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Sabotaging the ACA
Shutting down the government, threatening a public default, not signing up for Medicaid expansion, going to the Supreme court on dubious grounds, all kinds of scare tactics etc. etc. but there are also more subtle ways to sabotage ACA..

These Documents Show What an Attempt to Sabotage Obamacare Looks Like

BY JONATHAN COHN @citizencohn September 3, 2013


Republicans may have found a new way to undermine Obamacare: By harassing the organizations that are supposed to help people get health insurance.

Last week, Republicans on the House Energy and Commerce Committee sent letters to at least some of the 105 organizations that, earlier this month, received federal grants to serve as “navigators” for Obamacare. Navigators are supposed to help educate people about their insurance options under the new law—by, for example, explaining who is eligible to buy insurance in the new exchanges, or how to use the online marketplaces once they are operating. In some cases, they will actually help people enroll in the new insurance plans. The model for the Navigator program is the State Health Insurance Assistance Program, or SHIP, which has operated successfully for more than 20 years as part of the Medicare program.

The organizations that got federal navigator grants are a mix of non-profit groups and government agencies—everybody from the Missouri Alliance of Area Agencies on Aging to the Utah AIDS Foundation. Planned Parenthood chapters in Iowa, Montana, and New Hampshire are among those getting grants. But so are several religious organizations, including the Oak Hill Missionary Baptist Church Ministries in Mississippi. The organizations that got the five largest grants were all in states with high numbers of uninsured people—Texas, Florida, Georgia, Ohio, and Michigan. (The Centers for Medicare and Medicaid Services has a full list of the organizations, and Phil Galewitz of Kaiser Health News has more background on them, if you want more information.)

With the new insurance marketplaces set to open in exactly four weeks, these organizations are scrambling to get ready in time. But now, thanks to the House Republicans, they’re also scrambling to answer a committee request for information. “In order to better understand the work you will perform,” the letter states, the Committee is asking the organizations to schedule a briefing “to occur no later than September 13”—and to answer six lengthy questions about their operations.

There’s absolutely nothing wrong with a congressional committee performing its oversight role, particularly when it comes to a law as complex as the Affordable Care Act. And the navigators deserve at least some scrutiny. Do they have all the training and information necessary to give people the right advice? Can they be trusted with personal information? Even a few of the law's defenders—most conspicuously, California Insurance Commissioner Dave Jones—are asking those questions. House Republicans have a right to ask them too.

But the committee questions cover much more than training and security. And complying with the request will be no small thing for these organizations to do. Here’s the sixth item, just to give you a sense of how much information the committee is seeking:

Provide all documentation and communications to related to your Navigator grant. This would include, but is not limited to, materials your organization submitted in order to obtain the grant, materials provided to your organization upon obtaining the grant, and communications between your organization and representatives from HHS, CMS, CCIIO [the Center for Consumer Information and Insurance Oversight] or any other federal or state entity. This request also includes, but is not limited to, any documents provided by (or communications with), representatives from HHS, CMS, CCIIO, Enroll America, or any other entity including federal or state governments discussing individuals to target or solicit for enrollment under the PPACA including discussions or documents related to geographic area.

The letter and five-page guide for responding to committee requests are below if you want to see them for yourself. To people like Timothy Jost, the law professor at Washington and Lee and longtime proponent of reform, such a broad and detailed inquiry reeks of bad faith. Via e-mail, he told me:

Quote:Look at item 6 and the accompanying sheet defining documents subject to the request. This could include hundreds of documents and emails and could take days to locate and compile. It might have been reasonable to ask them to describe what they do and how they intend to do it. This is a much more intrusive and extensive request. It is also important to note that most of these organizations are doing this on a comparative shoestring, and this is the busiest time in their existence. They just got their grants, they are concluding cooperative agreements with HHS, they are hiring, training their employees, getting them certified, setting up security systems, making contacts, and even to have to take a day off to respond to this is too much. And the committee knows this. This is not about gathering information. It is about trying to stop a program.

Norm Ornstein, the political scientist at the American Enterprise Institute, had a similar reaction when he saw the request:

Quote:Requests for documents is not unprecedented; the Oversight and Investigations Subcommittee of Energy and Commerce did it all the time under Democrats. But this is qualitatively different. The scope and the timing simply smell. Oversight would commonly mean that after a program has been implemented you look to see if it was done well and if there was fraud or malfeasance or misfeasance. This is intimidation and another effort at sabotage.

Committee spokepersons didn't respond to media requests over the weekend. If they do, I'll update this item. But keep in mind that the navigators' primary job is to boost enrollment in Obamacare, a goal Republicans and their allies have made clear they don't share. On the contrary, Republicans and conservatives have actually tried to stymie or at least limit enrollment—by warning professional sports leagues not to promote the new insurance options, for example, and encouraging young people not to sign up. (Sandhya Somashekhar documented some of the latest efforts, at the state level, in the Washington Post last week.) And while sometimes these efforts are subtle, sometimes they aren't. During a recent, Ralph Hudgens, the state insurance commissioner of Georgia, told his fellow Republicans how he and his counterparts in Georgia's state government were treating Obamacare. "Let me tell what we’re doing,” Hudgens said. “Everything in our power to be an obstructionist.”

Is it possible House Republicans are simply performing due diligence, in order to make sure people who need Obamacare's help can get it? Sure. But it doesn't seem very likely.

Jonathan Cohn is a senior editor of the New Republic. Follow him on twitter @CitizenCohn

Quote:The Supreme Court’s 2012 decision to allow states to opt out of Medicaid expansion, and the decision by roughly three dozen states not to establish their own exchanges, have created cross-border disparities in coverage. Technical troubles with the federal website have depressed signups in many states that rely on it. The political climate in some states also has helped determine whether people enroll.

Missouri and Texas, where opposition to the law is strong, are among states that have enacted tough restrictions on who can serve as “navigators,” or “certified assistance counselors” to guide consumers through the enrollment process. That has frustrated Mona Walls, who runs a small team of enrollment counselors in rural southeastern Missouri.
Deadline Near, Health Signups Show Disparity NYT
How good your healthcare is seems to depend to a considerable degree on where you live, which depends in part on politics, not only the Medicaid expansion (or lack of it), but difference in acceptance or hostility plays a considerable role:

Quote:Indeed, a review of state-by-state enrollment data and other research, as well as interviews with patients, advocates, health policy analysts, elected officials, supporters and critics of the Affordable Care Act, suggest that, for consumers at least, the state of health care under the national law depends almost entirely on where a person lives...

Enrollment in private plans, as opposed to Medicaid, varies drastically across state lines. An analysis published this week by health economists at the University of Pennsylvania found that Vermont — a state that has long been hospitable to universal health care — is far and away the leader; 54 percent of Vermonters eligible to sign up for private insurance (a figure that includes those already covered by non-employer plans) have done so. But in South Dakota, the study found, just 6 percent of those eligible have enrolled.

The reasons for such disparities are complex, having to do with a state’s political climate, whether it administers its own website, how well that website is working, and how aggressive its nonprofit networks have been in reaching out to prospective enrollees. States with their own exchanges, set up within existing state agencies, tend to fare best.
Deadline Near, Health Signups Show Disparity NYT
Quote:While conservatives lost on the mandate issue in NFIB, they did score a ruling against Medicaid expansion. The law chugs along on years later, but millions of Americans do not have health insurance so Republican governors can brag that they’re standing up to Tyrant Obama’s evil government overreach. The more recent assaults merely undermine how the law is supposed to work. This is to the detriment of consumers and the insurers trying to cover them, to be sure, but it also creates market instability that Republicans can then use to rail against the Affordable Care Act. “It is kind of guerrilla warfare against the statute that is really having some effect and lends credence to the argument that the opponents are always making that the statute isn’t working,” Timothy Jost, a health law specialist at the Washington and Lee University School of Law, told TPM.
Republicans Are Breaking Obamacare So They Can Declare It Broken
No guesses why ACA improvements can't be implemented..

Quote:Zack Cooper, an assistant professor of health policy and of economics at Yale University, said the markets are not stable now, but they should be in 10 years. “New markets take a while to get right, and these markets are different from the past,” said Cooper. Obamacare was enacted in March 2010 and is still not fully implemented. Its growth has been hampered in part by partisan gridlock that has further undermined the exchanges. “They haven’t changed the law since it was passed, and it was passed in a very convoluted, rushed state,” said Gerard Anderson, a professor of health policy and management at Johns Hopkins Bloomberg School of Public Health. “Normally, what you would have had was a whole series of technical changes over the last six years to make the law better, but they haven’t been able to do it.”
Obamacare 'on the cusp of falling apart' as insurers flee health exchanges | Money | The Guardian
Here is a measure of the success of sabotage efforts:

Quote:A recent poll found that approximately one-third of Americans believe that Obamacare and the Affordable Care Act are different laws. They are mistaken; it is the same law.
Obamacare and the Affordable Care Act are the same thing
Here is one way the Republicans sabotaged the ACA:

Quote:An Oregon-based insurer scored a $214 million court victory this week in a case brought after congressional Republicans in 2014 hobbled the federal government's ability to fund an Affordable Care Act program.
The program, known as risk corridors payments, sought to blunt some of the risk insurers were taking on in the first three years of Obamacare's implementation.

The program shifted money from insurers that over-performed on expectations to those that underperformed. However, GOP lawmakers inserted an amendment in must-pass legislation barring the government from drawing funding for the program from elsewhere in the Department of Health and Human Services to make up any shortfalls between the money collected from insurers and the money owed. (Florida's GOP Sen. Marco Rubio, pictured above, led the charge against the risk corridors program.). As a result, insurers, on average, have received around 12 percent of the payments they have been owed.
Insurer Scores A $200M Court Win After GOP Move To Block O'Care Payments

And here is another, more recent one:

Quote:In the meantime, it appears that the Trump administration has done all it can to undercut the existing structure of the law. Data from the Centers for Medicare and Medicaid Services on Friday showed that enrollment for the federal exchanges through declined by 400,000 from the year before.

The drop came after a sharp fall-off in enrollment following Trump's inauguration as the administration significantly decreased the amount of advertising and promotion of the exchanges. Prior to Trump's inauguration, 800,000 Americans were enrolling per week, but that dropped to 200,000 per week post-inauguration.
Republican Obamacare repeal and replacement becomes repair - Business Insider
If not repeal, then sabotage..

Quote:Perhaps the two most striking changes are cutting in half the exchanges' 2018 open enrollment period and lowering minimum standards for care to qualify for the exchanges. The new rules propose having an open enrollment period, during which people without health insurance through their employer of Medicaid/Medicare can sign up for coverage, from November 1, 2017 to December 15, 2017. Previously,  open enrollment periods have run a total of three months from November 1 to January 31 of the next year. Additionally, the rules would lower the "de minimis range used for determining the level of coverage." Essentially, the ACA established minimum standards for coverage (here's a full breakdown from CMS) in order to be certified on the bronze, silver, and gold plan levels. The new rule would allow insurers to cover slightly fewer areas of health and still be counted at a certain medal level.
Trump HHS proposes Obamacare changes - Business Insider

Quote:The proposed rule (which I don’t see accompanied with the identification of two other rules that could be repealed, as per a Trump executive order) would cut in half the annual open enrollment period for exchanges, moving the deadline from January 31 to December 15. It would force higher verification standards on anyone who tries to elect coverage outside the open-enrollment period because of a significant life event (like unemployment, for example, or a marriage or the birth of a child). Insurance companies would be able to apply premium payments to a prior debt incurred by the same individual, allegedly to prevent gaming from customers who only pay sporadically but take advantage of guaranteed issue to get coverage when they need it.  This is the equivalent of putting an insurance-company storefront on the eighth floor with no elevator, so people too infirm to make it up the stairs cannot apply.
Behind the Scenes, Obamacare May Be in Grave Danger | The Nation
Quote:President Donald Trump told conservative groups that if the GOP leadership's American Health Care Act did not pass, he would allow Obamacare to collapse and blame its failure on Democrats.

Trump revealed his strategy during a meeting with the conservative groups FreedomWorks, Club for Growth, Heritage Action, Americans for Prosperity, and the Tea Party Patriots at the White House on Wednesday. His comments were first reported by CNN's Jim Acosta and were confirmed to Business Insider by a source with knowledge of the meeting.
Trump's Obamacare repeal backup plan blame Democrats for collapse - Business Insider

This is pretty stunning:
  • Yes, you heard that right, the President of the United States is willing to let more than 20 million people loose healthcare, and quite a number of these their health and even their life as a consequence, just to score political points. How about that for "keeping Americans safe"
  • Obamacare won't collapse on itself unless policy helps it collapsing, for instance by generating so much uncertainty about future policy that insurers withdraw from the exchanges. There are other ways policy can nudge this outcome closer, see earlier entries in this thread.
  • And this to appease the ideologues who want a "free market" solution for healthcare (that doesn't exist) and are against any entitlement: 
Quote:David McIntosh of the Club for Growth said the president "listened" to the groups' concerns. "The president wants to get something done, and he urged us to stay supportive," a statement from McIntosh said. "We laid out our major concerns about the lack of free-market reforms in this bill, the continuation of the Medicaid expansion, and the refundable tax credits."
Trump's Obamacare repeal backup plan blame Democrats for collapse - Business Insider

These ideologues have no problem with 20-30 million people losing their healthcare insurance simply because the solutions don't fit their fixed ideological schemes (market failures do not exist, entitlements are bad, government is always the problem, etc.).
Quote:Mr Obama's healthcare reform may remain in place, but its future is still murky. Although Congress has failed in its attempt to dismantle the law, the Trump administration can still do a great deal to undermine it through executive action - in fact, it already has. The mandate that all Americans purchase health insurance isn't being enforced. Efforts to encourage enrolment through the healthcare marketplaces are being curtailed. More states will be given leeway to alter and adjust how they implement their components of the law. All of this could significantly affect how Obamacare looks and operates across the US. Mr Trump has repeatedly said that it was the wiser political move for Republicans to let the Obamacare systems collapse on their own and then blame the resulting chaos on the Democrats. While the political wisdom of this strategy is uncertain, the fact remains that Mr Trump and his administration could go a long way toward causing the works to "implode and then explode", in the president's words.
How disastrous for Trump is healthcare collapse? - BBC News

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