The effects of a repeal of ACA

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In essence, the new proposal now on the table is simply Obamacare lite. It's generally meaner for those that are old and sick, better for the young, healthy and well off. But what the whole freaking point of it all is, well, only the Republicans can answer that. 

Actually, they can't.

In explaining why Trump didn’t endorse the House plan in his speech, Owens and Swan wrote: “The view internally is that the current plan — drafted by both House and Senate leadership — is going to struggle to get out of Congress. It would be foolish for Trump to walk all the way down the plank and utter the sentence: ‘I support the health care plan drafted by the House.’”

Trump’s hesitancy makes sense. He’s made big promises on health care — that his plan would have “insurance for everybody” even if they couldn’t afford it, that hewouldn’t cut Medicaid, that he’d tackle high prescription drug costs, and that he’d let insurers sell across state lines. The first two promises would be outright broken by the House GOP bill, and the latter two simply aren’t included.

But it’s dreadful news for House GOP leaders hoping to get the bill through. Republicans will have enough problems passing the bill even if Trump does fully endorse it, given their divisions between conservatives who feel the bill is too close to Obamacare and moderates fearful of imperiling coverage for their constituents.

Trump’s statement on the House GOP’s Obamacare bill is a non-endorsement - Vox

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This is why Republicans are rushing Trumpcare through Congress without a CBO score. Two experts from the Brookings Institution have adopted some of the Congressional Budget Office’s published assumptions to ballpark how many people will be projected to lose insurance under the GOP’s Obamacare repeal bill.
Spoiler: It is a lot of people. 

 [I]t’s plausible that the AHCA will increase the number of uninsured persons by more than 15 million, and unlikely that we’ll see a number much less than 15 million from the CBO.

Republicans have plenty of excuses for plunging ahead with major legislation before Congress’ in-house economists finish analyzing the consequences of it, but this is the real reason. Their legislation will screw over millions of people.

This is why Republicans are rushing Trumpcare through Congress without a CBO score. | New Republic

Up to 10 million Americans could lose their health insurance under the American Health Care Act (AHCA), the House GOP leadership's plan to repeal and replace the Affordable Care Act (aka Obamacare), according to a report published on Tuesday. In the report, S&P Global Ratings, a research arm of the credit-rating agency S&P, broke down the bill and its effect on the number of uninsured Americans, providing some clarity on one of the big questions about the legislation.

How many people will lose insurance if Obamacare repealed? - Business Insider

Republican governors complain that a GOP proposal to replace former President Barack Obama's healthcare law would force millions of lower-income earners off insurance rolls or stick states with the cost of keeping them covered. Governors, especially those from political battleground states, were generally cool to the bill put forth in the Republican-controlled US House. Some signaled that they would continue working on their own legislation to compete with the measure introduced Monday. 

At the heart of their criticisms is that the House plan would jeopardize coverage for roughly 11 million people covered through the Affordable Care Act's Medicaid expansion. The law allowed states to expand Medicaid to cover more low-income individuals and their families at costs borne largely by the federal government. Phasing out the federal supplement for Medicaid would hit hardest in states where governors chose to participate in the expansion, such as Michigan, Nevada, and Ohio.

Republican governors complain about GOP healthcare plan - Business Insider

This is just the ACA exchanges and Medicaid, and then there is this:

Chris Jacobs, a Republican health-policy adviser who worked under current Vice President Mike Pence during the original debate over Obamacare, reported in The Federalist on Monday that Republican staffers were expecting a rough score from the CBO. Jacobs said that sources told him the CBO could estimate that 10 million to 20 million people who have employer-based insurance could lose coverage, as companies could decide to allow people to use the tax credits under the AHCA to buy their own insurance instead of offering insurance through work. Additionally, Jacobs said, the CBO score could indicate that repealing the taxes associated with Obamacare while maintaining tax credits would lead to a sizable increase in the federal deficit.

CBO score looms for GOP Obamacare replacement - Business Insider

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We try a little summary so far about Trumpcare

• Between 10 and 15 million people could lose coverage
  
• 10-20 million people could lose employer based healthcare
  
• Losing coverage could lead to 36,000 deaths a year
  
• It violates basically all of Trump's promises
  
• More broken Trump promises
  
• Trump's address to Congress, and what he didn't say
  
• It eliminates all the taxes on the rich to fund for the subsidies
  
• And it opens the way for even more tax cuts for the wealthy in the future
  
• But it could still lead to a higher budget deficit
  
• The repeal tax cuts on the rich don't count in keeping taxes neutral, as Mnuchin promised
  

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From Vox:

7 details in the Republican health care bill that harm the poor

Obamacare gave more low-income Americans health coverage. The American Health Care Act would take it away.
Updated by Julia Belluz@juliaoftorontojulia.belluz@voxmedia.com  Mar 10, 2017, 9:00am EST

The Affordable Care Act, President Obama’s signature health reform, had one big goal: to make health insurance more affordable and accessible to those who had trouble getting coverage.

In essence, that meant finding ways to get America’s poor — the millions who couldn’t pay for private health insurance or were ineligible for Medicaid — health coverage.

The new GOP health reform plan, the American Health Care Act, is filled with provisions — some subtle, some not — that’ll undo that work.

1) The penalty for not buying insurance that replaces the individual mandate is most punishing for low-income Americans
It has long been a truism of American health care that a small group of patients cost the most money. And it is this minority, with their hefty medical bills, that are the most challenging group for any insurer to cover.

The Affordable Care Act’s answer to this problem was the individual mandate: Require everybody to buy insurance through the individual mandate, and put the young, old, sick, and healthy into the same pool, evening out the risk and offsetting some of the costs of covering that minority for insurers. Under Obamacare, if you didn’t buy health insurance, you faced a fine, which scaled up based on income.

The Republican plan does away with the individual mandate, and replaces it with a continuous coverage penalty: You can choose to be uninsured if you want, but when you try to buy insurance again, you face a 30 percent higher premium for a year.

A new analysis by the health research firm Avalere finds this new method will be more punishing for the poor than the individual mandate was, and will actually give the wealthy a break.

Just check out this chart from its report. It outlines the case of a 27-year-old seeking new health insurance on the individual market, and compares the fines he’d face under the current law (Obamacare) and under the AHCA:
Avalere
The red text indicates a worse deal under the Republican plan, and the green a better deal. You’ll notice that people in the higher income brackets are generally getting better deals than the lowest-income earners.
That means someone who brings home $59,400 a year (500 percent of the federal poverty level) and hasn’t had insurance for a year would effectively pay a smaller penalty under the AHCA than under Obamacare, Vox’s German Lopezwrites, and someone who's making $11,880 a year (100 percent of the federal poverty level) would pay more. Here’s Lopez again:

In general, the AHCA penalty is just harder for the poor. Since it doesn’t scale with income, everyone, from Bill Gates to someone making nothing a year, will have to pay the same amount: a flat 30 percent extra on a premium. But that penalty ... is a much bigger share of a person’s income if he or she makes $10,000 a year instead of $100,000, $1 million, or $1 billion.

2) The tax credit changes to help people buy insurance are less helpful for the poor, and more helpful for the upper middle-class
In order to help more people purchase insurance, Obamacare gave people income-based tax credits. Poorer people got more help buying their coverage than richer people. These credits were important for those who didn’t get health insurance through their work, didn’t qualify for Medicaid, and needed a little help to buy their insurance on the individual marketplace.

The new Republican plan gets rid of income-based subsidies and replaces them with a new system of tax credits based on age.
In a sentence: The new system will be less generous than the Obamacare variation for the poor and elderly, and more helpful for the upper middle-class. Just check out this chart, via Cynthia Cox at the Kaiser Family Foundation:
Kaiser Family Foundation
The group estimates that a 40-year-old making $20,000 (or 160 percent of the poverty line) would get $4,143 in subsidies under the ACA but only $3,000 under the GOP plan. A higher-earning 40-year-old, making $75,000 annually, would get no tax subsidy under the ACA but $3,000 under the Republican plan.

Older folks would also fare more poorly under the AHCA. A 60-year-old earning $20,000 a year (again, 160 percent of the poverty line) would get $9,874 under Obamacare and $4,000 — or less than half that — under the new Republican plan.

That’s why this Kaiser Family Foundation analysis noted, “People who are lower income, older, or live in high premium areas would be particularly disadvantaged under the American Health Care Act.”

3) The plan ends Medicaid expansion, a program designed to benefit people living below the poverty line
After 2020, Republicans also want to end Medicaid expansion, which means the federal government would no longer help states pay for extra enrollees who weren’t eligible for Medicaid before the ACA.

To understand what that means, let’s step back a bit. Prior to the passage of the law, in most states, only children and parents, pregnant women, or the disabled were eligible for Medicaid. So all other poor Americans — the working poor who didn’t have kids or who weren’t disabled — often couldn’t afford private health insurance but also weren’t eligible for Medicaid.

Obamacare came along in 2010 and changed that: Suddenly anyone whose family income fell below 138 percent of the federal poverty level (about $15,000 for an individual) was eligible for government health insurance. The federal government also offered states funding to pay for all the new enrollees in the program.

A majority of the states (32, including Washington, DC) took the money, expanding Medicaid. And it’s no surprise. The feds offered a sweet deal. The states and the federal government share the cost of Medicaid, but the feds paid a lot more for Medicaid expansion enrollees, matching 100 percent of the states’ costs for the first three years, with a plan to phase down to 90 percent by 2020 and beyond.

(Compare that with traditional Medicaid enrollees, whose costs are only partly matched by the federal government based on a formula tied to the state’s wealth. Richer places such as New York get a 50 percent match for Medicaid, while the feds pay poorer states like Mississippi up to 73 cents for every Medicaid dollar they spend.)

The ACA’s Medicaid push was a huge success. Of the 20 million-plus who got health insurance through Obamacare, at least half of them got it as a result of Medicaid expansion.

Now these folks are in jeopardy. Again, in 2020, the federal government will end Medicaid expansion. At the individual level, that means ACA Medicaid expansion enrollees would be covered until December 31, 2019 — assuming states don’t drop expansion before then in anticipation of the coming cuts.
Then in 2020, when Medicaid expansion ends, their health insurance status wouldn’t be secure anymore.

The government would only continue to match spending on the ACA Medicaid expansion enrollees who maintained continuous Medicaid coverage by staying below 138 percent of the federal poverty line. In practice, the continuous coverage requirement would mean a lot of people dropping from the program or facing a huge disincentive to earn more, said Benjamin Sommers, a Harvard health care researcher. “It’s a stealth attack on Medicaid expansion,” he said. "The reality is people move in and out of Medicaid a lot as they go between jobs, or their seasonal income goes up and down.”

4) The plan gets rid of Medicaid expansion for children living in poverty
It’s not just adults living in poverty who will get hurt by this plan. It’s kids too.
As Vox’s Dylan Matthews reports, the new plan would change how Medicaid and CHIP, (the Children’s Health Insurance Program) work together for children.
Prior to the enactment of the ACA, there were a bunch of different income levels qualifying children of different ages for Medicaid. This meant a lot of confusion for families, who might have some kids in a household on Medicaid, and others on CHIP.

The ACA expanded the eligibility rule by setting a uniform 133 percent of poverty Medicaid threshold for kids. The result was that a lot of kids moved from CHIP — which can charge premiums — to Medicaid, and families finally had their kids on one health insurance plan.

The AHCA would allow states to reverse that change, and the result will likely be moving kids back to the less generous CHIP program. “This is particularly concerning,” Matthews explained, “because CHIP funding is still slated to expire in September of this year, unless Congress acts.”

5) People living in “trigger states” are going to fare particularly badly
There are even more immediate risks to Medicaid expansion in some states. Eight of the 32 states (including DC) that expanded Medicaid under the ACA included language in their laws that said they’d only continue with the program as long as the federal government paid for most of it.
These “trigger states” were Arizona, Arkansas, Illinois, Indiana, Michigan, New Hampshire, New Mexico, and Washington. And in these places, Medicaid enrollees would be in particular jeopardy if the AHCA passes.

According to analysts at Georgetown University, if the AHCA were to pass, the trigger states could drop 3.3 million people from Medicaid in 2020 or revoke some of their benefits, depending on the language in the state’s legislation. (This is unlike the other states that expanded Medicaid, which might keep on ACA Medicaid enrollees so long as they maintained continuous coverage.)

6) For the first time, the plan caps spending on Medicaid — which will inevitably lead to cuts
Right now the federal government matches all the dollars states spend on Medicaid, based on the needs of people on the program. But Republicans are proposing a new funding approach, to kick in in 2020, whereby the feds will only match Medicaid spending to a certain fixed amount. If states exceed that cap to cover the needs of enrollees, they’re on the hook for 100 percent of their Medicaid costs. Researchers project the change will amount to a $280 billion cost shift to states over 10 years.

Because Medicaid spending can fluctuate a lot year to year — depending on the cost of drugs, for example, or any health crises that arise — a cap system like this could be really punishing to state economies. And this will most certainly put governors in the position of having to pare down Medicaid services, limit coverage, or drop people from the program altogether.

Medicaid researcher Joan Alker called this a politically “ingenious part of the Republican plan” because it’ll shift the burden to the governors to decide what to do to balance their books, and they’ll get blamed for the coverage losses that ensure. “They are going to have to raise taxes, cut services, or cut people off,” she added.

7) The plan discontinues retroactive medical bill coverage for the poor
There’s another stealth attack on Medicaid enrollees in the new GOP plan: It will also discontinue a program that got the medical bills of people who signed up for Medicaid covered retroactively for 90 days.

Under the ACA, people’s coverage extended back three months from before they enrolled in Medicaid. This was designed to protect people living in poverty who may end up in the hospital or sick with a lot of medical bills and only then learn that they were eligible for the program.
The GOP plan includes details that’ll undo this rule: People would only be eligible to get claims covered from within the same month in which they made their Medicaid application. This means that if they happen to apply for Medicaid at the beginning of the month, after racking up hospital charges for expensive treatments the month or months prior, they’ll be on the hook for all those bills. It’s another subtle change that’ll clearly sting people.

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Can these guys simply not stop lying and deceiving?

In their sales pitch for the American Health Care Act, House Speaker Paul Ryan and other Republicans have maintained that replacing the Affordable Care Act is necessary because the healthcare law, better known as Obamacare, is "collapsing."

The nonpartisan Congressional Budget Office, evidently, disagrees. In the CBO's report predicting the effects of the AHCA, the nonpartisan budget office on Monday said the individual health-insurance marketplace under both the current system and the proposed system would be stable. "In CBO and JCT's assessment, however, the non group market would probably be stable in most areas under either current law or the legislation," the report said.

The CBO said the ACA had maintained stability mostly because of its structure of providing tax subsidies for lower-income people to purchase insurance. While premiums have increased in the exchanges, Obamacare's tax credits adjust for income and cost of living, so a vast majority of people on the exchanges could access coverage for less than $100 a month.

CBO report says insurance market stable, unlike death-spiral narrative - Business Insider

And of course, it's these subsidies that are taken away, replaced by tax credits that are far less, in many cases. The penalty for not insuring is removed as well (the 'mandate') and replaced by a provision that if you're not covered for more than two months, your premium will increase by 30% (paid to the insurance company while the fine for not being insured under the ACA was paid to the government). 

We'll just have to wait and see whether that's enough of a penalty to keep young and healthy on the exchanges.

And then there is Mr. Tom Price, putting his foot in..

An internal White House analysis concluded that House Republicans’ Obamacare replacement bill, called the American Health Care Act, will cause up to 26 million people to lose their insurance coverage over the next decade, according to a copy of the analysis obtained by Politico.
That’s even more dire than the estimate the nonpartisan Congressional Budget Office released on Monday afternoon. The CBO projected that up to 24 million people could lose their insurance over the next decade.

Health and Human Services Department Secretary Tom Price told reporters on Monday that the Trump administration “strenuously disagrees” with the CBO’s estimate, adding, “It’s just not believable.”

White House analysis finds Trumpcare is even worse than the CBO estimated

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If you watched any television in 2010, you might recall that the Affordable Care Act cut $500 billion from Medicare over a decade. You probably learned that because House Republicans' campaign committee blanketed the country with ads attacking Democrats for cutting $500 billion from Medicare. "Let's save Medicare," the National Republican Congressional Committee said in one typical ad urging the election of a Republican majority. Seven years later, Republicans are fully in charge in Washington, and a "repeal" plan being considered by the House of Representatives this week would undo large parts of Obamacare. But it would leave the Medicare cuts in place.

Obamacare repeal gives rich what they want, not so much everyone else - Business Insider

Now that Republicans run the government, we are seeing which set of concerns they choose to prioritize, given limited available resources. The unsurprising answer is that Republicans will make a priority of repealing substantially all the tax increases in Obamacare, most of which fall on people who make over $200,000 a year. If House Speaker Paul Ryan gets his way, people who hated Obamacare because of the taxes it imposed will get nearly everything they wanted. But much of the rest of the law would stay in place. And people who hated the law for non-tax reasons — they thought insurance premiums were too high, they didn't like being penalized for not having insurance, they didn't like cuts to Medicare — mostly wouldn't get what they were expecting.

Obamacare repeal gives rich what they want, not so much everyone else - Business Insider

But a few players have praised the plan: The Wall Street Journal editorial board, the Chamber of Commerce, and the antitax advocate Grover Norquist, to name a few. What these people praising it have in common is that they are mostly interested in healthcare policy because healthcare spending is paid for with taxes, and the plan would cut taxes, including by reducing capital-gains taxes on high earners by 3.8 percentage points.

Obamacare repeal gives rich what they want, not so much everyone else - Business Insider

House Republicans have a plan to remake the U.S. health-care system—with a perk for wealthy investors. Included in their proposal to repeal and replace the Affordable Care Act is a tax break for the wealthy. The Obamacare replacement bill, unveiled on Monday night and endorsed by President Donald Trump with a tweet on Tuesday morning, eliminates the net investment income tax, a 3.8 percent surcharge on almost all earnings from investments. The net investment income tax is paid only by single people with incomes above $200,000 and married couples earning more than $250,000. The average hit from the NIIT doesn't get beyond three figures unless you're in the top 1 percent of earners. The tax casts a wide net, though. Investors must pay that additional 3.8 percent on proceeds that include capital gains, dividends, interest, royalties, rental income, and passive business income. "My sense is that this [tax] is not one that's easy to avoid or evade," said Roberton Williams, a fellow at the Tax Policy Center in Washington.

Republicans Give Rich Investors a Tax Break in Obamacare Revamp - Bloomberg

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Donald Trump added his own signature dose of shamelessness to the Republicans’ shameless crusade against Obamacare. “We’re going to have insurance for everybody,” Trump told the Washington Post after the election. Under Trumpcare, according to Trump, people “can expect to have great health care. It will be in much simplified form. Much less expensive and much better.” 

This was bolder and brasher than what more establishment-minded Republicans had said over the years. But it was, fundamentally, similar to promises and insinuations made by Paul Ryan, Mitch McConnell, and dozens of other Republicans. It’s not just that the Affordable Care Act was killing jobs and sentencing people to death panels. It’s that Republicans had some much better plan in their back pocket that would give Americans what they want — cheap, comprehensive health insurance that offers them oodles of choice.

It was a great line, and it helped Republicans win Congress and eventually the White House. But it was a lie, and now Trump and Republicans in Congress are paying for it..

Policy-minded conservatives have serious criticisms of President Obama’s health care law. They think it taxes rich people too much, and coddles Americans with excessively generous, excessively subsidized health insurance plans. They want a world of lower taxes on millionaires while millions of Americans put “skin in the game” in the form of higher deductibles and copayments. Exactly the opposite, in other words, of what Republican politicians have been promising. And this, more than tensions between the conservative and moderate flanks of the caucus, is why the prospect of actually legislating has brought the GOP to a crisis point. The chasm between what they’ve been saying they want to do and what their policy ideas actually do is simply much too large to be bridged.

They were taking a completely genuine conservative policy critique of the law — that it was making things a little too cushy for people, so they might decide to quit working — and turned it into roughly the opposite argument, that the Obamacare jackboot was going to prevent people who wanted jobs from finding work. The habit of doing this repeatedly — not just saying things that aren’t true, but refusing to state Republicans’ actual objections to the law — is what has painted the Republican Party into a corner.

Republicans are now paying the price for a years-long campaign of Obamacare lies - Vox

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Paul Ryan's wet dreams... cutting Medicaid. Unbelievable.

Speaking to National Review editor Rich Lowry at an event hosted by the conservative magazine, House Speaker Paul Ryan made the case for the American Health Care Act by presenting it as a once-in-a-lifetime opportunity to cut Medicaid spending. “We’ve been dreaming of this since I’ve been around,” Ryan says, before interrupting himself to clarify exactly how big of an opportunity this is, “since you and I were drinking out of kegs.”

AHCA’s Medicaid rollbacks would cost 14 million people their health insurance coverage, according to the Congressional Budget Office. But those 14 million people are people who only got Medicaid coverage relatively recently. Ryan’s youthful dream refers to provisions of the law that will cap per capita spending for the millions of other lower-income Americans who get Medicaid coverage.

Paul Ryan says he’s been “dreaming” of Medicaid cuts since he was “drinking out of kegs” - Vox

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Does Trump know how his healthcare plan works? Probably not. Or he doesn't care..

On March 8, Trump laid out his case for the American Health Care Act. Here’s what he said: It follows the guidelines I laid out in my congressional address: a plan that will lower costs, expand choices, increase competition, and ensure health care access for all Americans. This will be a plan where you can choose your doctor. This will be a plan where you can choose your plan. These talking points are familiar enough that it’s easy to let them fade into the background.

But it’s worth taking them seriously. This is Trump’s case for the bill he’s backing. Does he know that literally every single one of these points is wrong? The AHCA doesn’t lower costs.

Apples to apples, the Brookings Institution estimates “that premiums would be 13% (~$1,000) higher under the AHCA than under current law, holding plan generosity and the individual market age distribution fixed at their current law levels.” To the extent that the AHCA sees lower premiums, it’s because older people can’t afford care and younger people buy sparer plans. That is no one’s idea of lowering costs. The rest of the problems flow from there. 

Most people will have fewer affordable choices under the AHCA because their subsidies will be so much smaller (and many people will have no affordable choice at all, and so will go uninsured). 

Competition is likely to fall as the marketplaces shrink — fewer consumers wielding smaller tax credits will not prove an attractive market to insurers. The idea that the AHCA will “ensure health care access for all Americans” is sufficiently absurd that I’m not even going to spend time on it. 

But the idea that it will let you choose your doctor and plan is more interesting — it seems entirely possible to me that Trump doesn’t realize the limited choices people complain about in Obamacare are the result of people being unable to afford more generous plans with broader networks, and it seems likely to me that he doesn’t know the AHCA will make that problem worse, or why conservative health reformers think that’s a good thing.

Then on March 10, Trump said this: You all remember, you can keep your doctor, you can keep your plan. I know, Greg, you’ve never heard that, right? But it was said many, many times, and it turned out to be not true. This is the time we’re going to get it done. This is either an extremely foolish thing to say or it is the comment of a man who doesn’t realize that the plan he’s backing would, in a stroke, mean millions of people could no longer afford the subsidized insurance they were using, and would react with fury and surprise when they realize they were betrayed.

Does Donald Trump know what the GOP health bill does? - Vox

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The 30% premium hike for more than two months interruption of insurance, is that sufficient deterrent to keep people insured? Well..

Yuval Levin, a former policy adviser to George W. Bush and a conservative commentator, wrote in the National Review that the provision could actually keep people out of the healthcare market until they get sick. "It would create a disincentive for everyone who hasn’t been continuously covered to get coverage, by making insurance more expensive for them," Levin wrote. "But that disincentive would do more to drive away healthy people than sick people, since the added premium is more likely to be worth it to someone who otherwise would have higher costs than to someone just looking to get insurance for a rainy day. It would, in other words, exacerbate the problem it is trying to mitigate." One of the biggest problems for the ACA has been that the risk pools in the individual market — in other words, the demographics of the people signing up through Obamacare's exchanges — are tilted toward older, sicker people. This has led to large losses for some insurance companies, because the pool is more expensive to cover than was expected.

Continuous coverage provision of AHCA could be roadblock for bill - Business Insider

You simply need a mandate for people to insure themselves, but that is of course against rightwing notions of perfect markets that can solve every problem and notions of "freedom." 

But freedom of what, exactly? The freedom to impose cost on society when one gets ill, as people will still go to emergency rooms when in serious problems, then many will bankrupt themselves (medical debt is the biggest source of personal bankruptcies in the US) and the tax payer picks up the bill.