americans hangs in the balance

The election of Donald Trump as 45th president of the United States has triggered concerns in many globally important areas of public policy, including climate change. But for Americans, one of the most unsettling challenges is the future of domestic healthcare policy and the fate of the 2010 health reform law, the Affordable Care Act (ACA).

For 45 years, the US healthcare system has been accurately characterized as the most expensive among nations in the Organization for Economic Cooperation and Development (OECD), as mediocre regarding quality and effectiveness, as inadequate in that it left nearly 50 million Americans uninsured, and as substandard in core outcomes such as infant mortality and life expectancy. In short, the only category at which Americans seemed to excel was in spending the most money.1

Between 2005 and 2008, many sectors in American society became vocal in calling for comprehensive healthcare reform to address failings in access, quality, cost, and outcomes. Between January 2009 and March 2010, new President Barack Obama worked with hefty Democratic majorities in the US Senate and House of Representatives to fashion comprehensive reform to tackle these deficiencies, signing the ACA on 23 March 2010. Though some Republican members of Congress initially expressed support for reform, objections to the Democratic approach and political resistance from their grassroots left zero Republican supporters by the time that the ACA was signed. Continue reading “Explaining our Health Care Dilemma to the World”

Pre-Election Reflections on Health Reform in the 2016 Campaign

[This post appeared in the Health Affairs blog on November 7 2016. Happy election day, everyone!]

We are nearing the grand finale of our long and disheartening election opera, one we dare not ignore because the outcomes matter so much. While the election results will not be determined by public reactions to the Affordable Care Act, the ACA’s fate will be mightily determined by Tuesday’s outcomes. What have we learned about our collective health future over the past 18 months and what might this mean for our health system’s future?

Public opinion on health reform is as frozen today as it was in spring, 2015

Kaiser monthly tracking polls show reliably unfavorable attitudes toward the ACA, slightly beating favorables, and stuck since 2014 in 40 percent purgatory. The advantages millions of Americans feel from ACA insurance coverage expansions and other access reforms are balanced by those who now blame the ACA for everything bad that happens in health care. The misnamed Pottery Barn rule—“if you break it, you own it”—applies here even though the dish was broken well before the ACA. Beyond this, if there is one thing on which both sides of the new Republican divide concur, it is a deep hostility towards ObamaCare. The election cycle seems to have only hardened these views.

The essential differences between Democrats and Republicans are now more clear

We know more about the preferences of both parties with respect to the ACA than we did 18 months ago. Hillary Clinton, Donald Trump, and House Speaker Paul Ryan, have released health reform planks that clarify their intentions — regardless of Congressional feasibility.

Clinton wants to maintain and strengthen the ACA by improving premium affordability and by addressing excessive cost sharing in the Exchanges and beyond. She has an eight-point plan to address pharmaceutical prices. She will emphasize women’s health, and much more. Her campaign has articulated the first full agenda of any leading Democrat to improve and advance the ACA, helping to define the arena of possibility, whether far-fetched or not.

After early teasing about his admiration for the Canadian and Scottish single-payer systems, Trump embraced standard Republican orthodoxy on ObamaCare, most recently announcing his intention to call a special Congressional session as soon as possible to repeal the law. Two independent research institutes (Committee for a Responsible Federal Budget and the Commonwealth Fund) have concluded that Trump’s agenda, if implemented, would result in 20 million Americans losing health insurance and would increase the federal deficit by $330-550 billion over 10 years.

Meanwhile, Speaker Ryan announced in September his intention—if Republicans control both houses of Congress and the White House in January—to expedite budget reconciliation legislation that would repeal as much of ObamaCare as possible. Though Ryan’s plan is more ambitious than Trump’s, of the latter’s seven health policy planks, five also show up on the Speaker’s agenda.

The final week’s fireworks over premium increases in the individual health insurance market only emphasize that the political volatility of the ACA/ObamaCare has not diminished at all.

Differences involving the ACA are not about facts or data, but about fundamental values

One of my favorite political scientists, Deborah Stone, in her book Policy Paradox, writes that much of the policy process involves debates about values masquerading as debates about data and facts. That sure describes the past eight years of health reform. As my colleague Robert Blendon showed in his pre-election special report for The New England Journal of Medicine:

The political parties fundamentally differ over the role the federal government should play in intervening in the U.S. health care system, (and) the desirability of the federal government moving ahead with future efforts aimed at universal coverage…

Source: POLITICO, Harvard T.H. Chan School of Public Health Poll. Voters and health care in the 2016 election. September 14–21, 2016.

The notion that these differences might be leavened, for example, by changing the age-rating bands (the maximum amount an insurer can charge in premiums for young people versus older enrollees) in the Exchanges from three-to-one up to six-to-one, is delusional. Six and a half years after its signing, the ACA has yet to become settled policy because the differences are simply too deep and neither side of the political divide can risk the backlash of surrender.

Republicans don’t want to fix the ACA car at any cost; they are determined to smash it

The excessively high premium increases in 2017 in the ACA Exchanges, more than anything, are tied to elimination in 2017 of risk corridors and reinsurance, as well as the undermining of risk adjustment. This past summer, Alaska’s Republican Legislature established its own reinsurance mechanism to stabilize rates, and immediately saw premium increases drop from over 40 percent to under 10 percent.

In my time as a member of the Massachusetts House of Representatives (1985-1997), I learned that when political partners like and respect each other, the most difficult challenges could be met with seeming ease; and conversely, when parties disliked and disrespected each other, the easiest chores were impossible to achieve. And thus it is with the ACA Exchanges, eminently fixable technically, and utterly unfixable politically.

And ACA demolition is advanced with no clearly defined replacement alternative. Yes, Speaker Ryan advanced a health reform agenda this past summer; yet he and his team did not put their ideas into legislative language that could be scored by the Congressional Budget Office, perhaps because they knew that the results on both lost insurance coverage and rising costs would turn the public against them.

“The future, like everything else, is no longer quite what it used to be.” (Paul Valery, 1937, not Yogi Berra).

As I write this on November 3rd, the most likely outcome from November 8 is divided government, with a Senate majority hanging by a thread. (Please recall that Senator Al Franken (D-MN) took his U.S. Senate seat for the first time in July 2009 after an eight-month recount process.) Republicans know that the electoral map in 2018, all things being equal, will offer substantial gains in both the Senate and the House, particularly if their political base is pleased. Democrats know that they will need to deliver on at least some of their promises, and not allow the signal accomplishment of the Obama Administration to fall apart.

Dare I say it: we’re going to need some statesmanship at a time when that commodity is in short supply.

The Choices on Health Reform in the US Presidential and Congressional Elections

The commentary below was published in JAMA Internal Medicine online on October 10 2016 and was written by me and David K. Jones from the Boston University School of Public Health:

Although the outcomes of the US Presidential and Congressional elections in November 2016 will not be determined by attitudes toward the Affordable Care Act (ACA), the results will likely determine its long-term fate. As was the case in 2008 and 2012, the electorate’s decisions on whether the Republicans or the Democrats control the White House, the Senate, and the House of Representatives will have fundamental consequences for the future of national health reform.

A Republican victory that includes that party’s control of the White House, Senate, and House of Representatives would likely augur huge shifts in national health policy. A Democratic victory that included the White House and a Senate majority would likely further embed the ACA into state and federal health policy, and perhaps lead to further expansion and reforms. More than 6 years after President Barack Obama signed the legislation into law in 2010, the ACA has yet to become settled policy.

The Republican Agenda

Over the past 4 years, Republican members of Congress and conservative think tanks such as the American Enterprise Institute and the Manhattan Institute have advanced numerous proposals to repeal and replace the ACA. As the final stages of the 2016 campaign approach, 2 plans stand out: Republican presidential candidate Donald Trump’s agenda as outlined on his campaign website,1 and the House Republican leadership plan released by Speaker Paul Ryan (R-WI) in June 2016.2 Continue reading “The Choices on Health Reform in the US Presidential and Congressional Elections”

Explaining the New MassHealth 1115 Waiver Proposal

The article below — Baker’s Big Health Care Move — was published in the October 2016 issue of Commonwealth Magazine:

FOR THE THIRD time since 1996, the Massachusetts Medicaid program, called MassHealth, is preparing for transformation. After submitting a final proposal in July, state officials are anxiously awaiting a decision on the plan from the US Centers for Medicaid & Medicare Services. The goals are to: first, transform how medical services are delivered to many of MassHealth’s 1.86 million enrollees (including 40 percent of Massachusetts children); second, guarantee a five-year flow of nearly $8 billion in extra federal dollars into the state’s health care system; and third, better integrate substance abuse, mental health, and long-term services and supports into traditional medical care.

Chances are you have heard nothing about this plan that contains many worthy and some controversial changes. For state leaders, the stakes are high. Between 1997 and 2015, MassHealth’s share of the overall state budget doubled from 18 percent to 36 percent—with federal dollars accounting for more than half of the total share. At $16.4 billion in fiscal year 2017, MassHealth is the state’s biggest budget buster and most important lifeline for the state’s neediest populations. The new federal proposal represents Gov. Charlie Baker’s attempt to slow the growth rate while improving medical care and the health of enrollees.

For those who have been awaiting the Baker administration’s big health policy move, this may be it.

WHY IS THIS HAPPENING?

Since 1965, Medicaid has been a federal-state partnership that provides health coverage for low-income Americans. Originally just for poor mothers and kids on public assistance, today it is America’s largest health insurance program, covering more than 70 million people. The federal government provides most of the money, and sets tight rules governing how states run their programs. States can get flexibility from those rules by obtaining waivers from the federal government, the most pliable being the “Section 1115 research & demonstration waiver,” generally granted for 3-5 year terms. Even though federal rules require waivers to be “budget neutral,” states use creative medical and insurance redesigns to obtain substantial and desirable financial flexibility. Massachusetts Medicaid entered the 1115 game in 1997 with a major coverage expansion that transformed it into today’s MassHealth. Baker, then secretary of administration and finance under Gov. Bill Weld, was a key architect.

Since that time, Massachusetts’s 1115 waiver, now in its sixth iteration, has brought flexibility and extra dollars to support the state’s medical infrastructure for disadvantaged populations, chiefly through Boston Medical Center, Cambridge Health Alliance, and the state’s community health centers. It was the threatened loss of those extra federal dollars ($385 million in 2004) that jolted then-Gov. Mitt Romney and Sen. Ted Kennedy to formulate the plan leading to passage of the landmark 2006 Massachusetts Universal Health Care law, which in turn helped spark passage of the 2010 federal Affordable Care Act.

The state’s current 1115 funding ends in June 2017, and Baker administration officials, especially Secretary of Health and Human Services Marylou Sudders and MassHealth chief Daniel Tsai, are eager to lock in the next waiver—and the nearly $8 billion over five years—before Team Obama departs in January. Since arriving on Beacon Hill in January 2015, Team Baker has engaged in intensive planning with stakeholders, including consumer advocates, hospitals, physicians, insurers, and more. State leaders want federal approval by early fall. If federal officials like their plan—and Team Baker is hitting notes Team Obama wants to hear—they may get their wish.

WHAT’S THE PLAN?

The state’s application outlines five goals for the new five-year waiver that would begin in 2017:

Enact payment and delivery system reforms that promote integrated, coordinated care and hold providers accountable for the quality and total cost of care.
Improve integration of physical health, behavioral health, long-term services and supports, and health-related social services.
Maintain near-universal coverage.
Sustainably support safety net providers to ensure continued access to care for Medicaid and low-income uninsured individuals.
Address the opioid addiction crisis by expanding access to a broad spectrum of recovery-focused substance abuse disorder services.

The most controversial goal is the first: inducing Mass-Health medical providers (hospitals, physician groups, home health agencies, community providers, and post-acute providers such as rehabilitation hospitals and nursing homes) to form or expand “accountable care organizations” (ACOs) to assume responsibility for the total cost of care for their MassHealth members.

ACOs were invented in the Affordable Care Act to push providers away from fee-for-service payments that tend to reward volume over quality and efficiency. Since 2010, more than 800 ACOs have formed across the nation in Medicare, private coverage, and, increasingly, Medicaid, with 17 states now using ACOs or looking to do so. In 2012, in that year’s health care cost control law signed by then-Gov. Deval Patrick, the Legislature directed MassHealth to move quickly to adopt “alternative payment models” such as ACOs. So the new waiver will enable MassHealth to meet both federal objectives as well as its legislative mandate.

Currently, about 840,000 of MassHealth’s 1.86 million enrollees obtain care through one of the state’s Medicaid managed care organizations such as Neighborhood Health Plan or Boston Medical Center’s Health Net. About 383,000 others participate in the loosely managed Primary Care Clinician (PCC) program. The rest, especially seniors and persons with disabilities, are in fee-for-service. MassHealth officials want to push as many PCC enrollees as possible into managed care organizations or ACOs by curbing benefits such as eyeglasses, hearing aids, and chiropractic or orthotic care and imposing new out-of-pocket costs on unwilling enrollees who choose to stay with the PCC program.

This aspect concerns patients, advocates, and medical groups. Though ACOs have grown rapidly since 2010, their track record in reducing costs and in improving quality has been modest, and their future is a topic of urgent debate among health policy experts. Some data suggest that PCC enrollees are no more expensive than managed care enrollees. Many PCC enrollees have serious, complex medical needs that can be poorly served by Medicaid managed care organizations with exclusive provider networks.

On the other side, encouraging states to jump into ACO-style “value-based payment”—and away from uncoordinated and unmanaged fee-for-service care—is among the highest priorities of federal officials such as US Health and Human Services Secretary Sylvia Burwell. If Massachusetts wants any hope of keeping the $8 billion in extra federal dollars flowing, they need to excite federal officials with ambitious designs of this variety.

The second goal—integrating physical health, behavioral health (the combined term for mental health and substance abuse treatment), long-term services and supports (the new term of art for long-term care), and health-related social services—is a major health system improvement goal advocated nationally and in Massachusetts by many, especially Sudders, a former clinical social worker and state mental health commissioner who has long fought to demolish medical care siloes.

Under the new waiver, new MassHealth ACOs will be required to build partnerships with certified “community partner” organizations that provide behavioral health plus long-term services and supports while managing the total cost of care of their enrollees. Providers will operate with per-person capitated payments that require improving the health and well-being of enrollee populations rather than just treating sick patients, a paradigm-shift for providers trained to care—and bill—for one patient at a time.

In response to health care providers worried about adapting to this new system, state officials emphasize the five-year transition to an ACO-centered MassHealth set to launch October 1, 2017. They also note that the $8 billion in federal waiver money will include $1.8 billion in additional federal payments (called Delivery System Reform Incentive Payments) specifically to help providers undertake the transition.

LET THE GAMES BEGIN – OR NOT

Opaque is a word often applied to 1115 waivers, one the Obama administration has attempted to replace with “transparent.” States must now conduct open public hearings on new waiver applications and make public all sorts of information relating to 1115 applications. MassHealth’s information, including the application, is here.

Noteworthy are 94 stakeholder letters submitted in July, 400 pages of praise and criticism from organizations large (Massachusetts Hospital Association, Massachusetts Medical Society) and small (Home Care Aide Council, Autism Housing Pathways). One letter from Leann DiDomenico, the mother of a 12-year-old adopted foster child, caught my eye:

“My son…spent the first three years of his life in an abusive birth home followed by 18 months in three different foster homes leaving him with a number of behavioral health issues, including PTSD and reactive attachment disorder (RAD). Over the past seven years my husband and I have worked hard alongside [his] primary care provider and various therapists to help [him] to heal and develop the tools he needs to live a full, productive life in spite of his mental health issues. If/when [he] is transitioned to an ACO, I have no confidence that we will be able to keep the professionals we currently have in place that are working well for [him].”

Leann’s letter gives voice to the concerns advocates have raised about the waiver plan. In 2013, MassHealth launched another ambitious demonstration to move their disabled enrollees into a new managed care program called One Care. Though One Care has made substantial improvements in quality, only about 13,000 of 115,000 MassHealth eligible enrollees have signed up after a rocky implementation (see “No time to go wobbly on One Care,” CW, Fall 2015). The new 1115 waiver is even more ambitious and dicey. Many PCC enrollees and their families have painstakingly built personal provider networks to address their serious and unique needs. ACO implementation risks serious disruption for them. MassHealth should offer these individuals and families a no-penalty “opt-out” until this experiment proves itself.

Baker’s 1115 waiver plan includes major steps forward for Massachusetts health care that may pay important dividends well into the future. Until they have demonstrated the capacity to implement this without harming any of their enrollees, they should proceed with more caution.

How Might Democrats Try to Expand and Improve the ACA in 2017?

[Below is a new commentary just released by the Milbank Quarterly on their website — to be published in their fall edition.]

In 2017, if Democrats hold the White House and recapture a majority in the US Senate (control of the US House is considered unachievable), how might they try to change the Affordable Care Act (ACA)?

Despite congressional gridlock, changes to the ACA have happened. Six years since its enactment, the ACA has been altered 24 times by Congress and the president, mostly in response to Republican demands that generated some support from Democratic lawmakers as in the 2013 wholesale repeal of the ACA’s Title VIII, a new disability cash assistance program known as Community Living Assistance Services and Supports (CLASS—RIP).¹

While Democrats and progressive groups have wish lists for ACA improvements, they have kept these low-key, prioritizing instead the need to repel repeated existential threats to the law, such as the 2 anti-ACA lawsuits that reached the US Supreme Court in 2012 and 2015 (National Federation of Independent Business v Sebelius and King v Burwell, respectively). Continue reading “How Might Democrats Try to Expand and Improve the ACA in 2017?”

Obama, Clinton and the New Public Option

The era of Democratic silence on strengthening and improving the Affordable Care Act is officially over. President Barack Obama’s tour de force review of the ACA’s successes in the new Journal of the American Medical Association is also important for his identification of key ACA improvements needed on insurance affordability, Medicaid, prescription drug prices and more. I note his call for a “public option” health plan to spur competition in states with low numbers of health insurers participating in state ACA exchanges/marketplaces:

“…(I)n the original debate over health reform, Congress considered and I supported including a Medicare-like public plan. … Now, based on experience with the ACA, I think Congress should revisit a public plan to compete alongside private insurers in areas of the country where competition is limited. Adding a public plan in such areas would strengthen the Marketplace approach, giving consumers more affordable options while also creating savings for the federal government.”

Serendipitously, Sect. Hillary Clinton is now actively promoting the public option in her White House run, partially to woo backers of her Democratic opponent, Sen. Bernie Sanders (D-VT), and also because she has supported this idea since 2008:

“To make immediate progress toward that goal, Hillary will work with interested governors, using current flexibility under the Affordable Care Act, to empower states to establish a public option choice.”

What does the “public option” mean and why now? Continue reading “Obama, Clinton and the New Public Option”

House GOP ACA Replacement Plan Is an Empty Backpack

This week, US House Speaker Paul Ryan released a long-promised plan to replace the Affordable Care Act. Most of the plan, “A Better Way: Health Care,” developed by a House task force, includes familiar ideas that have been in Republican rhetoric even prior to the ACA. Coverage of the plan’s basics can be found here and here and here. Is there anything new, important, or revealing in this? Yes. Here is my list:

First, Team Ryan does not want you to know the cost or coverage impact of their proposal. Team Ryan is plenty capable of producing a legislative draft that could be scored by the Congressional Budget Office, and chose not to do so because that would be telling. Indeed. The ACA repeal legislation they sent to President Obama’s desk (subsequently vetoed) this past January would have eliminated health insurance for 22 million Americans who got it via the ACA. Is this new plan better? Team Ryan doesn’t want you to know.

Second, Team Ryan wants to eliminate income-based subsidies in favor of a flat tax credit. The most important reason people lack health insurance is because they don’t have enough income to afford it. The ACA’s structure is based on income – the most assistance goes to those with the least means, ending at 4 times the federal poverty level, or $97,200 for a household of four. Team Ryan offers a flat tax credit for anyone who can’t get employer coverage that would leave most people under 300% unable to afford coverage. How many? It’s impossible to say because Team Ryan doesn’t indicate the size of the credit. Continue reading “House GOP ACA Replacement Plan Is an Empty Backpack”

Back to the Future with Speaker Paul Ryan

This past week at Georgetown University, House Speaker Paul Ryan proposed scrapping an essential component of the Affordable Care Act (ACA) that bans health insurance companies from imposing pre-existing condition exclusions on consumers and prohibits the practice of “medical underwriting” to discriminate against anyone with a current or prior medical condition. Instead, he proposed, states could re-establish “high risk pools” from which those with pre-existing conditions could obtain coverage, leaving standard health insurance only for the “healthy.”

Paul Ryan 2 Christopher Lloyd

Wow. Ryan may or may not realize it – but his speech just changed the stakes regarding the ACA and the November 8 federal elections.

Prior to Ryan’s speech, conventional wisdom, as evidenced in Republican Congressional and conservative think tank proposals, was to preserve the ACA’s ban on pre-existing conditions, albeit only for those who maintain “continuous coverage.” This stance enabled Republican office-holders to affirm their support for the pre-ex ban, even as their proposals’ fine print would reintroduce medical underwriting. Continue reading “Back to the Future with Speaker Paul Ryan”

Behind the Bipartisan Kumbaya on Substance Abuse

[This op-ed was posted yesterday on the website of the Milbank Quarterly.]

For several years, Republicans and Democrats alike have been concerned about the crisis of opioid and heroin addiction in the United States. It is hard to find anyone who rejects the notion of a serious problem that demands at least a partial governmental response. Across the nation, governors and legislatures are hard at work seeking solutions and avoiding partisan bickering. Numerous current and former presidential candidates in the 2016 campaign cycle got favorable attention explaining how the crisis has affected their families and friends in personal ways.

Behavioral health

The question is whether there is any meaningful difference between Republicans and Democrats when it comes to substance abuse (and, for that matter, behavioral health—the merger of substance abuse and mental health).

The answer is yes, and the difference comes down to the Affordable Care Act (ACA). Continue reading “Behind the Bipartisan Kumbaya on Substance Abuse”