Relevant and even prescient commentary on news, politics and the economy.

First Vote to Amend and Repeal Rejected

The first vote in the Senate to amend the PPACA was rejected.

“Senators voted 57-43 late Tuesday to reject the plan in the first vote on an amendment to the bill. Those voting “no” included nine defecting Republicans. The vote underscored problems Republicans will have in winning enough votes to recast Obama’s statute.

The rejected proposal included language by Senate Majority Leader Mitch McConnell erasing the Obama law’s tax penalties on people not buying insurance and cutting Medicaid.

Language by Texas Republican Sen. Ted Cruz would let insurers sell cut-rate policies with skimpy coverage. And there was an additional $100 billion to help states ease costs for people losing Medicaid sought by Midwestern.

By 57-43 — including nine GOP defectors — it blocked a wide-ranging proposal by McConnell to erase and replace much of the statute. It included language by Sen. Ted Cruz, R-Texas, letting insurers sell cut-rate policies with skimpy coverage, plus an additional $100 billion to help states ease out-of-pocket costs for people losing Medicaid sought by Midwestern moderates including Rob Portman, R-Ohio.”

Senate blocks proposal to repeal ‘Obamacare’

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What Will It Take for Republicans to Be Able to Revise the ACA

The first section of issues McConnell and Republicans must overcome requires 60 votes due to the Parliamentarian ruling the provisions of the BCHA violate the Byrd Rule; consequently, the Reconciliation procedure requiring only 51 votes can not be used to repeal the Affordable Care Act (ACA) or waive the Byrd rule. The second set of provisions ruled upon by the Parliamentarian only require 51 or a majority vote to pass these changes.

There is little McConnell and Republicans can do to get past a supermajority vote. McConnell appears to be confident and it may also be possible to kill the supermajority vote. It will be interesting to see what he is thinking. The vote will take place this week unless canceled or rescheduled.

The provisions that the Parliamentarian ruled may be stricken if raised by a point of order include (requires 60 votes to waive the Byrd rule)

• The provision defunding Planned Parenthood;
• The provisions prohibiting the use of small business tax credits and individual market premium tax credits to pay for health plans that cover abortions;
• The sunset of an essential health benefit coverage requirement for Medicaid plans;
• The section funding cost-sharing reductions (CSRs), which the Parliamentarian ruled was redundant of current law, which already funds them (this ruling seems contrary to the lower court’s ruling in House v. Price that money had not been appropriated for the CSRs, but is consistent with the belief that the CSRs are already built into the budget baseline, thus an appropriation does not affect the deficit. A bill to clarify the appropriation situation could, of course, be passed separately from the reconciliation act;
• The six-month waiting period for individuals who have not maintained continuous coverage;
• The provision sunsetting the federal medical loss ratio requirement and allowing states to set the medical loss ratio;
• A provision, that has been removed from the most recent version of the BCRA, that might have allowed states to rollover unused Medicaid block grant funds and possibly use them for other purposes;
• The “Buffalo Bailout” which would have limited the ability of New York State to require counties other than those in New York City to contribute funding to the state’s Medicaid program (the ruling on this provision should caution against including further state-specific provisions in future versions of the legislation);
• A provision grandfathering certain Medicaid waivers and prioritizing Medicaid Home and Community-Based Services Waivers;
• A provision requiring a report by the Department of Health and Human Services (HHS) to Congress regarding the preferability of adopting a different system for reporting Medicaid data; and,
• A section requiring HHS to consult with the states before finalizing Medicaid rules,
• The provision allowing age rating at a 1 to 5 rather than the current 1 to 3 ratio, increasing premiums for older people and decreasing them for younger; and
• The provisions allowing small business association health plans that would be regulated as large group health plans, largely free from state regulation.

The Parliamentarian upheld against a Byrd rule challenge (requires majority vote to pass):

• A provision allowing state the option of imposing work requirement on Medicaid enrollees who are not disabled, elderly, pregnant, or within 60 days of giving birth;
• A provision granting $10 billion to Medicaid non-expansion states;
• The state stability and innovation fund, which imposes abortion restrictions by funding the program through the Children’s Health Insurance Program, which already prohibits abortion funding;
• A provision adjusting per capita cap targets for low-spending and high-spending states to promote equity;
• The permanent repeal of the cost-sharing reduction program beginning in 2020; and,
• A provision requiring states to include information on per capita enrollment and expenditures, psychiatric hospital expenditures, and children with complex conditions in their Medicaid expenditure reports.

There are a few more issues the Parliamentarian still has to rule upon which I have not included; but, you can find them on the link I have provided. Senate Parliamentarian Rules on BCRA July 25, 2017

Senate GOP Wins Vote To Debate Health Care, Then Loses Vote On ACA Replacement Bill July 26, 2017, Tim Jost, Health Affairs Blog

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Still Not a Win and Just a Delay

The biggest lie coming out of the Senate today:

“’One of the major problems with Obamacare was that it was written on a strict party-line basis and driven through Congress without a single Republican vote,’ McCain said. He added that Congress must now ‘hold hearings, receive input from members of both parties, and heed the recommendations of our nation’s governors.’”

An African-American comes to be President and Republicans vow from day one to obstruct. McConnell made it his “single most important thing to achieve is for President Obama to be a one-term president.” There was no intent to ever work with Barack Obama then or Democrats today.

Lets not forget, the Republicans have until EOM September to pass a bill under Reconciliation to change the ACA. October 1 is a new budget year and the Republicans will have to decide whether to change those parts of the ACA using Reconciliation or pass Tax Reform using Reconciliation. They can not do two Reconciliations in one budget year. One or the other will have to wait.

Besides blocking the Risk Corridor Program which caused much of the premium increase since 2015, insurance companies to lose money and withdraw from healthcare exchanges, and Coops to go bankrupt; President Trump has threatened to withhold CSR subsidies for out-of pocket expenses to those 100% – 250% FPL with Silver Plans. This subsidy goes directly to insurance companies. Withholding it will cause premiums again to increase and more companies to withdraw from the exchanges.

The second biggest lie coming out of Congress comes from a Congressman who relied on SS benefits to put him through college and who hopes to deny healthcare to his constituents and others as well.

“’The Senate’s got to pass a bill for us to even move the process forward,’ Congressman Ryan said. ‘That’s the next step. So, we’re hoping that they can achieve that next step so that we can bring real relief.’”

This is what Trump means by making the ACA fail or worst than what has occurred to date with Republican meddling in it.

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Will the Reign of Witches Pass?

“our present situation is not a natural one.”

Many want to change to the popular vote to elect a president as HRC the loser in the election received more popular votes than the election winner and lost in the Electoral College. There are activities going on today with regard to the EC and how it’s vote will be determined in the future. The EC vote is being driven by the numbers of Congressional Representatives in each state plus the Senators. Since the number of House Representatives has been frozen at 435, the bias in power and representation has been slowly shifting to lower population and/or small states.

City Limits Org. quotes David Birdsell on the bias we are experiencing in our government. “ By 2040, 70 percent of Americans are expected to live in the 15 largest states, which are also home to the overwhelming majority of the 30 largest cities in the country. By extension, 30 percent of Americans will live in the other 35 states. Bluntly meaning, 70 percent of Americans will be represented by 30 Senators and 30 percent of Americans represented by 70 Senators.”

I could not find the direct article to support the 70% of the population living in 15 states by 2040 other than the quote on City Limits Org. I was able to construct my own Excel spreadsheet using 2016 numbers off of Wikipedia – U.S. states and territories by population.

Congressional Districts 2
Using the Wikipedia numbers, I found 66% of the US population resides in the 15 largest states. If population continues to grow at

its present rate, I would think we would be at 70% of the population in 15 states well before 2040. Well so what, what does this mean (redundant alert)? 66% of the United States population living in 15 states are represented by 30 Senators and the other 34% of the population in 35 states are represented by 70 Senators. In the Senate, ~ two thirds of the population in the US is underrepresented in the Senate by design. Nothing is going to change this dynamic, as the Senate was established by the framers of the constitution to give equal representation by state. In other words, we are stuck with the present Senate representation by state. Article V states:

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McConnell Again on Healthcare

Mitch McConnell and the Republicans in the Senate are not satisfied with the Tom Price appointed CBO chief, who insists that there are four fingers in front of his face and apparently won’t make numbers up to help take away health insurance from 22 million people.

So Mitch McConnell and the Republicans will rely upon, and I am not making this up, “ALTERNATIVE SCORING” to further the Ted Cruz amendment to Obamacare repeal through the Senate. Republicans are expecting it will take weeks to get the scoring from the CBO.”

Repubs are running out of time to repeal the ACA and achieve tax reform under reconciliation. The budget year ends EOM September. If the ACA is not repealed by then, it has to wait until next budget year. You can not do two reconciliations in one year and the other one is tax reform.

McConnell To Use Alternative Scoring for Healthcare Bill, Crooks and Liars, Frances Langum, July 13, 2017

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California’s Single Payer Plan

Reader EM put this comment up in the AB open thread. I thought it was interesting enough to place on AB as I also wonder about the question being asked and the answer; “can a state divert Medicare funds to support a state single payer system?” The simple answer is “no,” Medicare funds can not be allocated to states and the same holds true for VA funding for healthcare and the tax credit to companies for healthcare insurance. Congress would have to approve it in new legislation. David Dayan discusses this issue of California Single Payer starting at minute 31 David Dayen on CA’s SIngle-Payer Debacle on Politics and Reality Radio. This is in direct answer to EM’s question.

Furthermore for Medicaid and CHIPS a 1332 wavier for state contributions must be deficit neutral and not create a deficit in the Federal Program which is required for CHIP and Medicaid. I assume a similar wavier for Medicare fund diversion would also have to be deficit neutral so as not to cause harm to overall Medicare.

The state of California is one of the top 10 states in income (median income 9th). If a state such as California pulls out of Medicare, who makes up the difference in funding? There are other states such as McConnell’s Kentucky who rank in the bottom 10 with the lowest income (median income 46th) and a higher percentage of people living in poverty.

Here is EM’s dilemma:

Mother Jones, Kevin Drum, June 29, 2017 12:38 PM; “I Get Letters

The single biggest proponent of SB562, California’s single-payer health care bill, is the California Nurses Association. But here’s something I didn’t know until yesterday: the CNA is aggressively using support for SB562 as a litmus test for being a true progressive. The bill is basically unpassable, but it’s being used as a way of whipping up the Bernie wing of the Democratic Party against traitors who fail to support it.

Apparently this applies even to B-list bloggers. I got an email today from Chuck Idelson, Communications Director for CNA’s umbrella organization, National Nurses United. Here is how it ended:

“Having seen two years of your hatred for Bernie Sanders, it’s not surprising you would be equally hostile to ideas he champions like single payer, but it would be nice if you were a little more honest with your readers, or maybe you can recommend the name of your magazine be changed from Mother Jones – who actually fought for working people – to Milton Friedman, which would better reflect your class sympathies.”

It is good to see that progressive organizations are learning communications skills from the Trump administration. But, I wonder if this kind of attitude is helpful in attracting and maintaining support for progressive causes?

POSTSCRIPT: “Just for the record, I have supported single-payer health care for at least the past 25 years. But for a variety of reasons, it needs to be done at the national level. No state has ever been able to make it work.”

EM: Still trying to find answers to this Cal single payer thing in terms of financing.

New Republic, Clio Chang, June 30, 2017, “ What Killed Single Payer in California?

“A legislative analysis found that California’s single-payer plan would cost $400 billion to implement, $200 billion of which would be new spending. Critics were quick to point out that this “hefty” price tag is twice the state budget. Furthermore, the bill did not include a funding plan (although the bill’s language ensured that Healthy California would not launch unless it was funded).

However, a report by professors at the University of Massachusetts Amherst, commissioned in part by National Nurses United, estimated that after taking in the savings of single-payer, such as lower administrative costs and prices of pharmaceuticals, the actual cost of the plan would end up at around $331 billion. And, because 70 percent of the state’s current health care spending is covered by public programs like Medicare and Medi-Cal, California would only need to come up with $106 billion in new revenue, which researchers proposed could be done through two new taxes (a 2.3 percent gross receipts and sales tax), with exemptions for small businesses and tax credits to offset costs for low-income families. In exchange, nearly all of Californians’ medical expenses would be covered, doing away with premiums, copays, and deductibles . . .

But according to the Affordable Care Act’s Innovation Waiver, if a state comes up with a credible alternative to the ACA, the federal government is obligated to provide the funding. Pollin said that while it is impossible to know in advance what the Trump administration will do, “you can also pass the bill, and obviously it has to be contingent on us continuing to get 70 percent of funding that we now get.” Pollin felt that Rendon’s objections were technical ones — they need to be addressed, but don’t raise any issues that can’t be worked through. “The concerns that they raised were pretty narrow. Nobody said this is crazy, we can’t do this,” he said.

There are problems other than the fact that the bill did not include a specific funding mechanism. The biggest hurdle may be Proposition 98, a complicated California funding law that requires that around 40 percent of the state’s budget go to schools. This means that a huge portion of any increase in the state budget would have to go to education, so legislators would have to come up with almost double the money to cover the single-payer plan. To get around this, voters would have to first pass a ballot initiative.”

EM: I cannot find anything at all in the ACA’s Innovation Waiver that says Medicare funds can be used.

FamiliesUSA,Cheryl Fish-Parcham, January, 2016 “ What Advocates Should Know about 1332 State Innovation Waivers

“The 1332 waivers apply only to private health insurance coverage and the marketplace, not to public programs like Medicare or Medicaid. But states can seek multiple waivers from HHS at the same time. For example, they might ask permission to change their Medicaid programs under an 1115 waiver and their marketplace coverage under a 1332 waiver. However, the federal government will evaluate each type of waiver separately – an 1115 waiver must still meet all of the existing standards for Medicaid 1115 waivers, and a 1332 waiver must meet the requirements we describe below. How Could a 1332 Waiver Affect Medicaid or CHIP?

EM: I cannot believe there is anything in Medicare law that would allow such a transfer, and it does not appear to me there is anything in the ACA that even mentions using Medicare funds.

Perhaps someone in here has more knowledge than I have been able to find, but I see no purpose whatsoever in this financing plan from Pollin that relies on funds that cannot be accessed. All this thing does is confuse the issue.

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Senate AHCA Version – Premium Increases and Subsidy Reductions

CBPP has this pictorial analysis of the increased premiums resulting from the Senate version of the AHCA for a 60 year old at 350% FPL with an ACA Silver plan. “For a 60-year-old with income of 350 percent of the poverty level (about $42 ,000 today) facing the average premium on HealthCare.gov, out-of-pocket premiums would jump by an estimated $4,994. Premiums would rise by $ 2,022 for a 45-year-old at this income level, and fall by $75 for a 30-year-old. Premiums would rise by $2,694 for a 60-year old with income of 300 percent of the poverty line, and by $1,903 for a 60-year old with income of 150 percent of the poverty line.”

Premium Increase The Senate AHCA Bill increases Premium Costs .

A sixty year old slightly above 350% FPL would face the loss of thousands of dollars in tax credits. Presently, the ACA covers up to 400% FPL and limits how much can be charged for age to 300%. The AHCA goes to 500% and reduces the subsidy coverage to 350% FPL.

Losses in Tax Credits Senate AHCA eliminates subsidies (difference between total cost of the plan and a percentage of income) for those between 350% and 400% FPL resulting in $thousand of dollars in cost for those in the Individuals Market. Tax-credit subsidies would cover only 58 percent of health care costs, rather than 70 percent as under current law a decrease in actuarial value. People in higher healthcare cost states would have to pay more as depicted in the CBPP chart.

Under either Republican Plan, higher premiums and deductibles would force people into lower level plans covering less at greater cost. Why do this and incite anger amongst constituents when you can just keep on doing what you have done in the past and undermine the ACA with blocking the Risk Corridor program and cut deductible subsidies by killing the CSR? I believe McConnell is thinking along these lines and can shift the blame of the resulting ACA failure to Dems. Dems would take the blame as no one would understand how it came to be and little would be explained by the press.

Senate Bill Still Cuts Tax Credits, Increases Premiums and Deductibles for Marketplace Consumers CBPP, Aviva Aron-Dine and Tara Straw, June 25, 2017

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McConnell’s AHCA Bill Text and WP Interpretation

I have not had a chance to read through this; but, I thought I would put this out here for all of us to read, Senate Version AHCA McConnell

Updated this post with the changes proposed in the McConnell Senate Bill as taken from today’s Washington Post.

Washington Post Version

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How Senate Republicans Plan to Dismantle Obamacare; Washington Post; Haeyoun Park and Margot Sanger – Katz; June 22, 2017

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Mitch McConnell, Healthcare, and the ACA

I am always curious about why certain people make it a mission to get rid of things. I think it truly is about Addison Mitchell McConnell trying to erase the accomplishments of what the first black President Barack Obama did as the president. I did some rather easy digging and pulled up Wikipedia. here is what they said about Mitch.

As a youth, Addison (Mitch) McConnell overcame polio. He received “government-provided healthcare” in Warm Springs saving him from being disabled for the rest of his life.” Addison Mitchell McConnell

Given that you Senator McConnell received government-provided healthcare during your youth which saved you from being disabled, why do you feel the need to strip 24 million people of their healthcare? This healthcare may save their lives also.

Paul Ryan benefited from government survivor benefits which allowed him to go to college.

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