The effects of a repeal of ACA

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And then to think that Paul Ryan was deemed a RINO in many quarters..

Weekday evening programming on the largest cable and broadcast news outlets almost completely ignored a long-standing Medicare privatization scheme favored by Speaker of the House Paul Ryan (R-WI) in the days since he first resurrected the idea of radically reshaping the American health care system toward for-profit interests.

During a November 10 interview with Fox News host Bret Baier, Ryan misleadingly claimed that due to mounting “fiscal pressures” created by the Affordable Care Act, the Republican-led Congress would be forced to engage with what Baier called “entitlement reform” sometime next year.

Ryan falsely claimed that “because of Obamacare, Medicare is going broke” and that the popular health insurance system for American seniors will have to be changed as part of any legislation to “repeal and replace” President Obama’s health care reform legacy.

Evening News Virtually Ignores Paul Ryan’s Medicare Privatization Plan

The truth is, of course, that Medicare cost increases actually declined markedly and that Obamacare has at least something to do with that:

What’s not widely known is that the cost-saving measures included in the Affordable Care Act, a.k.a. Obamacare, have been remarkably successful in their efforts to “bend the curve” — to rein in the long-term rise in Medicare expenses. In fact, since 2010 Medicare outlays per beneficiary have risen only 1.4 percent a year, less than the inflation rate. This success is one main reason long-term budget projections have dramatically improved.

So why try to destroy this successful program, which is in important respects doing better than ever? The main answer, from the point of view of people like Mr. Ryan, is probably that Medicare is in the cross hairs precisely because of its success: It would be very helpful for opponents of government to do away with a program that clearly demonstrates the power of government to improve people’s lives.

And there’s an additional benefit to the right from Medicare privatization: It would create a lot of opportunities for private profits, earned by diverting dollars that could have been used to provide health care.

The Medicare Killers - The New York Times

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Turkey's voting for Christmas..

As Greg Sargent points out, the choice of Tom Price for HHS probably means the death of Obamacare. Never mind the supposed replacement; it will be a bust. So here’s the question: how many people just shot themselves in the face?

My first pass answer is, between 3.5 and 4 million. But someone who’s better at trawling through Census data can no doubt do better.
Here’s my calculation: we start with the Census-measured decline in uninsurance among non-Hispanic whites, which was 6 million between 2013 and 2015. Essentially all of those gains will be lost if Price gets his way.

How many of those white insurance-losers voted for Trump? Whites in general gave him 57 percent of their votes. Whites without a college degree — much more likely to have been uninsured pre-Obama — gave him 66 percent. Apportioning the insurance-losers using these numbers gives us 3.42 million if we use the overall vote share, or 3.96 million if we use the non-college vote share.

There are various ways this calculation could be off, in either direction. Also, maybe we should add a million Latinos who, if we believe the exit polls, also voted to lose coverage. But it’s likely to be in the ballpark. And it’s pretty awesome.

How Many People Just Voted Themselves Out of Health Care?

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One way or another repeal and replace is going to messy, with numerous victims. And we're polite, here.

Laszewski doesn’t hide his point of view: He’s no fan of the Affordable Care Act. But he sees the Republicans’ new Obamacare strategy — to repeal the law, but leave it in place for three years as they work to create a replacement plan — as an absolutely terrible way to fix it. “The problem is when you have an insurance market, and the new administration declares it DOA, it will go into death throes,” Laszewski says.

Laszewski argues that the one way to stabilize the insurance market — to ensure that health insurers don’t flee — is for the federal government to guarantee to cover their losses. But the politics of that aren’t easy: This would mean reestablishing an Obamacare program that Republicans have previously branded “a bailout for insurance companies.”

“Republicans are being awfully naive”: an expert explains why Obamacare repeal and delay won’t work - Vox

And then there is the new health secretary..

Another key aspect of Obamacare — one Trump has said he would consider keeping — that prevents insurers from denying coverage based on a preexisting condition, would change. Under Price's proposal, people would be able to continue coverage if they shifted from the employer market to the individual market, but only if they have no interruptions in coverage.

Thus, a break in care would allow insurers to deny coverage to people with an illness. For those who do not maintain that care, Price's plan would institute state-level high-risk pools to help cover them. The Price plan would provide $1 billion in federal funding to help control costs for these pools. The Commonwealth Fund, however, a nonpartisan health-policy think thank, estimates that these pools would require well over $170 billion a year in federal funding to cover those who today have ACA-based plans.

Additionally, such high-risk pools typically have premium costs double those of normal individual-market plans. The expansion of Medicaid under Obamacare would also be rolled back under Price's plan, shifting roughly 15 million people from the government-sponsored insurance to the individual marketplace. The expansion provided coverage for those making roughly $16,490 and below annually. Questions loom over, even with a subsidy, how affordable it will be for those people to obtain plans on the individual market.

Tom Price, Donald Trump HHS secretary, wants Obamacare gone - Business Insider

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And some more

How will they protect against insurance discrimination? The signs here are already not good. Trump has spoken as if the only problem of insurance discrimination before the ACA was the fact that insurers wouldn't cover pre-existing illnesses. But a much larger problem is that insurers could simply deny any coverage altogether to the sick, or charge them outrageous prices. If you had previously had breast cancer, for example, insurers would refuse to insure you for any illness; so even if you broke your leg, you would not have insurance. 

Republican alternatives propose to remove these measures and replace them with a flat tax credit amount which will not vary by income or health. Example: a 40-year-old person would get a set credit of $3,000 to buy insurance. But this type of tax credit makes health insurance unaffordable for the poor. If a person with a $10,000-a-year income faces a premium of $6,000, a flat $3,000 tax credit would mean that they must pay $3,000, or 30% of their income, out of pocket. In contrast, the ACA would have asked this person to pay very little, if anything, for their insurance, making it affordable.

Trump’s tricky Obamacare operation - NY Daily News

Take away "crappy insurance" and see what happens..

Some of the Republicans agitating to repeal Obamacare say they aren’t worried about taking health insurance away from more than 20 million people. Their theory: The program is wildly unpopular and even the people with coverage wouldn’t miss it, no matter what takes it place. “People have crappy insurance,” Rep. John Shimkus (R-Ill.) told Politico last week. “This fear that they’re going to lose something that they don’t think they have anyway is crazy.”
Anna Meyers would beg to differ.. 

In just the last year, both the Commonwealth Fund and the Henry J. Kaiser Foundation have conducted surveys of people getting coverage through the law. The surveys studied different, overlapping groups. Kaiser looked at people buying coverage on their own, breaking out those who got coverage through one of the law’s exchanges and those buying directly from insurers. Commonwealth looked specifically at people who got insurance through the exchanges, as well as people who had enrolled in Medicaid. The questions covered all the important issues, from premiums and deductibles to doctor choice. The results were remarkably consistent across the board. When asked to judge the plans overall, majorities rated their insurance as good, very good or excellent.

Republicans Who Think Nobody Would Miss Obamacare Should Ask People Who Depend On It | The Huffington Post

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Forget your insurance, back to emergency care, guys..

JUAN WILLIAMS (CO-HOST): What about these 20 million people who got coverage [through the Affordable Care Act]? What about the people who said I like keeping my kid on until 26? What about people with pre-existing conditions? Oh no, well you can't take care of them because we have no mandate. Which I know is a big objection of yours. And we don't have a plan. And so, even President-elect Trump once said, you can't just put these people out on the street.  ERIC BOLLING (CO-HOST): They're not on the street. You still have Medicare and Medicaid. So that's always going to be there. And you have emergency rooms which we had before. Until another plan is floated, that's acceptable.

Fox Host: Ripping Health Care Away From 20 Million Is "Acceptable" Because We "Have Emergency Rooms"

Senator John Cornyn, the Republican majority whip, said he expects a repeal to move forward in the first 100 days of the Trump administration, even if the Senate is "jammed up" with confirmations of appointments by the new president. But undoing President Barack Obama’s signature law is easier said than done. There are at least five major obstacles the GOP must overcome.

Sixty-nine percent of Americans support the pre-existing condition provision, including majorities of Republicans, Democrats and independents, according to a Kaiser Family Foundation poll released Thursday. Yet only 35 percent support the individual mandate to buy insurance or pay a tax penalty. That disconnect will be tough to reconcile. The mandate is seen by many health policy experts -- as well as the insurance industry -- as inextricable from the pre-existing conditions guarantee, as it increases participation of healthier people to defray the high costs of caring for sick customers.

The ACA cut $700 billion from Medicare reimbursements to providers, helping extend the solvency of the program from an initially projected date of 2016 to 2026, according to its trustees. Repealing the law and restoring those expenses could create an imminent solvency problem for Medicare, which many Senate Republicans say is a conversation they’re not ready to deal with.

GOP’s Delayed-Repeal Obamacare Strategy Faces Major Obstacles - Bloomberg Politics

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Ideology is going to drive the process, and many will be victims as a result. 

Early media coverage of the Republican health-care agenda has concentrated on plans to repeal and then replace the Affordable Care Act. The larger story is GOP preparations for a health policy trifecta: to fundamentally change the ACA, Medicaid and Medicare–all three of health care’s major programs–and in the process, fundamentally alter the direction of the federal role in health and core elements of the social contract.

The Bigger Story, and Agenda, Behind GOP Changes to Obamacare, Medicare and Medicaid - Washington Wire - WSJ

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"We estimate that the partial ACA repeal would increase the number of uninsured people by 29.8 million by 2019, raising the total number of uninsured to 58.7 million people — 21 percent of the non-elderly population — compared with 28.9 million people uninsured if the ACA remains in effect," said the report, which was authored by Linda Blumberg, Matthew Buettgens, and John Holahan.

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

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And the authors said the Republican repeal plan could hit certain groups of working-class families most. "The vast majority of those becoming uninsured would be members of working families (82 percent), and more than half (56 percent) would be non-Hispanic whites," the study said. "The vast majority of adults becoming uninsured would lack college degrees (80 percent)."

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

TThe nonpartisan Urban Institute released a study Tuesday explaining that repeal without an eventual replacement would result in such a destructive unraveling of the individual insurance market that the health-care system would end up far worse off than before Obamacare, with some 30 million people losing coverage, uninsured rates spiking and strapped state governments facing massive new uncompensated health-care liabilities..

The GOP could wreck the health-care system, and soon - The Washington Post

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If we are serious about reform, we need to move beyond the current obsession with coverage to a real debate about accountability, transparency, cost and quality. 

Unfortunately, there are worrisome signs that the incoming Trump administration is less committed to the idea of value-based care. It will be important to differentiate between the baby (payment reform) and the bathwater (onerous regulations and reporting requirements) if we're ever going to get to true value in health care.

Obamacare reform GOP health care—commentary

Experts across the political spectrum are warning that the individual health insurance market could be devastated by the uncertainty around the Affordable Care Act’s future. The individual market, which sells health plans to those who don’t have insurance through work or public programs, was highly regulated and subsidized by the ACA. Insurers that have remained in the market could well pull out in the face of tremendous uncertainty, causing the market to “very possibly” collapse in some parts of the country, centrist think tank the Brookings Institution said in a report last week.

What is the individual health insurance market and why is everyone so worried about it? - MarketWatch

In its place, she’d like to see a new law in which people pay for their insurance as a percentage of their income, so that everyone has some “skin in the game.” When I asked her if the Obamacare subsidies, which reimburse people making less than about $48,000 for a portion of their health-insurance premiums based on their income level, come close enough to this kind of system, she balked. “I do not like the Obamacare subsidies,” she said.

What Donald Trump Voters Want Instead of Obamacare - The Atlantic

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Getting cold feet..

The original "repeal and delay" plan that was floated in November would have delayed the repeal date until 2019, after the first mid-term election. Obviously this move would carry significant risks. Politically, Trump could lose his re-election bid, thus denying the GOP a chance at repeal.

From the market side, a long delay could cause insurers to pull out of the individual insurance market in anticipation of the move, destabilizing coverage for millions and causing prices in the market to soar.
Bloomberg also reported that Republicans are planning to present the current Obamacare law as failing on its own, thus making repeal more palatable despite the coverage increases.

Counter to this narrative, however, the Department of Health and Human Services reported last week that 6.4 million people have signed up for Obamacare exchange plans since open enrollment began on November 1— the quickest sign-up pace in the history of the exchanges..

Republicans possibly delay Obamacare repeal until after 2020 election - Business Insider