Wednesday, May 17, 2017
Friday, May 5, 2017
- The ACA slightly transferred some funds from the rich to the poor, but the AHCA massively transfers money from the poor to the rich. It is an $880 billion transfer from people on Medicaid to people making more than $200K a year.
- The bill passed without hearings, with the final text made available mere hours before the vote, with many members of the House saying they had not read it, and without a CBO analysis.
- There was no public support for the bill: no provider groups, no patient groups, and no hospitals came out in support of the AHCA.
- As written it may benefit a few young healthy people, but it will harm many old, sick and low-income people.
- Finally, note that supporters of the AHCA are still telling lies about the ACA – but now they are also telling lies about the AHCA (basically trying to convince people it’s not as bad as it is).
Stein said there’s nothing wrong with the structure of a reinsurance program like MGARA, but the key is how well it’s funded.
“In the end, it all comes down to how much money is put in,” Stein said.
And the invisible high-risk pool, Stein says, is just one small proposal within the larger health bill.
“There’s nothing inherently wrong with it, but it doesn’t really fix all the other problems of the bill,” he says.
Stein says those include changes to essential health benefits and cuts to the Medicaid program.
High-risk pools can work in theory, but only if they’re properly funded, said Mitchell Stein, a health policy expert who worked for the advocacy group Consumers for Affordable Health Care when Maine passed PL 90. They usually aren’t and historically have failed, leaving people with pre-existing conditions facing unaffordable premiums, he said. “It all comes down to money, as it usually does,” Stein said.
Under congressional Republicans’ plan, $110 billion would fund a high-risk pool over 10 years. One study estimates that it would cost at least $178 billion every year to adequately fund it. “The dollar amounts the Republicans are talking about are woefully inadequate chump change,” Stein said.
Saturday, March 25, 2017
- Why Medicaid Work Requirements Won’t Work
- Everything You Need To Know About Block Grants — The Heart Of GOP’s Medicaid Plans
“No federal benefits program -- not Medicare, not Medicaid, not the marketplace -- can thrive without constant adjustment, from administrators and legislators. Since inception, the ACA marketplace has been denied such essential adjustment, and has in fact had to withstand outright sabotage from Republicans -- who threw up hurdles to the training of enrollment counselors, undercut funding for a crucial risk adjustment program, and refused to fix obvious flaws, such as the so-called "family glitch" that renders many whose employers offer family coverage they find unaffordable ineligible for marketplace subsidies.” Xpostfactoid
- First, we need to create balanced risk pools that include both healthy and less healthy persons in individual insurance markets.
- Second, we need to extend subsidies higher up the income scale than the ACA’s limit of 400% of the federal poverty level.
- Third, if we want private insurers to participate in ensuring that Americans have access to affordable insurance, the business of selling this product must be viable.
- Fourth, and perhaps most important, public and private stakeholders must accelerate efforts to control the costs of health care services, which are the primary determinants of the cost of health insurance in all markets, including employer-sponsored, individual, and public.
Sunday, February 26, 2017
- Fri AM - First analysis of the net financial impact on Americans of the proposed Republican modifications to health care premiums after tax credits, plus cost sharing.
- Fri PM – Leaked full text of Republican legislation presumably presented to CBO for scoring (dated February 10, 2017)
- Fri PM – updated Medicaid details leaked
- Sat – Presentation to National Governor’s Association on the impact of ACA replacement
- For funding, the plan would eliminate all of the ACA taxes and instead limit the tax deductibility of employer-sponsored health insurance. This is an approach that has been supported by economists on both the right and the left for years (think Cadillac tax), but the forces stakeholders will marshal to prevent this change are formidable.
- Regarding Medicaid, the draft eliminates the expansion and changes the entire program to a per-capita funding basis. These changes have been called a “non-starter” by some in Congress and by several governors (including prominent Republicans).
- Regarding private insurance, the essential health benefits definition is eliminated, a continuous coverage requirement for pre-existing condition coverages is added, and the individual mandate is eliminated. Taken together, these changes are a recipe for market instability.
- Kasich says Dems, Republicans need to work together to fix ObamaCare
- Republican Governor Scott Walker Warns Against Medicaid Cuts
- GOP Rep. Mo Brooks says town hall protests may prevent Obamacare repeal
- Repeal of Health Law Faces Obstacles in House, Not Just in Senate “While the 218 votes needed in the House to get the ball rolling remain likely, it is no longer the slam dunk that Republicans had with previous bills to repeal the law, when lawmakers knew their efforts would die in the Senate or on Mr. Obama’s desk.”
- Leaked Draft Shows GOP Plan Will Not Only Replace Obamacare, But Transform Medicaid “The draft would replace Obamacare’s means-tested tax credits with tax credits that are not adjusted for income. This is the key flaw in the House leadership plan, because it means that millions of highly vulnerable people—those near the poverty line and those with poor health status—will not receive enough in tax credits to afford the coverage they need.” – Avik Roy (He was a health care policy advisor to Mitt Romney's 2012 campaign and was the senior advisor to Rick Perry's 2016 campaign. After Rick Perry withdrew from the race, Roy joined the 2016 presidential campaign of Marco Rubio as a policy advisor.)
- Continuous coverage requirement for pre-existing condition coverage
- Tax credits by age, not income, not adjusted for premium costs
- 5:1 rating band based on age (as opposed to current 3:1)
- Essential health benefits package up to each state
- Continue to allow “grandfathered” plans and allow to enroll new members
- Eliminate funding for Medicaid expansion
- Turn Medicaid into a per-capita program, sending each state fixed sum (on a scale of 1-10, with 1 being block grants, per-capita is a 2.
- $100 billion over a decade to finance state programs that would cover people with the highest medical costs (including but not limited to high-risk pools)
- “The impact would vary by state, but in a sample state that expanded Medicaid, it's estimated that:
- The state would lose $635 million in federal funding, a 65 percent decrease.
- 110,000 current enrollees would no longer be able to afford a plan.
- 20,000 currently uninsured people would buy a plan with the new tax credit provided by the GOP plan.
- Additionally, 115,000 low-income people may lose Medicaid coverage, with no affordable alternative on the individual market.
- A per capita cap — which would limit funding for each person in the program — would reduce federal spending by 24 percent over five years, requiring the state to spend $6.2 billion to close the gap.
- The state would lose $885 million in federal funding, an 80 percent decrease.
- 130,000 current enrollees would no longer be able to afford a plan.
- 10,000 currently uninsured people would be able to buy coverage with the new tax credit.
- A per capita cap would reduce federal spending by 6 percent over five years, requiring states to spend $1.5 billion to close the gap
- Medicaid caps are likely to result in state funding gaps
- Capped funding is likely to be paired with more flexibility for states on coverage and benefits
- Because states must balance their budgets annually, reductions in federal funding may lead to cuts in eligibility, benefits, or payment rates
- Per capita caps offer more flexibility to respond to enrollment growth, but they cannot easily adapt to new products or technology (e.g., high-cost drugs)
Tuesday, February 14, 2017
Representative Poliquin of Maine’s second district has prepared a handy form letter to send to constituents who write or call his office expressing support for the ACA. I thought it would be helpful to walk through some of his statements to see how they hold up. A full copy of the letter is at the end of this post (I’ve removed the name of the recipient who shared the letter with me).
Just for fun, along with each of my comments, I’ll include sources for my statements – you know, facts. Before we get started, a note about my perspective. As many of you know, I support the ACA and continue to think it is a great step forward. Twenty million more people have health insurance now than before the law was passed. However, no one denies that the law needs adjustments. Changes are often required after a complicated law gets passed. Unfortunately, in this case, due to the partisan rancor in DC, once the law was passed there were no fixes permitted by Congress, leading to the current issues.
Now let's look at some specifics.
“…suffocating under the spiking ObamaCare monthly premiums...”
Yes, premiums went up for 2017 at a greater rate than they did the previous two years - but let’s remember how premiums acted before the passage of the ACA – they went up in even greater increments. It is also worth noting is that the headlines regarding spiking premiums refer to averages across carriers and across the country. In many states, the market is working well. States that have chosen to expand Medicaid (MaineCare) have seen lower premium increases than states like Maine that have not. Additionally, the subsidies received by many of the enrollees will shield them from the increases.
“…losses of more than 30 million of taxpayer dollars...”
He is referring to Maine Community Health Options (MCHO), one of the COOP plans that were created through the ACA. These plans do not receive federal money. What they have received is loan guarantees from the Federal Government. While MCHO had a bad year in 2016, they are recovering; as noted by Maine’s Bureau of Insurance: “CHO's ability to stabilize its operations in 2016 and achieve plan results up to this point is encouraging and merits its re-entry into the Maine individual health insurance market for 2017.”
“…supported the Obamacare repeal initiation vote...”
Many times, over the past several years the house has voted to repeal the ACA. In all that time, they have not come up with a replacement plan. It’s easy to vote for a bill that you know will be vetoed – it’s a lot harder to come up with workable policy proposals.
This link is a walk through the history of promises by the Republicans to come up with a replacement plan: https://storify.com/JeffYoung/just-in-time
“…replacement includes coverage for pre-existing health conditions...”
Slogans are easy; policy is hard. What does Rep. Poliquin mean by including coverage for pre-existing conditions? If, as in the ACA, it means they will be charged the same rate as everyone else then there will need to be a mechanism, like the mandate, so that people do not just purchase coverage when they need it. If they mean something else, we need details – it will be easy to say it includes coverage but how much might that coverage cost? Will they require "continuous coverage" - an ideal state that in the real world is hard to execute?
“…eliminate job-killing taxes...”
My question here is how will the replacement plan be financed if the taxes associated with the ACA are eliminated? Providing Medicaid or subsidies takes money. If the taxes are repealed, how will the replacement plan be funded? What do you think the chances are that the Republican House and Senate will impose new taxes to cover their “replacement” plan?
If they don’t intend to provide subsidies at least as large as the current ones, millions of people will lose coverage, contrary to the current promises of Republican leadership and the President. Don't be fooled by the phrase "universal access”. Access is not coverage. I have access to purchasing a Lamborghini, but that doesn't mean I have the funds to do so.
To sum up, the letter below contains several half-truths and misdirections. It also gives no credit to the positive impact the law has had. As the debate over the future of the ACA continues, let's try and stick to the facts.
Monday, June 8, 2015
Saturday, March 21, 2015
The job of any doctor, Bludau later told me, is to support quality of life, by which he meant two things: as much freedom from the ravages of disease as possible and the retention of enough function for active engagement in the world. Most doctors treat disease and figure that the rest will take care of itself. And if it doesn't— if a patient is becoming infirm and heading toward a nursing home— well, that isn't really a medical problem, is it?
This is the consequence of a society that faces the final phase of the human life cycle by trying not to think about it. We end up with institutions that address any number of societal goals— from freeing up hospital beds to taking burdens off families’ hands to coping with poverty among the elderly— but never the goal that matters to the people who reside in them: how to make life worth living when we’re weak and frail and can’t fend for ourselves anymore.
Tolstoy saw the chasm of perspective between those who have to contend with life’s fragility and those who don’t. He grasped the particular anguish of having to bear such knowledge alone. But he saw something else, as well: even when a sense of mortality reorders our desires, these desires are not impossible to satisfy.
A colleague once told her, Wilson said, “We want autonomy for ourselves and safety for those we love.” That remains the main problem and paradox for the frail. “Many of the things that we want for those we care about are things that we would adamantly oppose for ourselves because they would infringe upon our sense of self.”
And the insight was that as people’s capacities wane, whether through age or ill health, making their lives better often requires curbing our purely medical imperatives— resisting the urge to fiddle and fix and control. It was not hard to see how important this idea could be for the patients I encountered in my daily practice— people facing mortal circumstances at every phase of life. But it posed a difficult question: When should we try to fix and when should we not? (emphasis added)
People with serious illness have priorities besides simply prolonging their lives. Surveys find that their top concerns include avoiding suffering, strengthening relationships with family and friends, being mentally aware, not being a burden on others, and achieving a sense that their life is complete. Our system of technological medical care has utterly failed to meet these needs, and the cost of this failure is measured in far more than dollars. The question therefore is not how we can afford this system’s expense. It is how we can build a health care system that will actually help people achieve what’s most important to them at the end of their lives.
The trouble is that we've built our medical system and culture around the long tail. We've created a multitrillion-dollar edifice for dispensing the medical equivalent of lottery tickets— and have only the rudiments of a system to prepare patients for the near certainty that those tickets will not win. Hope is not a plan, but hope is our plan.
In other words, people who had substantive discussions with their doctor about their end-of-life preferences were far more likely to die at peace and in control of their situation and to spare their family anguish.