The Battle for Healthcare in the US

In 2026, an estimated 52 million would be uninsured in the US, a dramatic reversal from the 2016 uninsured count of 28/29 million. Pretty much, the Republicans will put healthcare back to the way it was pre-2014 if Paul Ryan’s bill is passed by Congress and Donald signs the bill in its present form.

– By 2018, 14 million could be uninsured with many of the uninsured practicing the tyranny of a minority, as John S. Mill might call it, upon the rest of the insured population as they drop out. Others will simply lose healthcare insurance as states withdraw from the Medicaid expansion and employers drop the coverage they were required to carry as they had 50 or more employees. Many of today’s insured will be unable to afford the increased premiums due to smaller subsidies. The elderly will be faced with smaller subsidies and a higher 5:1 ratio premium, which is up from the present 3:1 under the ACA program.

– Doctors, clinics, and hospitals have seen increased numbers of patients coming through the front door rather than the rear door due to the expansion of Medicaid to 138% FPL and subsidies for healthcare insurance to those under 400% FPL. My own PCP has seen many new patients who have never been to a doctor before except at the ER. With the proposed reversal of the mandate to have healthcare insurance and the dropping of Medicaid, it will fall upon hospitals and doctors to still provide stabilizing care as defined by law to all who arrive at their door. Except this time, the subsidizing payments for care for the uninsured to hospitals and clinics will not be available as it was reduced with the advent of the PPACA. It appears the AHA is not too pleased with Paul Ryan’s AHCA bill either.

– Our new Health and Human Services Secretary Tom Price had this to say; “You’re falling into the same old trap of individuals who are measuring the success of Medicaid by how much money we put into it. We ought not be measuring programs by how much money we put into it, we ought to be measuring them by whether or not they work.” Or take one aspirin and you will be alright in the morning. Interestingly, Republicans are happy with constituents paying a surcharge/mandate for not having healthcare insurance or healthcare. And if they suddenly have to have healthcare insurance, they pay the penalty to private companies rather than use it to fund subsidies. Who would have thought?

– Medicaid currently is not working according to Tom Price and as many as one in three doctors are not accepting Medicaid patients. That part is partially true. In a survey of its membership, the American Academy of Family Physicians discovered 68% of its members accepting new Medicaid patients in 2016. This is the highest level of Medicaid acceptance since 2004. The same argument was made for Medicare in the past. As Health Beat’s Maggie Mahar has said, “if Medicare is the largest business in town, are you going to ignore it or work within its confines?”

– Mr. Price argues on behalf of states claiming the granting of greater flexibility would result in better results and quality. My own observations with Michigan Medicaid when there was no Federal Government expansion disagrees with Tom Price’s claims. Michigan State Senator Joseph Hune said it all in one sentence when he stated; “I am ‘sick to his stomach with the expansion of Medicaid in Michigan.” Even with the expansion, the state legislature delayed the implementation of it to the following year so they could go on Christmas vacation and lost $thousands in Federal aid. This occurred in a state which can not fix its roads and bridges, argues about replacing Flint lead pipes, and wastes money going to 6th District COA and SCOTUS because it does not like rulings conflicting with its absurd beliefs. After all, Hune and his associates have their healthcare for life having been in the legislature for short periods of time; why should 600,000 Michigan residents matter to Hune and his associates.

Pre-Michigan expansion in order for adults to be insured and they had to be working. If they were working they had to be making just so much in order to be eligible. If they were not working, they were ineligible. Michigan and State Senator Joe Hune did their damnest to block people from access to healthcare. If this is Tom Price’s better results and quality, it did not work then and will only make it worse now.

Joan Aker at Georgetown University Healthcare Policy Institute puts greater state flexibility into perspective:

“So in practical terms what does that mean? States could get new flexibility to limit enrollment. They could gain the ability to limit enrollment directly by imposing enrollment caps or rolling back eligibility; or indirectly by putting up barriers such as imposing work requirements or lockout periods, which reduce enrollment. States could also gain more flexibility in determining what benefits people receive (in the case of children this might mean limits on the child-centered EPSDT benefit) or on how much families have to pay for those services (including premiums, cost-sharing or spend down rules before seniors qualify for long term services and supports). In fact, one piece of this so-called “flexibility” that is included in the repeal bill would allow states to require seniors to spend down even more of their assets before qualifying for long-term care services and supports by placing restrictions on how much equity seniors can have in their homes.” We did this in Michigan already and pre-PPACA.

– The AHCA penalizes the poor and elderly more severely than the ACA did. The ACA has a penalty for not getting healthcare insurance, which is based on the income of the uninsured and is paid yearly at tax time. The AHCA also has a penalty for not getting healthcare insurance. It is based upon the premium you would pay, not income, and each person pays the same penalty regardless on income; however if you are older, the 5:1 ratio will apply to your penalty. As I showed using a Avalere* chart, a 27 year old person making $11,880 annually would be paying $695 at tax time under the ACA and under the AHCA plan $1,006 for a bronze plan.

If the insured was 50 years old and made $11,880 annually, the penalty under the ACA is determined by income and remains the same; however under the AHCA, the penalty under a Bronze plan format jumps to $1,713. This is an ~ $700 difference between a 27 year old and a 50 year old. If it is a Silver plan add ~100 dollars for a 27 year old and ~ $250 for a 50 year old. Whether 27 or 50 and making $11,880 annually; the payment is harsh and is harder to pay the larger it gets.

As I get more information I will pass it on. There is much going on at a rapid pace and it takes a bit to gather it up.

*After leaving the White House Office of Management and Budget in 2000, Dan Mendelson founded what is today Avalere firm and initially named it The Health Strategies Consultancy LLC.

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