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Where the ACA Should Go Next?

run75441: This is the first in a series of 3 posts written by Maggie Mahar discussing Medicare, what it covers, and what it lacks in coverage. Maggie touches on the Public Option and Medicare. I start to get edgy when people talk about the Public Option, Universal Coverage, Single Payor, Medicare-For-All, etc. as they do not really define it and who will control its funding. We have a Congress which is intent on cutting the PPACA/ACA/Obamacare, which many take offense to today, and leave us with far less. I am not so sure we can trust Congress and politics to insure our healthcare.

On Tue, Sep 9, 2014 at 1:47 PM, Dan <cdansplace2@aol.com> emailed:

Rortybomb, New Piece on Where the ACA Should Go Next Rorty touts the 2009 House Bill which calls for a Public Option and described here To improve ‘Obamacare,’ reconsider the original House bill

Maggie Mahar replies:

Originally I favored a public option, but in fact, at the time, no one really spelled out who would run the public option–or how it would be run.

One of the best things about the ACA is that lets both HHS and CMS make end-runs around Congress. I would never want a public option that was run by Congress.

Here is the comment I just posted in reply to the post “Where the ACA Should Go Next”

I would need to know far more about the public option—and how it would be different from Medicare– before voting for it.

Medicare is extraordinarily wasteful– 1/3 of Medicare dollars are squandered on unnecessary treatments that provide no benefit to the patient. Why? Because Congress is Medicare’s board of directors, and lobbyists representing various specialist’ groups, hospitals, device-makers and drug-makers control Congress.

Meanwhile, Medicare does not cover much needed care, ie. vision checks are just one example. This is why the vast majority of Medicare beneficiaries must buy separate private insurance (MediGap or Medicare Advantage) to supplement what medicare doesn’t cover.

Finally, I favor narrow networks. They keep costs down. The doctors and hospitals that are not included in the networks are those that refuse to negotiate  prices.  By excluding them we remind doctors and hospitals that we can no longer afford letting providers charge whatever they wish. No other developed nation allows doctors and hospitals to simply set prices.

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Dancin With the Stars or “Why is there an Exemption for Representatives, Senators, and Washington staff?

After being confronted by TPM reporter Alice Ollstein about the exemption for Washington elected officials and their staff, it was obvious they were caught off guard. Read some of the answers dancing around the issue.

New Jersey Republican Representative Tom MacArthur who proposed an amendment allowing states to opt out of key PPACA requirements. Read what he and other Republican House Representatives had to say when they were asked about the exempt to the latest AHCA amendment I had writen about.

Rep. Tom MacArthur (R-NJ); he is working to fix the language in question.

Rep. MacArthur puts out statement saying Congress shouldn’t get special treatment, they are working to fix exemption.

Rep. Scott Desjarleis (R-TN); “I don’t know about that. That’s a good question,”

Rep. Morgan Griffith (R-VA).; “I’ll have to read the language more closely,”

Rep. Chris Collins (R-NY); “I didn’t know there was [an exemption for members of Congress]. I don’t know what you’re talking about,”

Rep. Mark Meadows (R-NC), ” because D.C. is not a state, it can not apply for or receive the same waivers states can under their bill.”

Rep. David Brat (R-VA) “an exemption for members of Congress seeking to deregulate the health care market “would be, politically, completely tone deaf.”

Other Republicans: “the carve-out would have to be addressed with a new piece of legislation for complicated parliamentary reasons. A senior leadership staff member confirmed that they are working on a ‘stand-alone effort’ to undo the exemption, which lawmakers would vote on at the same time as the larger health care package.

Freedom Caucasus member Rep. Morgan Griffith (R-VA): “the fix has to come through a separate bill. Did not know whether D.C. could get the same waivers as a state under the legislation; but, Griffith said it did not matter because ‘liberal’ D.C. wouldn’t seek a waiver in the first place.

Republican lawmakers and staff: it was inserted in the first place in order to ensure that it could pass the Senate under what is known as the Byrd Rule, though they did not fully explain why.

The Byrd Rule dictates that strict budgetary legislation that does not increase the federal deficit after 10 years can be fast-tracked through the Senate on a simple majority vote.

Rep. Kevin Brady (R-TX); the Byrd Rule was ‘the genesis’ of the exemption provision, but promised that “every member of Congress is going to vote to make sure we are treated like everybody else.”

Again Rep. Mark Meadows (R-NC): It was a provision that, from a fatal standpoint, would not allow us to address it because jurisdictionally on the budget reconciliation instructions, that were narrowly tailored to two different committees of jurisdiction. To fully address that would had to have gone over to another area which would have made it fatal.” huh?

And the truth?
Health care law expert and professor at Washington and Lee University, Tim Jost: “D.C. is clearly defined as a state in the Affordable Care Act. And I don’t see anything in the AHCA that changes that, including this provision,” he said. “The provision provides for congressional coverage through the marketplace, and the language is clear [regarding the exemption].”

I think most of these reps are residents of the state they represent in Congress, so why wouldn’t they be exempt from the exclusion as defined by the amendment?

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Congressional Republicans looking Out for Your Health, Healthcare Insurance, and Their’s Too . . .

One Happy Republican House Representative
invisible hand If you have not been paying attention, it looks like the Republicans are getting ready again to submit another version of a PPACA/ACA repeal bill. New Jersey Republican Representative Tom MacArthur is proposing an amendment allowing states to opt out of key PPACA requirements. For example:

- Preventative Care: The PPACA has 62 preventative measures or Essential Preventive Care benefits which are no cost to a patient. Cholesterol screening, Type 2 Diabetes screening various immunizations for adults and children, breast cancer screenings, hepatitis B screenings, HIV tests, lead screening for children, etc.

- Community Rating: In the good old days when people had a heart attack , disorder, or illness; insurance companies would rate the individual and either insure them at a much higher rate or deny insurance to them. The PPACA acting like a true insurance pool spread the risk amongst the community adapting a more uniform rate for people. Two exceptions were smoking at 150% of the lowest cost individual and 300% for older people (Republicans wish to increase this to 500%). Where people with pre-existing conditions had to pay much higher rates or had no insurance, the PPACA established rates covering them and spreading the cost.

This new GOP amendment allows states to waive community rating. Insurers could again charge people based on their health and expected health care costs. The state would have to participate in the Patient and State Stability Fund (which would be underfunded) before it could waive out of Community Rating. The PSS is a pool of money in the AHCA that states can use to set up high-risk pools or shore up insurers that get stuck with really expensive patients (think of Corridor Risk and Reissuance programs which Republicans defunded).

Initially, the AHCA as proposed by Republicans would have resulted in an estimated 24 million people becoming uninsured over 10 years with a loss of 14 million in one year. We would be back to pre-PPACA with no single payer, universal, public option, Medicare-for-all in sight. The change in the Community Rating would target those with severe illness or disorders, the elderly, and those with pre-existing conditions. Removing the Preventative Care portion of the PPACA targets women and children and again patients would have to pay for them. There is just the healthy left or healthy today and the rest of the populations gets to fend for themselves. That would certainly lower healthcare insurance costs until the healthcare industry sucked it up in increasing prices. Not quite sure who the Republicans are tossing a bone to with this amendment, the healthcare industry or healthcare insurance companies?

As Vox’s Sarah Kliff points out; when the PPACA came into play, all Representatives and staffers had to purchase healthcare insurance on the individuals exchange. What was good for the gander was also good for the goose so to speak. I seem to remember differently; but, let’s go with this for now. There was quite a bit of grumbling going on in Congress when this was proposed.

invisible hand Fast forward to today’s amendment by New Jersey Republican Representative Tom MacArthur; it appears Congress now likes the PPACA when it comes to their healthcare insurance. If Representatives and staffers live in one of those states waiving out of Preventative Care and Community Ratings, Congress is exempt from the wavier. Looking at section 1312(d)(3)(D) of the amendment (sixth page) there is an exemption for those who will not be included in a state’s waiver. Senators, House Representative, their staffers and I am sure every other staffer in Washington, the Cabinet and their staffers, Bannon, etc. are all excluded from any state wavier on healthcare. I am glad they are looking out for us and the people who vote for them.

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Pence Makes Deciding Vote Allowing States to Defund Planned Parenthood

Second time Pence has cast the deciding vote in the Senate. Last VP to do so was Cheney in 2008.

VP Pence has made it no secret he is opposed to allowing women the right to decide on having an abortions. While in Congress, Pence sponsored the first bill to defund Planned Parenthood in 2007 and when it did not pass then he continued the effort until it did pass in the House in 2011.

More recently a Federal Court blocked a bill signed by then Indiana Governor Pence forcing women to have a funeral for the aborted fetus which would then go through a burial or cremation. The cost of the burial or cremation would have increased the cost of the abortion dramatically in Indiana. The court ruled Pence’s law would have blocked a woman’s right to choose.

If you remember VP Pence had used his tie breaker vote to approve Betsy DeVos as Secretary of Education. Today, VP Pence was again called upon to break a Senate tie involving the right of states to defund Planned Parenthood.

The Department of Health and Human Services under President Obama ruled organizations providing family planning and preventive health care services could not be barred by states from receiving Title X grant dollars for any reason other than those related to their “ability to deliver services to program beneficiaries in an effective manner.” It required states and local governments to distribute federal Title X funding for services related to contraception, fertility, pregnancy care and cervical cancer screenings to health providers without regard for whether those facilities also performed abortions outside of Title X. Title X funding covers services such as contraception, STD screenings, treatments and can not be used to pay for abortion services.

Weighing in after the tie-breaking vote to overrule President Obama’s Department of Health and Human Services, Senate Majority Leader McConnell had this to say:

“It was the Obama administration’s move that hurt ‘local communities’ by substituting Washington’s judgment for the needs of real people. This regulation is an unnecessary restriction on states that know their residents a lot better than the federal government.”

Not sure what needs McConnell’s real-people would have to block a woman’s decision to have an abortion which is not taken lightly by a woman and using it as an excuse to defund Planned Parenthood. It appears McConnell, Pence, and the Republicans are practicing a tyranny of a majority to disregard the rights of an individual in favor of their own views.

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Question; Have you Experienced the Same?

I was reading an article on one of the other blogs as written by an economist. In his article he discussed the 0.18% of total expenditures on one category. Then the blogger went on to describe the total expenditure as not being “18%, but rather a little less than one-fifth of 1 percent.” I asked the economist about the why of the additional explanation and whether this would be a legitimate fear that people might mistake 0.18% as being 18% and not less than 2 tenths of 1%. The answer was “yes,” he did not want the total expenditures in this category to be mistook as 18% as it was important. He went to greater length to explain it. He had experienced errors by others in misinterpreting a portion of a 1 percent as something greater than 1%.

Have you experienced the same innumeracy amongst others?

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Repeal of the PPACA Vote On Hold

House leaders postponed a vote Thursday on their plan to overhaul the nation’s health-care system, casting doubt on whether President Trump and House Speaker Paul D. Ryan (R-Wis.) can deliver on one of the GOP’s central promises to the voters who placed Republicans in power.
Lawmakers and White House officials continued to express confidence that the revisions to the Affordable Care Act would pass by week’s end, and talks resumed soon after leaders announced the postponement. As evening came, members of the conservative House Freedom Caucus filed into the office of Speaker Paul D. Ryan (R-Wis.), as did White House Chief of Staff Reince Priebus and Trump’s chief strategist, Steve Bannon.”

It would be nice to snatch their healthcare at the same time or make sure some of those old folk get to pay for premiums at a 5:1 ratio. New CBO scoring after changes to the bill shows only $150 billion saved. Also the changes to the bill do nothing to prevent 14 million from being uninsured in the next year.

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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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Increased Penalties for the Uninsured Under the Republican’s AHCA?

Caroline Pearson at Avalere has a piece on how the House of Representatives AHAC healthcare program penalizes older and lower income people more so than higher incomes and younger people. Just to refresh your memory, the ACA penalizes people who do not have insurance based upon income.

While the penalties under the ACA are based upon income, the penalties under the AHCA are based upon age determinant premiums. Older people under the AHCA have higher premiums up to 5:1 of the younger insured rather than the 3:1 ratio under the ACA. Remember too, the ACA does not use age as a determinant of the size of penalty which is based upon income. While most likely the healthiest, many Millenials have lower incomes and could an have issues paying the penalty under the AHCA as the size of the penalty at lower income is a larger percentage of annual income. The impact of large groups of the younger and healthier Millenials not buying insurance could be felt in the risk pool potentially forcing higher premiums for everyone. Different than the penalty being paid to the government under the ACA, the penalty under the AHCA is paid to a private company. It will be interesting to see if this is be tested in court also

Younger Adults
Young Adults with Insurance

Older Adults
Old People with Insurance

If young adults are discouraged by the penalty and cannot afford to enroll, it could hurt the risk pool. While a recent RAND analysis showed that young people as a whole moving in or out of coverage may not have a large impact on the risk pool, the healthiest and least expensive young adults not enrolling could still result in a significant negative impact on the pool. A recent CBO report confirms a similar projection of those deterred from enrolling due to the continuous coverage provision will tend to be healthier and a penalty could have a significant negative impact on the risk pool and result in higher premiums. Certainly the size of the penalty regardless of income will have an impact as well as the age/premium factor.

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Paul Ryan not taking Phone Calls Faxes, or Petitions

A suggestion from Michael Halasy:

The Randian Congressman Paul Ryan has turned off ALL of his public telephones & fax machines in response to protests in favor of the Affordable Care Act, Planned Parenthood, Medicare, etc. He is also NOT accepting signed petitions and is TURNING-AWAY voters who deliver the petitions. So, let’s see what 67 million postcards looks like in his driveway. Please start mailing postcards to his HOME:

Congressman Paul Ryan
700 St. Lawrence Ave.
Janesville, WI 53545

Costs less than a buck to deliver this protest and makes sense to me.

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