Paul Ryan – Health Stew

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 28^th 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 “MayDay! The ACA Is Still Alive and Still in Danger”

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 “The State of Play Post-Trump/RyanCare”

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

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.

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

Five Affordable Care Act Questions for the GOP

[This commentary was published today on the website of Commonwealth Magazine.]

SO, REPUBLICANS ARE planning a major blitz to repeal and delay/replace/collapse the Affordable Care Act/ACA/ObamaCare. I’ve got five questions to ask leaders of the Grand Old Party.

First, if your guarantees are honest that your replacement law will be better than the ACA, why not share real numbers?

President-elect Donald Trump, Speaker Paul Ryan, and Majority Leader Mitch McConnell have each promised that their ACA replacement will cover as many Americans as the ACA with higher quality and lower costs. Bully for that!

Here’s the problem. None of the plans you’ve produced, including the 2016 Reconciliation bill, Trump’s platform, Ryan’s Better Way, Health & Human Services Secretary designee Tom Price’s Empowering Patients First plan, or others from Republicans and conservatives, comes close. Except for this year’s reconciliation bill, none has been submitted to the Congressional Budget Office for a score. Reputable analysts peg the drop in insured lives between 20-30 million currently insured.

Your message is “trust us.” Would businessman Trump take such a deal?

Second, when you promise to continue “guaranteed issue” of health insurance with no-pre-existing conditions or medical underwriting, why do you always fail to mention the fine print?

Trump, Ryan, and other Republicans’ statements are clear – any reform will maintain “guaranteed issue.” Yet your written plans tell another story – guaranteed issue will be kept only for persons who maintain “continuous coverage” (undefined). This means if you lose your insurance and have a coverage gap beyond the allowed time, you will be newly subject to medical underwriting and pre-existing condition exclusions for an unspecified period (forever?).

How many people might fall into this new medical underwriting Circle of Hell (CoH)? Start with 28-29 million currently uninsured, add the estimated 20-30 million increase because of Republican plans to eliminate income-based premium subsidies. We start at 48-58 million Americans, and the numbers will only grow as more fall into the medical underwriting CoH.

This is detailed in numerous replacement plans, including Ryan’s. Yet you never mention this life-important detail when talking with media who buy your line that you will continue the ACA’s elimination of pre-existing conditions for everyone. Untrue.

Third, what will you do about enormous losses for those dealing with substance abuse and mental health needs under your plans?

Most Americans don’t realize that the ACA is the biggest law ever in covering Americans for substance abuse and mental health services (aka: behavioral health). It’s true. ACA guaranteed issue means no one can be denied insurance because they had or have substance abuse/mental health problems. Bans on lifetime and annual benefit limits allows countless persons with expensive substance abuse or mental health disorders to keep covered. Requiring insurers to cover 10 “essential health benefits” insures that nearly all Americans have behavioral health coverage (#5) PLUS prescription drugs (#6) to treat their disorders.

All Republican plans – Trump, Ryan, Price etc. – propose eliminating “essential health benefits.” They propose eroding guaranteed issue (see above) and canceling elimination of annual benefit limits. So, the ACA’s enormous advances for mental health and substance abuse would become major losses under Republicans’ plans. I’m not sure you get this at all. I am certain most Americans have zero idea of this and they will strongly object when they find out.

Fourth, why are you so mean to the nation’s hospitals?

In crafting the ACA, America’s hospitals committed a mortal sin in Republicans’ eyes by making a deal with President Barack Obama and the US Senate. In exchange for Democrats’ commitment to get as close to universal coverage as politically possible, hospitals agreed to $155 billion in federal payment reductions between 2010-19 (now about $350 billion between 2016-2025). They did this to stop being the default caretakers of America’s uninsured.

Now Republicans plan to repeal the ACA’s new taxes on wealthy Americans, on drug, medical device, and health insurance companies, even on indoor tanning salons! And, they plan to leave in place the $350 billion in payment cuts to hospitals even as their policies will send as many as 30 million recently insured Americans back into the ranks of the uninsured and back to America’s emergency departments.

The American Hospital Association and the Federation of American Hospitals, who brokered the 2009 deal, wrote a letter on December 7 to Republicans: “…any repeal legislation … must include repeal of the reductions in payments for hospital services embedded in the ACA.” Sounds reasonable to me, but maybe not to others because if Congress sends the money back, it will raise Medicare’s costs for the next decade and beyond, resulting in premium increases for Medicare enrollees across the nation, and shortening the lifespan of the Medicare Hospital Trust Fund (now solvent through 2028) by years. Sad! (Read this excellent Kaiser Health Policy Brief for more details on the impact of ACA repeal on Medicare.)

Fifth, why don’t you just fix the ACA exchanges instead of killing them?

A parable: Last summer, Alaska realized that premiums in its health exchange and individual health insurance market would be rising in 2017 by over 40 percent. In response, the Republican legislature established a state reinsurance pool to protect insurers against high losses; after passing the law, insurance companies dropped their premium increases to about 7 percent.

Some health insurance exchanges (i.e., California, New York, Massachusetts) are working well, and some are having high rate increase problems. These problems are fixable with sufficient political will to address them. The problem is that Republican lawmakers don’t want fixes – they want repeal. In 2014, 2015, and 2016, exchange premium increases were below projections. In 2017, they have risen at high rates in most states because of the end of rate protections known as “risk corridors” and “reinsurance” as well as the underfunding of “risk adjustment” in the ACA. All of these “3Rs” are permanent features of the Medicare Part D prescription drug program that Republicans support there and despise in the ACA.

These exchange problems are fixable. Yet you refuse to support them and fix the problems because that would undermine your case for ACA repeal.

These are my top five questions right now. Any answers, my friends?

The Price Is Wrong — Trump’s Health Secretary Is a Bad Sign for Health Reform

[This column was printed today on Commonwealth Magazine’s website.]

PRESIDENT-ELECT DONALD TRUMP has nominated Rep. Tom Price of George, an orthopedic surgeon and the House Budget Committee chairman, to be his first secretary of health and human services. For those lulled into believing that Trump was moderating his views on the Affordable Care Act because of recent statements on 60 Minutes that he leaned toward supporting ACA provisions on banning pre-existing condition requirements and allowing young adults to stay on their parents’ insurance plans, this nomination is a bucket of ice cold water.

UNITED STATES - APRIL 16: Rep. Paul Ryan, R-Wisc., right, Chairman of the House Budget Committee, and Rep. Tom Price, R-Ga., prepare for a hearing in Cannon Building titled "The President's FY2014 Revenue and Economic Policy Proposals," featuring testimony by Treasury Secretary Jack Lew. (Photo By Tom Williams/CQ Roll Call) — UNITED STATES – APRIL 16: Rep. Paul Ryan, R-Wisc., right, Chairman of the House Budget Committee, and Rep. Tom Price, R-Ga., prepare for a hearing titled “The President’s FY2014 Revenue and Economic Policy Proposals,” . (Photo By Tom Williams/CQ Roll Call)

Price, a leading member of the House GOP’s “doctor caucus,” and a founding member of the Tea Party caucus, has been a strident ACA critic from the start, issuing and reissuing his own ACA replacement plan – the “Empowering Patients First Act” – on several occasions. He has carved a role as House Speaker Paul Ryan’s strongest ally in proposing a radical reconstruction not just of the ACA but of the entire US health security landscape, seeking not just to obliterate President Obama’s health legacy, but also that of President Lyndon Johnson, who signed Medicare and Medicaid into law way back in 1965.

The Ryan-Price agenda includes four key components:

As far as possible, repealing the ACA’s private health insurance and Medicaid coverage expansions, along with most of the new taxes that finance them;
Reengineering the Medicare program into “premium support” in which enrollees will receive fixed dollar vouchers to purchase health insurance policies;
Reconstructing Medicaid into a “per capita allotment” financing model to drastically limit federal dollars to state governments that would be incentivized to limit eligibility and benefits to low income enrollees while increasing cost sharing; and
Capping the federal employer health insurance tax deduction that would sharply increase insurance costs for workers and their employers.

Continue reading “The Price Is Wrong — Trump’s Health Secretary Is a Bad Sign for Health Reform”

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”

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”

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”