ObamaCare – Page 4 – Health Stew

Bernie Sanders and Hillary Clinton on Health Care – Who’s Got the Plan?

It’s funny how things turn out on the campaign trail. Since all Republican presidential candidates pledge to repeal the Affordable Care Act/ObamaCare, they have little to argue about. The fireworks are among Democrats as Hillary Clinton and Bernie Sanders argue the future of US health reform and, specifically, the merits of Sanders’ new single payer/Medicare for All scheme, released Sunday evening hours before the Democrats’ final pre-primary debate.

Clinton, fighting a Sanders surge in the Iowa and New Hampshire Democratic primaries, has been landing punches to throw his momentum off balance. Meanwhile, Sanders keeps humming the single payer tune that the Democratic base adores (see the Kaiser Poll below), offering some new melodies and riffs in his revised plan.

Sanders’ proposal matters because it shows how progressive thinking has shifted and because it calls into question whether Democrats have the staying power and political will to defend one of their principal accomplishments in the past 50 years, the ACA. Here are key points about the Sanders plan: Continue reading “Bernie Sanders and Hillary Clinton on Health Care – Who’s Got the Plan?”

Please Remember This Number – 22 Million

22 million – that’s how many Americans would lose their health insurance, according to the U.S. Congressional Budget Office, if the reconciliation legislation approved by the U.S. House of Representative yesterday by a 240-181 vote were to become law.

The U.S. Senate approved the same bill in December and the House adopted it yesterday with no changes, so it is heading to the White House where President Obama is certain to veto the measure. The likelihood that House or Senate Republican leaders could summon the needed votes to override that veto is zero.

It’s easy to dive into the political games involved in this legislation because there are so many. Doing so, though, ignores our responsibility to recognize what this Congress has done – put itself on record to cancel health insurance for tens of millions of Americans and offer nothing, zero, to mitigate the harm to mostly low and lower middle income families.

Here are the bill’s key elements:

Eliminate the ACA Medicaid expansion
Eliminate the ACA’s premium and cost sharing subsidies to help lower middle income Americans buy private health insurance
Repeal the ACA’s individual mandate which helps to ensure a healthy risk pool of enrollees to keep premiums affordable
Cancel all federal funds to Planned Parenthood

Continue reading “Please Remember This Number – 22 Million”

Why Republicans Hate the ACA So Much

both increases literally reversed the majority of the last 20 years decline in the effective tax rate of America’s 400 wealthiest taxpayers!

This week, the US House of Representatives will take up reconciliation legislation, amended and approved in the US Senate last month, that would drill major, damaging holes in the Affordable Care Act. Though the bill has zero chances of becoming law because of a certain veto by President Obama, it is – by the Democrats’ count – the 61^st time the House has voted to repeal all or significant parts of the health reform law.

Why, people often ask me, do Republicans hate the ACA so much?

This past week’s New York Times Upshot article, I believe, provides a major part of the answer. Briefly, “it’s the taxes on the wealthy, stupid.” Specifically, it’s about two new Medicare taxes that went into effect in 2013 only on higher income Americans:

ACA Medicare Part A Payroll Tax: Beginning in 2013, individuals with earnings above $200,000 and married couples making more than $250,000 got an increase in the Medicare part A payroll tax of 2.35%, up from 1.45% (a .9% increase), on adjusted income over the threshold. (2016-25 take = $123 billion)
ACA Unearned Income Tax: This same group also now pays a new 3.8% unearned income (capital gains) tax on interest, dividends, annuities, royalties, rents, and gains on the sale of investments over the threshold. (2016-25 take = $222.8 billion)

It’s a lot of money and it’s a lot of money taken exclusively from the top 5% of America’s wealthiest, ($345.8 billion between 2016-25) and especially from the most wealthy as the chart below demonstrates: how-much-does-the-affordable-care-act-raise-taxes-really-01

As the Times article makes clear, these new taxes are so damn big (when combined with higher taxes from the 2012 American Taxpayer Relief Act) that both increases literally reversed the majority of the last 20 years decline in the effective tax rate of America’s 400 wealthiest taxpayers! Continue reading “Why Republicans Hate the ACA So Much”

An ACA Damage Assessment: Real, Non-Critical, and TBD

The post below was first published yesterday on the Commonwealth Magazine website:

On one thing all Affordable Care Act watchers can agree: This autumn saw important developments and changes relating to the nation’s health reform law. How much and how serious? Any immediate assessment is incomplete and the full impact only will be evident through the lens of the 2016 presidential and Congressional election results. Until then, some impacts are clear. So let’s consider…

First, what has happened? Here is my list of key developments:

Congress delayed or suspended for one or two years the operation of three taxes that help finance the ACA: the so-called “Cadillac tax” on high-cost employer-sponsored health insurance policies; the medical device industry tax; and the health insurance provider tax.
The House and Senate are close to final agreement (coming in January) to use the budget reconciliation process to repeal major, critical portions of the ACA, legislation that President Obama will veto and will see his veto sustained.
14 of 23 co-op health insurance plans created from the ACA have collapsed; also, UnitedHealthcare is dropping out of the ACA market.
The third Open Enrollment process is proceeding smoothly with larger than expected numbers signing up for coverage – final numbers yet to come.
On Medicaid, more holdout states are warming up to accepting the ACA expansion, and Kentucky’s new Tea Party governor has abandoned his campaign commitment to repeal that state’s expansion.
More and more experts, from both sides of the ACA divide, are advancing robust and noteworthy proposals for ACA replacement or improvement.

Continue reading “An ACA Damage Assessment: Real, Non-Critical, and TBD”

The $879 Billion Footnote — And The Financing Path To ACA Repeal

[This post was originally published on December 4th on the Health Affairs Blog. It was co-written by me and Max Fletcher, a student at the Harvard TH Chan School of Public Health.]

The November 3 election of Matt Bevin as governor of Kentucky will provide an important indication of the seriousness of Republican intentions to undermine and repeal the health insurance expansions of the Affordable Care Act (ACA). Early in Bevin’s campaign, he expressed unambiguous intent to repeal Governor Steve Beshear’s executive order that expanded Medicaid; during the general election campaign, Bevin backpedaled and proposed adopting an Indiana-like Medicaid waiver to require significant enrollee cost sharing and an enrollment freeze. Bevin also prefers to close the successful Kynect health insurance exchange and transfer operating duties to the U.S. Department of Health & Human Services.

Whatever the outcome, the moves by the Tea Party-endorsed new governor will provide the best preview of what the nation may expect if Republicans take control of the White House and retain majorities in the Senate and the House of Representatives in January 2017. Many eyes will watch Governor Bevin’s health care moves from across the political spectrum. Continue reading “The $879 Billion Footnote — And The Financing Path To ACA Repeal”

Will 61 Be the Charm? The New Republican Effort to Gut the ACA

[Note: This post was first published on the Health Affairs Blog.]

For the 61st time since 2011, Congressional Republicans are moving legislation to undermine and dismantle key elements of the Affordable Care Act (ACA). This time, though, will be different.

First, this will be the first time Republicans will use the budget process known as “reconciliation” to advance repeal. Using a budget reconciliation bill prevents Democrats from filibustering the legislation in the Senate, meaning only 51 votes are needed for passage in expedited debate.

Second, this will be the first time that the House and Senate both pass similar legislation to damage the law. As a result, this will be the first time that anti-ACA legislation will reach President Barack Obama’s desk. The President’s veto of this measure is guaranteed, as are the needed votes in the House and Senate to sustain his veto. So this will be another exercise in ObamaCare-Kabuki Theater with some new twists.

What’s In The Reconciliation Package?

The key elements in the legislation, developed by three House Committees (Ways and Means, Energy and Commerce, Education and the Workforce) including: Continue reading “Will 61 Be the Charm? The New Republican Effort to Gut the ACA”

What Would Republicans Do Instead of the Affordable Care Act?

(This article was published on Friday, September 18 on the Health Affairs Blog. It was prepared by me and Max Fletcher, a Master of Public Health student at the Harvard TH Chan School of Public Health.)

A new spate of proposals from Republican presidential candidates to repeal and/or replace the Affordable Care Act (ACA) raises the important question: Given an unobstructed opportunity, what would Republicans really do with the Affordable Care Act? Would they repeal the law wholly or just in part? With what might they replace it?

Some suggest that Republican Congressional leaders only advance full repeal to placate their Party’s conservative base, knowing well that repeal cannot survive a certain veto while Barack Obama is President. In January 2017, that obstacle will vanish if Republicans control the White House and both branches of the U.S. Congress. What then?

Unfortunately, the proposals now being advanced by the Presidential candidates are far less than comprehensive, and leave many more issues unanswered than answered.

Though no ACA replacement plan has progressed in either branch (or in any standing committee) of Congress since the law’s 2010 signing, Republican office holders and conservative think tanks have advanced expansive proposals. We identified eight plans offered between 2012 and 2015 that address the ACA’s fate and propose substantive replacement. We examined each in detail to determine the extent of agreement on alternatives to the ACA. We created a chart comparing the eight proposals according to key policies. Table 1 below provides identifying information about the eight plans:

Of the eight proposals, four were advanced by Republican Members of Congress. The most prominent of these is the Patient CARE Act offered by Sens. Richard Burr (R-NC) and Orrin Hatch (R-UT) and Rep. Fred Upton (R-MI); the latter two are the current chairmen of the Senate Finance Committee and the House Committee on Energy and Commerce respectively, both committees with primary ACA jurisdiction. Though narrative versions of Burr-Hatch-Upton were released in 2014 and 2015, the authors have not translated their proposal into legislative language that can be evaluated by the Congressional Budget Office (CBO). While the other Congressional proposals have been introduced as legislation, none have received CBO scores. Continue reading “What Would Republicans Do Instead of the Affordable Care Act?”

Not Ready for Primetime: Republican Presidential Candidates on Health Reform

If you were among the few looking closely, you may have noticed buzz and hoopla this past week on the release of two health reform proposals from Republican presidential candidates Gov. Scott Walker (R-WI) and Sen. Marco Rubio (R-FL). Not surprisingly, while Affordable Care Act supporters were quick to criticize, ACA detractors were complimentary: “serious plans” and “the opening theme music of health policy reform for Republican presidential primary voters.”

So, how do these two plans stack up? Not well. Here’s a handy table with which you can compare – and I’ve left nothing of out:

Category	Gov. Scott Walker	Sen. Marco Rubio
*Title*	The Day One Patient Freedom Plan: My Plan to Repeal and Replace Obamacare	Real Reform in the Post-Obamacare Era
*ACA/Obamacare*	“Repeal … in its entirety”	“Demand that we repeal Obamacare and replace it with a conservative solution.” (website)
*Tax Credits to Purchase Health Insurance*	“Available to anyone without employer coverage based coverage” – the amount based on age only: 0-17: $900 18-34: $1200 35-49: $2100 50-64: $3,000	“… advanceable, refundable tax credit that all Americans can use to purchase health insurance…”
*Access to Health Savings Accounts (HSAs)*	Anyone signing up for an HSA gets a $1000 refundable tax credit	“…should be expanded.”
*Sale of Health Insurance across State Lines*	Allow individuals to shop in any state for insurance	N/A
*Pre-Existing Conditions*	Banned for individuals who “maintain continuous creditable coverage”	“Those with pre-existing conditions should have access to affordable care through mechanisms such as federal-supported, actuarially-sound and state-based high risk pools.”
*State High-Risk Pools*	“…make it easier for states to expand these pools”	See above.
*Mandated Essential Health Benefits, including for Young Adults <26*	“…return regulatory authority to states”	N/A
*Medicaid*	Capped state allotment for: 1. Low-income families 2. Non-disabled adults; 3. Long term services & support	“… move … into a per capita system preserving funding for Medicaid’s unique populations while freeing states from Washington mandates.”
*Insurance Pooling*	“… allow for new purchasing arrangements so farmers, small business, religious groups, individual membership associations and others could join together…”	N/A
*Long Term Care Insurance*	Deregulate the current market	N/A
*Medical Malpractice*	“… incentivize states to pass meaningful lawsuit reform…”	N/A
*Financing*	“… repeal all of ObamaCare’s $1 trillion in new taxes…” No specifics on substitute financing.	N/A
*Tax treatment of employer provided health insurance*	N/A	“Glide path” downward to match the value of individual tax credits within a decade
*Medicare*	N/A	“A premium support system, empowering seniors with choice and market competition, just like Medicare Advantage and Part D already do.”

Some observations:

First, even for a campaign document, these plans are wafer thin, raising far more questions than providing answers. Walker’s plan has just seven pages of substance, and Rubio’s is based on two short op-eds for Fox News and Politico. Continue reading “Not Ready for Primetime: Republican Presidential Candidates on Health Reform”

Creating Better Affordability in the Affordable Care Act

Every day, so many reports emerge about aspects of ObamaCare/ACA that it’s difficult to decide which ones to note. Here’s one I note today from the Urban Institute – “After King v. Burwell: Next Steps for the Affordable Care Act” written by the always perceptive Linda Blumberg and John Holahan.

The report’s basic and important message is this: though it has vastly increased health insurance security and affordability for millions of vulnerable Americans, the Affordable Care Act is not affordable enough. Knowing what we know now, the law needs better affordability for millions of Americans who need access to subsidized insurance that includes more affordable premiums and stronger cost sharing protections:

“The premium and cost-sharing structures established under the law were delineated with the intention of meeting specific budget targets that now seem overly constraining. As a result, several problems occurred. Premium tax credits are substantial, but they are still inadequate for many individuals and families, given their incomes. Similarly, many individuals with modest incomes may struggle to afford the Level of cost-sharing required in the plans for which the premium tax credits are pegged. Premium tax credits are tied to a product with cost-sharing requirements that significantly exceed the typical large employer-sponsored plan. In particular, older individuals with incomes just above the current tax credit eligibility range face high premiums relative to their incomes, and because they tend to use more medical care than do their younger counterparts, they face a total bill for premiums plus out-of-pocket spending that can be very high.”

Continue reading “Creating Better Affordability in the Affordable Care Act”

The Sounds of Silence in the Republican Debate

I had one mission last evening watching the Republican-Fox News debate among their party’s top ten presidential contenders: what, if anything, could we learn about the state of play regarding the Affordable Care Act and U.S. health policy?

What I observed: the impassioned debate about the Affordable Care Act/ACA/ObamaCare is over, even among Republicans.

Here is what I noted from the debate that referenced the ACA:

First, Ohio Governor John Kasich restated his strong support for his decision to expand Ohio’s state’s Medicaid program as enabled and financed by the ACA, invoking President Ronald Reagan as someone who “expanded Medicaid three or four times.” He emphasized how the expansion helps both Ohio’s working poor as well as the mentally ill in prisons. No apology, no retreat, and no damage or attacks from any of his rivals.

Second, asked about his prior public support for a Canadian-style single payer health care system, Donald Trump commented that “single payer works well in Canada and incredibly well in Scotland.” He said he wants a “private system without artificial lines around states” (so much for states’ rights) and opposes “insurance companies that make a fortune because they have total control of the politicians. Get rid of the artificial lines. Take care of the people who can’t take care of themselves.” Oddly, at the end of his closing statement at the very end of the program, he added, apropos of nothing: “We have to end Obamacare and make our country great again.”

Former Florida Governor Jeb Bush said he wants to “get rid of Obamacare and replace it with something that doesn’t suppress wages.” No indication of what the “something” might be.

Wisconsin Governor Scott Walker simply said he wants to “repeal Obamacare.”

That’s it. Except for Trump’s, none of the others’ closing statements mentioned the issue. Even Texas Senator Ted Cruz, in his lengthy litany of first-day-as-President actions, left executive action on the ACA off his list. Cruz, as many will recall, was the key instigator of the 2013 federal government shutdown as a final gasp to prevent implementation of the ACA’s insurance coverage expansions on January 1 2014.

The only question from the panel of three Fox news journalists relating to health reform was the one to Trump regarding his past support for single payer health insurance – more a Fox gotcha moment than a thrust into health policy.

I looked at dozens of news accounts of the program from journalists across the political spectrum. Obamacare/ACA merited no mention anywhere in the their accounts and analyses.

This is the sound of silence as the ACA disappears from the nation’s political radar screen.

Yes, U.S. health policy is becoming boring again, still a never-ending feast for the policy wonks, still a continuous hand-wringing exercise for patients and medical providers dealing with their daily challenges, and now a big nothing-burger for most Americans focused on other concerns.

On two other health related issues, we heard repeated statements of opposition to public funding for Planned Parenthood and, of course, strident statements of opposition to abortion where the focus put candidates on the defensive who are willing to allow abortion in cases of rape, incest, and to save the life of the mother.

And nothing about Ebola!

I am sure in future debates, the ACA will return and receive a higher profile. But temperatures are cooling and this program last evening was important affirmation.