Both Sides Now on the ACA at AEI

On Friday, December 16 I participated in a panel on the future of U.S. health reform at the new headquarters of the American Enterprise Institute at 1789 Massachusetts Avenue in Washington DC (note the street address number).  There were two panels on the program called “What’s Next for Health Care?”

AEI’s Joe Antos and James Capretta were the session moderators.  Former Urban Institute Chief Bob Reischauer and I, respectively, were the ACA defenders on each of the two panels.

Feel welcome to watch the full session below — my panel starts about 1 hour into the 2 hour event which was also shown on CSPAN.

What I picked up from the session is lots of uncertainty on the Republican/ conservative side on how to proceed, both on process and substance.  Some of them are now suggesting the need for a 4-year transition, not 2 or 3 are previously discussed.  Repealing and replacing the ACA is not going to be easy for them.

Meanwhile, please check out this new column by Noam Levey in the LA Times: “Trump and the GOP are charging forward with ObamaCare repeal, but few are eager to follow.”   Levey could not identify “a single major organization representing patients, physicians, hospitals or others who work in the nation’s healthcare system (that) backs the GOP’s Obamacare strategy.”  Neither can I.

The Republicans’ ObamaCare death march is getting more interesting every day as we move closer to the cliff.

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:

  1. 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;
  2. Reengineering the Medicare program into “premium support” in which enrollees will receive fixed dollar vouchers to purchase health insurance policies;
  3. 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
  4. 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”

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.

John McDonough

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

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”

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 2Christopher 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”

Trump’s Health Plan = 21 Million Uninsured, $270-500 Billion Budget Hole

On March 14, the Committee for a Responsible Federal Budget (CRFB), a bipartisan federal budget watchdog group, released an economic analysis of the recent health proposals made by Republican Presidential candidate Donald Trump.  Their key findings:

“Donald Trump’s plan to repeal and replace Obamacare would cost nearly $500 billion over a decade, or $270 billion incorporating economic growth.

“The plan would nearly double the number of uninsured, causing almost 21 million people to lose coverage.”

To my knowledge, this is the first serious and independent economic analysis of any Republican or conservative health reform plan released since the Affordable Care Act (ACA) was signed in 2010.  It’s not a pretty picture.


In addition to “completely repeal(ing) Obamacare,” Trump’s proposal would:

  • Allow sale of health insurance across state lines;
  • Allow individuals to fully deduct health insurance premiums from their income tax obligations;
  • Allow individuals to use Health Savings Accounts;
  • Require transparency from all health care providers;
  • Block grant Medicaid to the states;
  • Remove barriers to entry into free markets for drug providers.

Continue reading “Trump’s Health Plan = 21 Million Uninsured, $270-500 Billion Budget Hole”

Is the Fate of the ACA Settle or Not?

Below is an op-ed I wrote late last year for the Milbank Quarterly, published today.

Once upon a time, I believed that efforts to repeal the Affordable Care Act (ACA) would wither and die once the ACA’s major Medicaid and private insurance expansions became effective on January 1, 2014. After all, opponents had let Senator Ted Cruz (R-TX) trigger a 3-week federal government shutdown in October 2013 in a desperate final attempt to thwart the expansions. Over the course of 2 open enrollment periods, between 2013 and 2015, as many as 17 million previously uninsured Americans obtained coverage. Surely the worst was over. Now I am not so certain.

Since 2010, Americans have witnessed 3 near-death experiences relating to national health reform: first, the election of Scott Brown (R-MA) to the US Senate in January 2010, ending Democrats’ 60-vote filibuster-proof majority; second, the US Supreme Court’s decision in June 2012 upholding the constitutionality of the ACA writ large; and third, the November 6, 2012, federal elections in which a victory for presidential candidate Mitt Romney would have augured substantial repeal. By this standard, the October 2013 government shutdown and the 2015 Supreme Court case, King v Burwell, were faux near-death experiences, not the real thing. Continue reading “Is the Fate of the ACA Settle or Not?”

How Difficult Would It Be to Repeal Obamacare for Good?

A new website called “The Conversation” posted this article earlier today:

If the leading Republican candidates agree on one thing, it’s doing away with Obamacare.

“The one thing we have to do is repeal and replace Obamacare,” Donald Trump has written on his campaign website, while Marco Rubio has outlined his plan to “Repeal Obamacare” and “replace it with a 21st century, market-driven alternative.” Likewise, Senator Ted Cruz emphatically declared during the February 25 GOP debate that “As president, I will repeal every word of Obamacare.”

Is this the bombastic rhetoric of candidates trying to fire up their base? Or would Republicans actually be able to repeal Obamacare under a Republican president?

In short: yes, they could. But it wouldn’t be easy.

The main GOP obstacle

The essential requirement to achieve repeal is Republican control of the White House, the U.S. Senate and the House of Representatives in January 2017.

Unless both houses of Congress and the executive branch are under GOP control, Democrats would be able to block any repeal effort – and the Obamacare trench warfare that’s taken place since Democrats lost control of Congress in January 2011 would continue.

But even if Republicans control Congress and the White House, Senate Democrats could filibuster any legislation that repeals Obamacare.

Sixty senators must vote to close a filibuster – a Senate parliamentary tool designed to protect the rights of senators to slow or stall legislation and other matters. While, historically, filibusters took the form of long speeches on the Senate floor, these days it’s a less heroic procedural maneuver.

It’s unlikely that Republicans will have a 60-vote majority in the Senate in 2017. Meanwhile, Senate Democrats have been unanimous against repeal, and the number of Democrats in the chamber next year is predicted to increase over their current 46.

For this reason, even in if they’re in the minority, Democrats could block any straight repeal legislation and compel Republicans to resort to another path.

Skirting the filibuster with reconciliation

Republicans could then initiate an arcane legislative process called budget reconciliation. Invented in 1974 by the late West Virginia Senator Robert Byrd (arguably the shrewdest legislative tactician ever), budget reconciliation is a special legislative process that enables federal budget bills to be approved in an expedited fashion.

Reconciliation is the brainchild of West Virginia Senator Robert Byrd. Wikimedia Commons

The advantage of reconciliation is that it permits a bill to be approved by 51 votes. (If Republicans hold 50 votes in the new Senate – a possibility – a Republican vice president can provide the 51st vote.)

Since reconciliation bills cannot be filibustered, any Obamacare repeal bill done using reconciliation wouldn’t need a 60-vote majority to proceed. And debate on a reconciliation bill is limited to 20 hours. For a frustrated Senate that doesn’t have a 60-plus vote filibuster-proof majority, it’s the most potent legislative shortcut imaginable.

But there’s a vital catch: any item in a reconciliation bill must have a measurable, direct impact on federal spending, up or down.

The individual who decides what legislative items do and do not conform to this rule is the Senate parliamentarian – the individual tasked with advising Senate leaders on the interpretation of Senate rules. Appointed by the Senate majority leader whenever the prior parliamentarian steps down, a former Senate librarian clerk named Elizabeth MacDonough currently holds the position.

A full ACA repeal bill would be deemed noncompliant by MacDonough and set aside because so many of its individual provisions do not have a significant budget impact. In a process known as the “Byrd bath,” Senators can challenge any entire bill, section, subsection, paragraph, sentence or word as “out of order,” meaning there is no significant budget impact. Items eliminated by the parliamentarian – called “Byrd droppings” – are removed from the bill.

But could Republicans then devise a partial – and critically damaging – ACA repeal bill that might pass muster with MacDonough or her successor?

Yes, they can. In fact, they’ve already done so.

GOP shows it can be done

This past December and January, the Senate and the House passed a reconciliation bill that would have repealed fundamental building blocks of Obamacare, including subsidies to help moderate-income Americans afford health insurance and funds to expand Medicaid to low-income, uninsured individuals.

The Congressional Budget Office reviewed the proposal and determined that it would cancel insurance coverage for about 22 million Americans by 2018.

When the bill reached President Obama’s desk, he vetoed it. On February 2, Groundhog Day, the House failed to override his veto – their 63rd vote to repeal all or part of the ACA – voting almost completely along party lines.

Some observers declared that vote a waste of time because the outcome was known from the outset. This is erroneous.

A bill repealing crucial building blocks of Obamacare sits on a desk after being signed by U.S. House Speaker Paul Ryan on January 7, 2016. Jonathan Ernst/Reuters

Prior to the reconciliation bill passing the Senate this past December, many, including Senate Minority Leader Harry Reid, confidently predicted that Republicans would never successfully navigate the treacherous and confounding reconciliation waters.

But they did.

As a result, congressional Republicans have demonstrated that they can achieve effective deconstruction and de facto ACA repeal using reconciliation. It’s no longer an idle threat.

Every 2016 Republican presidential candidate has publicly declared his or her support for complete ACA repeal. Of the eight ACA replacement plans advanced by members of Congress and conservative think tanks, all but one presume total or near total repeal. And it’s difficult to identify more than a handful of Republican members who express any reservations about repeal.

So if there were a Republican president in Obama’s place, could a GOP-controlled Congress repeal the ACA early next year?

Maybe and maybe not.

A Senate majority in flux

It’s likely that Republicans will return to the Senate next January with fewer than their current 54 votes – and may even lose their majority.

That is because, in recent times, presidential election years have attracted more Democrats and liberals than midterm election years, which tend to result in more Republican, conservative leaning outcomes. Furthermore, Democrats have had notable success so far this cycle recruiting their top choices in key battleground states. Wisconsin Senator Russ Feingold is running for his old seat, while New Hampshire Governor Maggie Hassan now running against incumbent Republican Senator Kelly Ayotte.

Even more important, some Republicans appear to have supported January’s reconciliation bill precisely because they knew it would never become law.

One example is West Virginia Senator Shelley Moore Capito. Capito made it clear that she did not want to take Medicaid away from 160,000 low-income West Virginians. Other more moderate Republican senators – Maine’s Susan Collins, Illinois’ Mark Kirk, and New Hampshire’s Kelly Ayotte – might also think twice about voting to eliminate health coverage for vulnerable constituents for real.

Since President Obama signed the ACA in 2010, Republican Congressional leaders, especially House Speaker Paul Ryan, have cockily promised to move legislation to replace Obamacare.

It’s been six years of broken promises with their latest replacement show now underway. One reason for their inability is deep disagreement within the Republican conference about what could replace the ACA.

While Republicans find it easy to vote to repeal the law, their consensus vanishes when the topic turns to replacement. Look no further than the GOP debates, where candidates have been unable to articulate a consistent vision for health care policy beyond allowing the sale of health insurance across state lines and expanding high deductible health insurance policies.

So if Republicans capture the White House, Senate and House, will they repeal the ACA?

Maybe they can’t.

Continue reading “How Difficult Would It Be to Repeal Obamacare for Good?”

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.

Recon 2016It’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”