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

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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Trumpcare Saves Social Security By Killing People!

by Barkley Rosser  (originally from Econospeak)

Trumpcare Saves Social Security By Killing People!

Yes, there it is in black and white in Table 3 footnote f on p. 33 of the Congressional Budget Office (CBO) official report on the proposed American Health Care Act, aka Trumpcare. Between now and 2026 spending by the Social Security Administration is projected to decline by $3 billion if Trumpcare passes. This is due to a projected 1 out of 830 people dying who would not under the status quo, this based on a study of what happened to death rates in Massachusetts after Romneycare came in. The projected deaths are about 17,000 in 2018 and up to about 29,000 in 2026.

Another great thing? There will be a reduction in accumulated deficits of about $300 billion, with a reduction of revenues of about $0.9 trillion and a reduction of outlays of about $1.2 trillion. The former will be due to cuts in taxes on high income people while the latter will be due to eliminating subsidies to help poorer people pay for health insurance on the exchanges as well as cutbacks in Medicaid spending for even poorer people. How fortunate can we get?

Barkley Rosser

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No One Knows What It’s Like to be Paul Ryan

Who can tell us how he feels knowing that no one likes his health care reform ?
The Who can tell us how he feels knowing that no one likes his health care reform !

This is some cause for optimism, as we can note The Who’s further forecast that, by the last verse, he will recognize the importance of access to emergency medical care and the moral imperative to share with those in need.

No one knows what it’s like
To be the bad man
To be the sad man
Behind blue eyes

ryan

No one knows what it’s like
To be hated
To be fated
To telling only lies

But my dreams
They aren’t as empty
As my conscience seems to be
I have hours, only lonely
My love is vengeance
That’s never free

ryansad

No one knows what it’s like
To feel these feelings
Like I do
And I blame you

No one bites back as hard
On their anger
None of my pain and woe
Can show through

But my dreams
They aren’t as empty
As my conscience seems to be
I have hours, only lonely
My love is vengeance
That’s never free

ryanlaughs

When my fist clenches, crack it open
Before I use it and lose my cool
When I smile, tell me some bad news
Before I laugh and act like a fool

And if I swallow anything evil
Put your finger down my throat
And if I shiver, please give me a blanket
Keep me warm, let me wear your coat

coats

No one knows what it’s like
To be the bad man
To be the sad man
Behind blue eyes

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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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Dumbest Statement Coming Out of Congress Yet on Healthcare . . .

A partial of the Republican plan:

introduced by Rep. Mark Sanford (R-S.C.) and Sen. Rand Paul (R-Ky.), would end Medicaid expansion, decouple health insurance from employers, offer a tax credit of up to $5,000 to fund HSAs, and eliminate most regulations on what health plans must cover. Insurers would be able to sell policies across state lines; regulations that mandate birth-control coverage would be nixed.

Hmmmm, that’s nice . . .

This is about the dumbest statement I have read yet by Senator Rand Paul;

“What if 30 percent of the public had health savings accounts?” Paul asked. “What do you do when you use your own money? You call up doctors and ask the price. . . . If you create a real marketplace, you drive prices down.”

“What if” we were all billionaires, able to buy the best care, and negotiate with multi-billion dollar hospitals? Yea “what if” . . . “What if” all the Senators and Congressmen, and Judges had our very same healthcare plan? Yea “what if” . . . “What if” all of those people fighting against the PPACA had really put some effort into learning about it, put the effort into forcing Congress to move forward with making it better . . . where would we be today? Yea “What if” . . .

Still love kicking the one layer deep naysayers around as they too will get a douse of what this is all about if ESI disappears as well as birth-control. Healthcare policies across state lines will be similar to what bank chartering is like with a couple of states controlling all the policies and no real competition (just like interest rates and usury).

“What if . . . “

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PPACA Repeal and How to Make Reconciliation Work for You.

In this post, I am going to expand upon the impact of the new House Rules H. RES. 5 upon the Repeal of the PPACA. As I explained here Paul Ryan deliberately changed the House Rules and the Republicans following party line approved them with the exception of 3 who voted with the Democrats. The House Rules went from just this:

“The Director of the Congressional Budget Office shall, to the extent practicable, prepare an estimate of whether a bill or joint resolution reported by a committee (other than the Committee on Appropriations), or amendment thereto or conference report thereon, would cause, relative to current law, a net increase in direct spending in excess of $5,000,000,000 in any of the 4 consecutive 10 fiscal year periods beginning with the first fiscal year that is 10 fiscal years after the current fiscal year.”

plus this additional statement:

“This subsection shall not apply to any bill or joint resolution, or amendment thereto or conference report thereon—

(A) repealing the Patient Protection and Affordable Care Act and title I and subtitle B of title II of the Health Care and Education Affordability Reconciliation Act of 2010;

(B) reforming the Patient Protection and Affordable Care Act and the Health Care and Education Affordability Reconciliation Act of 2010.”

neatly hidden away on pages 25 and 26 of 115th Congress House H. RES. 5.

Ok, so the Republicans are up to their old craftiness of slipping it to the Democrats when they want to block something the Democrats have done in the past. There is reason to why Congressman wants to block the CBO from reporting on this. It deals with making it more difficult 10 years down the road to change the repeal.

If you remember, Bush’s tax cuts were passed using Reconciliation and the CBO did a cost analysis showing it would create a deficit. Using Reconciliation to pass a bill, the legislation passed and creating a deficit must expire in 10 years. Bush’s tax cuts did create a deficit and a big one much of which was reversed by Obama.

For sure, Congressman Paul Ryan knows the repeal of the PPACA will create a deficit and Republicans know the repeal will create a large deficit. To make sure no one else knows, Mr. Ryan has blocked the CBO from analyzing it before repeal. Also unbeknownst to many, if the CBO does not do its typical independent analysis of the costs (if any) created by the PPACA repeal and how much it increases the deficit, there is no requirement for the legislation to expire after 10 years. Republicans would have repealed the PPACA as they have wanted to do since 2010, and would have blocked it from ever coming back after 10 years.

Crafty little weasel that Mr. Paul Ryan!. Then too Mr. Rand Paul is ready to sell you his healthcare policy (Obamacare Replacement Act) which does cover pre-existing conditions up to a guaranteed two years. After two years, and miss a payment or your healthcare insurance lapses and the healthcare insurance company can charge you the going rate just like the good-old-days. Also keep in mind, “Americans will never learn how devastating the PPACA repeal will be to Medicare’s long term solvency that was extended a couple of decades because of the Affordable Care Act’s execution.”

Where are the Democrats in all of this?

GOP Prohibits CBO From Reporting How Much ACA Repeal Blows Up the Deficit RMuse, Politicus usa January 11, 2017

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Aurora, Colorado; Republican Congressional Representatives in Action

In Colorado, on Saturday, Republican Rep. Mike Coffman held an event for his constituents at a
Coffman a public library in Aurora, Colorado. At least 150 constituents showed up, most of them hoping to ask Coffman about his recent vote to repeal the Affordable Care Act and his plans for a replacement. But only about 70 people got to meet with Coffman: Despite booking a large room with ample space, Coffman allowed in only four constituents at once for five minutes at a time. When the crowd grew restless, police put up crime scene tape and Coffman snuck out the back door—six minutes before the event was scheduled to end.

Coffman co-authored a Denver Post op-ed on Friday urging the full and immediate repeal of the ACA. About 419,000 Coloradans have gained health care coverage since the enactment of the law, and many of them stand to lose their insurance if it is repealed. Yet Coffman has not proposed a clear replacement for the law, an issue constituents hoped to ask him about on Saturday. “I am potentially going to lose my health insurance,” Berthie Ruoff told NBC 9 while she waited to meet with her representative. “I’ve had a preexisting condition. I’ve had breast cancer. What’s going to happen to me? My spouse who had health insurance passed away. What do I do? You know, what am I supposed to do?”

But neither Ruoff nor many other constituents who stand to lose coverage had an opportunity meet with Coffman. When it grew clear that Coffman would refuse to meet with a majority of those at the event, the crowd channeled its agitation into patriotic songs:
This show of unity, however, did not impress Coffman. Indeed, it appears to have scared him: Rather than address the crowd, Coffman had police officers secretly escort him out of the back door before the event was set to conclude.

A few people noticed Coffman sneaking out and attempted to address him. “Next time,” one woman pleaded, “please be sure you hear all your constituents!” Coffman ignored them, hopped into a waiting car, and drove away.

“Have a good afternoon!” yelled another exasperated woman.

GOP Rep. Sneaks Out of Townhall Meeting, Mark Joseph Stern, Slate, January 15, 2016

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Millions Are Uninsured

When People claim “Millions Are Uninsured Under the PPACA,” it is a garbage statement meant to elicit a negative reaction without going into the detail of who is uninsured and why. Repeatedly Charles Gaba, Maggie Mahar, Commonwealth Fund, Urban Institute, Kaiser Foundation, etc. have explained the numbers and the whys of the uninsured, most of which are not the fault on the PPACA.

I see commenters come to AB and outside AB discussing the uninsured. Some being legitimate bloggers claim “millions are uninsured” and some have exaggerated it even more with citing “tens of millions” with their credibility disappearing as they can not recite the make-up of or the reasons for the number as they do not know it or are trying to make a political statement. The latter being worst than the ignorance of the former.

invisible hand

There are reasons for the uninsured as detailed by Kaiser Family Foundation. For example, Republican states which do not allow expansion of Medicaid accounts for 2.6 million, undocumented citizens 5.4 million, those eligible for Employee sponsored insurance 4.5 million, and 3.0 million who could have unsubsidized insurance. Then there are 6.4 million adults and children eligible for Medicaid and another 5.3 million eligible for Premium Subsidies and for some reason have not chosen to be insured. Some states like Michigan do make it difficult to enroll in Medicaid. These are the Kaiser numbers for 2016 and they total ~27 millionfor uninsured and why. A “tens of millions” uninsured is a BS numeric when we start accounting for Republicans blocking Medicaid Expansion in states, undocumented immigrants, ESI available insurance, 6.4 million eligible for Medicaid, and another 5.3 million eligible for subsidies. Other than undocumented citizens and states blocking the Medicaid Expansion, there is access to healthcare insurance in one form or another through the PPACA, much of which exists today due to the PPACA, or Employer Sponsored Insurance. When we account , the number drop as there are those without subsidy who chose not to be insured, others who could be on Medicare or have Premium subsidies, and those who could have Employee Sponsored Insurance.

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