The effects of a repeal of ACA

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Soo, it looks like repeal is on the cards:

Republican leaders are betting that the only way for Congress to repeal the Affordable Care Act is to set a bill in motion and gamble that fellow GOP lawmakers won’t dare to block it. Party leaders are poised to act on the strategy as early as this week, after it has become obvious they can’t craft a proposal that will carry an easy majority in either chamber. Lawmakers return to Washington on Monday after a week of raucous town halls in their districts that amplified pressure on Republicans to forge ahead with their health-care plans.

GOP may set Affordable Care Act repeal into motion this week - MarketWatch

The plan, leaked to reporters Friday, largely mirrors previous blueprints proposed by Republican lawmakers. It would repeal Obamacare's individual mandate requiring all Americans purchase health insurance or pay a penalty. It would also eliminate all of the taxes used to fund Obamacare subsidies and the Medicaid expansion, including the controversial tax on medical devices. Also to be eliminated: the planned expansion of Medicaid in 2020. The draft also includes a provision to eliminate funding for Planned Parenthood for one year.

House GOP Finally Puts Obamacare Repeal Plan on Paper - TheStreet

Those tax cuts, all of them will be eliminated, are on the rich. Eliminating these is the main driving force behind the drive to repeal Obamacare, of course.

And millions are going to loose coverage. How's that going to "keep Americans safe?":

Republican replacement plans for Obamacare would lead to significant declines in the number of Americans with health insurance coverage, according to an analysis presented Saturday at the National Governors Association and obtained by Vox. The analysis was conducted by the health research firm Avalere Health and the consulting firm McKinsey and Company.

The report estimates what would happen in a hypothetical state with 300,000 people in the individual market that has also expanded Medicaid. In the individual market, enrollment would fall 30 percent and 90,000 people would become uninsured. An additional 115,000 people in that hypothetical state may also lose coverage because they are enrolled in Medicaid and cannot find an affordable private plan.

The report estimates that coverage declines would be even higher in states that did not expand Medicaid — largely those run by Republican governors. There, the report presents an example of a state with 235,000 in the individual market. It estimates that coverage would decline by 120,000 people, about 50 percent.

Leaked report suggests millions could lose coverage under GOP health proposal - Vox

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As if we needed any more proof that it's the tax cuts for the wealthy that trump everything, including healthcare coverage of millions and the lives of thousands.

Referring to his own enthusiasm for tax reform, Trump explained, “I can’t do it until we do health care, because we have to know what the health care is going to cost and — statutorily — that’s the way it is. So for those people who say, ‘oh, gee, I wish we could do the tax first,’ it just doesn’t work that way. I would like to do the tax first.”

Trump is wrong about this. There is no statutory requirement for him to do health care before he works on tax reform. What’s at issue is simply Paul Ryan’s legislative strategy.

Ryan wants to pass a tax reform plan with a party-line vote, which means he needs to use the budget reconciliation process to avoid a Senate filibuster. You can’t write a reconciliation bill that increases the deficit over the long term. So Ryan’s plan is to repeal the Affordable Care Act — which, among other things, would sharply reduce taxes on the rich, but would avoid increasing the deficit since the cuts will be offset by spending less on insurance for the poor and middle class. Then, having locked that tax cut into place, Republicans could move on to a revenue-neutral tax reform using the lower revenue number as the baseline.

Trump says “nobody knew that health care could be so complicated” - Vox

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Trump the candidate pledged to ask Congress to “immediately deliver a full repeal of Obamacare” on his first day as president and said he would “have a series of reforms ready” that would make health care better, cheaper and more broadly available.

Why Repealing Obamacare Is Harder Than It Sounds: QuickTake Q&A - Bloomberg

Hahahaha...

But then there is this, distinctly not funny..

Some industry experts warn that repealing portions of the ACA without a plan to replace it could lead to a collapse of the individual market, jeopardizing coverage for millions of people. They say the uncertainty, combined with a potential end to key parts of the ACA such as the requirement that all people buy health insurance, would lead many insurers to stop offering health plans for 2018, as a number of them already have or are already threatening to do. In response, the Trump administration has proposed giving insurers a number of changes they had been seeking..

Why Repealing Obamacare Is Harder Than It Sounds: QuickTake Q&A - Bloomberg

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And one might also want to realize this..

For starters, repealing Obamacare will cost the federal government as much as $350 billion, according to a recent analysis by the nonpartisan Committee for a Responsible Budget. Most of the law's opponents have focused on the added cost of subsidizing health insurance. But the law also includes dozens of provisions that cut health care and raise taxes that more than offset the money spent.

Trump's pledge to cut health -care costs won't come cheap

But of course one of the main motivations is to get rid of those taxes on the rich that are used to pay for the coverage expansion in subsidies (for those that cannot afford the premiums).

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The 'guidance' from the President.. Good luck with that, from Vox:

Here’s the grand total of the Obamacare repeal-and-replace plan, as offered in Trump’s speech:

First, we should ensure that Americans with preexisting conditions have access to coverage, and that we have a stable transition for Americans currently enrolled in the health care exchanges.

Secondly, we should help Americans purchase their own coverage, through the use of tax credits and expanded health savings accounts — but it must be the plan they want, not the plan forced on them by the government.

Thirdly, we should give our great state governors the resources and flexibility they need with Medicaid to make sure no one is left out.

Fourthly, we should implement legal reforms that protect patients and doctors from unnecessary costs that drive up the price of insurance — and work to bring down the artificially high price of drugs, and bring them down immediately.

Finally, the time has come to give Americans the freedom to purchase health insurance across state lines –- creating a truly competitive national marketplace that will bring cost way down and provide far better care.

With this, Sarah Kliff explained, Trump merely "told party leaders they are on the right track, but he did not provide any further direction or a pitch for unity." The plan Trump is describing above strongly matches the Better Way plan that House Speaker Paul Ryan and allies unveiled last summer. Both preserve a tax credit system to pay for insurance, expand health savings accounts, block-grant Medicaid and turn it over to the states, and demand insurance sales across state lines.

But think about what Trump left off:

• He didn’t say whether the tax credits should be refundable, as in A Better Way and Obamacare, or nonrefundable, so that people not paying income taxes can’t benefit. A lot of conservatives in the House and Senate have denounced refundable credits as “Obamacare lite,” or “a major and unstoppable entitlement” because they redistribute money to pay for low-income people’s health care. It seems like Trump disagrees with that. But does he? And how does he plan to convince those skeptics?
  
• Trump says he wants to kick Medicaid back to the states. Will he do that through a per capita cap or a full block grant, the latter of which would let states aggressively drop people from rolls? Should Medicaid expansion states continue to get federal money they started receiving under the ACA? Will all states see funding cuts? What about congressional Republicans who appear skeptical about all this?
  
• How will Trump continue to ensure that people with preexisting conditions get coverage? Will the legal requirement remain? Some other weaker measure?
  
• How will Trump’s plan keep healthy people buying insurance? Obamacare does this with the individual mandate. Will Trump require people to maintain insurance coverage continuously or else face penalties in the future — even though that could be unpopular for the same reasons as the individual mandate?
  
• Trump promises “a stable transition” for Obamacare enrollees. How? When would the law be phased out? How much time would enrollees get to find new arrangements? Will Trump sign a repeal bill before this transition is specified in law?
  

All of these things are controversial, all offend various stakeholders and please others, and each will provoke a major fight in Congress. Presidential guidance can help steer his party’s legislative path and minimize conflicts on these points. But Trump offered little to none.

Effectively, this was a punt back to Ryan: Trump is not going to step in and help him get the caucus in line. The result will be months more of wrangling over repeal options, with no clear path to passing anything.

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Keeping American's 'safe'..

Nearly 36,000 people could die every year, year after year, if the incoming president signs legislation repealing the Affordable Care Act. This figure is based on new data from the Urban Institute examining how many people will become uninsured if the law is repealed, as well as a study of mortality rates both before and after the state of Massachusetts enacted health reforms similar to Obamacare.

Here’s how many people could die every year if Obamacare is repealed

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The Brutal (and Fact-Checked) Numbers on Killing Obamacare | Mother Jones

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LOL..

Billy House and Arit John at Bloomberg reported Wednesday that the House GOP plan is being kept in a secretive reading room and is only available to read in that room for members of the House Energy and Commerce Committee and their staff starting on Thursday.

But reporters, and even members of Congress, were let in to that room, they found it empty with no apparent piece of legislation in sight. Subsequent reports said the secure location had been moved.

"We're on a treasure hunt, I guess," said Rep. Jan Schakowsky, a Democrat from Illinois. A draft of the House GOP plan was leaked last week, and it drew rebuke from Democrats and more conservative lawmakers in both the House and Senate.

It also appeared that the room in which the bill was being kept was being guarded by Capitol police. The Twitter account for Democratic members of the House Ways and Means Committee tweeted a picture of police standing outside a room in the Capitol, saying, "House Republicans are literally guarding their health care bill with Capitol Police. Is it *that* dangerous?"

Rep. Chris Collins, a Republican, told Bloomberg that the House may mark up the bill — essentially, reviewing it in committee and making changes to the law — next week without a score from the Congressional Budget Office (CBO). The CBO provides nonpartisan estimates of the costs of all bills and coverage implications for those dealing with healthcare.

Members from both sides of the aisle on Thursday decried the secrecy over the bill, with Democratic House Minority Leader Nancy Pelosi drawing attention to it during a press conference on Thursday and Republican Sen. Rand Paul railing against the methods in a tweetstorm..

Obamacare replacement bill in secret room - Business Insider

Secret room? Guarded by police? No CBO scoring??!

They apparently have great confidence in their replacement law..

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These were just words anyway, and now he's already backtracking..

While promising again that President Trump’s tax cut will focus on “middle-income” Americans and high-income Americans won’t get an overall tax cut, Treasury Secretary Steven Mnuchin now says that rule shouldn’t apply to the tax cuts that the wealthiest Americans will receive if policymakers repeal the Affordable Care Act (ACA).

Mnuchin Rule Should Apply to ACA Repeal | Center on Budget and Policy Priorities

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It's almost inevitable that repeal and replace is going to hurt a lot of people, from Business Insider:

Trump has 5 priorities for his Obamacare replacement — here's what they could mean for you

[*]Bob Bryan

In his speech to the joint session of Congress on Tuesday, President Trump took time to attack the Affordable Care Act, better known as Obamacare, and laid out a broad vision for the future of healthcare in the US.

"Obamacare is collapsing and we must act decisively to protect all Americans," Trump said. "Action is not a choice — it is a necessity. So I am calling on all Democrats and Republicans in the Congress to work with us to save Americans from this imploding Obamacare disaster."

The president went on to lay out five principles that he says he wants to see in an Obamacare replacement — from preexisting conditions to funding to help the poorest American buy coverage. Here's what these plans could mean for many Americans.

1. 'Ensure that Americans with preexisting conditions have access to coverage.'

Before the Affordable Care Act, Americans with health problems ranging from asthma to cancer could find it hard or even impossible to obtain health insurance, if they didn't have it through an employer or other group.

Obamacare's rule forbidding insurance companies from excluding these Americans with preexisting conditions has become one of the most popular parts of the law. Trump has longed vowed to maintain that.

But there are a few different things this could mean.

In a leaked draft of the House GOP's repeal-and-replace bill, people cannot be denied coverage based on a preexisting condition, but many could be placed into separate marketplaces called "high-risk pools."

In the ACA's individual health-insurance exchanges, healthy people and people with preexisting conditions are in the same pool. For insurers, this helps to balance the risk and costs and mitigate losses from the exchange. Since there are limits to how much people in the same pool can be charged, this also leads to healthier people having slightly higher premiums than they would otherwise and those with preexisting conditions to have somewhat cheaper premiums.

Republicans would separate the two groups, bringing down costs for healthy people who want insurance through the individual marketplace. It would also most likely mean that those people with preexisting conditions would see their costs rise.

Thirty-five states had their own high-risk pools before the ACA. The Kaiser Family Foundation, a leading nonpartisan health-policy think tank, found that the average cost for those enrolled in these pre-ACA high-risk pools was anywhere between 125% and 200% more than the average premium cost outside of the pools and many people did not enroll because of the prohibitive cost.

Additionally, the key word in this part is "access." As health-policy experts have pointed out, access is not the guarantee for coverage, and the expensive plans in the high-risk pools, while theoretically accessible to people with preexisting conditions, could price many people out.

2. Help people purchase insurance with the use of tax credits and health savings accounts.

The next principle laid out in Trump's speech is designed to help Americans get affordable health insurance.

The leaked Republican plan proposes giving all Americans a tax credit up front to buy insurance based on their age. The bill would create three age brackets. Those under 35 would get $2,000, for example.

Currently, Obamacare has a different structure of tax credits. These are tied to a recipient's income and location, not age. This has allowed about 73% of people in the exchanges to get coverage for $75 or less in premiums per month, though they did leave some out since they were capped at an income of 400% of the federal poverty line.

Kaiser also looked at the House draft bill's proposals for these block grants, which are roughly in line with the ideas proposed in House Speaker Paul Ryan's "Better Way" plan and new secretary for health and human services secretary Tom Price's "Putting Patients First" act.

The study by Kaiser found that, overall, the block credit would shift the balance of assistance.

"For current marketplace enrollees, the House Discussion Draft and Price bill would provide substantially lower tax credits overall than the ACA. People who are lower income, older, or live in high premium areas would be particularly disadvantaged under the House Discussion Draft and Price bill relative to the ACA," the Kaiser report said.

For Instance, under the current ACA credits, the average single beneficiary over the age of 60 with an income of $20,000 would receive $9,874 per year to pay for their insurance. Under the House draft, this tax credit would be capped at $4,000.


Kaiser Family Foundation

It also seems that Trump is being less aggressive about repealing the tax credits than the most conservative members of his party. Hard-line Republicans want to repeal all funding for tax credits because they believe they are not fiscally responsible. By endorsing these tax credits, it shows that the president is more on the side of House Speaker Paul Ryan than conservatives such as the House Freedom Caucus or Sen. Ted Cruz.

3. Allow states and governors the "flexibility they need with Medicaid to make sure no one is left out."

This may be one of the most controversial statements from Trump within his own party.

The ACA expanded Medicaid coverage from the federal government so that a person making up to 138% over the federal poverty line could get insurance through the government program. According to estimates this allowed more than 11 million low-income Americans who otherwise would not have access to insurance get covered.

Some conservatives in the GOP want to roll back the federal funding for this program, while Republican lawmakers and governors in states that have expanded the program want to keep the expansion. These lawmakers fear that rolling back coverage for those on Medicaid could be politically costly: Polls show 80% of Americans want to keep the expansion.

The House GOP's draft proposes this: repeal federal funding for the expansion by 2020 and then move to block grants.

These would ultimately offer less funding to the states.

4. "Implement legal reforms that protect patients and doctors from unnecessary costs that drive up the price of insurance."

While this section is particularly vague, Trump did say that he wants to "bring down the artificially high price of drugs."

Trump has advocated allowing Medicare to negotiate drug prices to bring down these costs for seniors, an idea that has been long supported by Democrats and opposed by Republicans.

Other than that promise for lower drug costs, it is unclear what he means by this line.

5. Allow the sale of health insurance "across state lines."

This has long been an idea of Republicans, which would allow insurers to get a plan approved in one state — say, Oregon — and, as long as it is approved in that state, it can be sold in any other state.

The idea is that it would allow insurers to be in more markets and compete with one another, and that could lower prices and be more attractive to consumers.

One of the biggest problems is that most healthcare experts don't think it would do much to move the needle in bringing down costs.

The biggest barrier for insurers in entering a market is developing contracts with local healthcare providers such as doctors' networks and hospitals. Even if a plan were approved in Oregon, the insurance company would still have to set up contracts with a hospital if they wanted to offer the plan in South Carolina. Given distances and cost, most policy experts agree this isn't an attractive option.

Additionally, the ACA already has a limited provision that allows a similar sale of insurance across state lines. Despite a handful of states opening themselves for cross-state sales, no insurers have taken advantage of this.

While it is unclear which of these reforms the legislature and Trump will be able to agree on — especially since the Republican Party seems divided on some of the ideas — the speech did provide the broad strokes of what Trumpcare could look like.

Here are all the roads to repealing, and perhaps replacing, Obamacare.

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Samantha Lee / Business Insider