The Senate version of AHCA – What to watch for

Senate Republicans are set to release their revised American Health Care Act today – here’s what we know about their version, and what to watch for.

An excellent summary is here.

Medicaid – the biggest, most significant, and most important changes are to Medicaid.

74 million Americans are covered by Medicaid, and about 2/3rds of Medicaid funds go to elderly and disabled Americans.  Reportedly the Senate bill will:

  • eliminate Medicaid expansion funds over several years, and
  • significantly reduce future federal funding for Medicaid

As a result, more than 14 million low-income, disabled, and elderly Americans will lose coverage for nursing home care, rehabilitation, and all other healthcare services.

Individual and employer mandate

The mandate would be effectively repealed by eliminating enforcement. Today individuals and employers with more than 50 FTEs have to provide coverage or pay a penalty. Note – there has never been a requirement that employers with fewer than 50 workers provide insurance.

Insurance subsidies for lower-income Americans

The Senate version reportedly has preserved some of the current income-based subsidy provisions, unlike the House bill.

Pre-existing condition coverage

Cloudy would best describe what we know about the Senate bill’s approach to ensuring people with pre-existing conditions are covered. There just aren’t enough details, however even if pre-ex conditions must be covered, it appears insurers will be able to charge much higher premiums for those with pre-ex conditions, and/or exclude treatment for those conditions from their insurance policies.

Benefits

There are mandatory benefits in ACA; these would be eliminated in the Senate version, so your insurance plan might not cover mental/behavioral health and addiction coverage, and/or coverage for different types of care such as physical therapy or hospital services. While this provision would likely reduce premiums, it reduces coverage as well.

Tax changes and the federal deficit

All ACA-related tax increases are repealed with the exception of the Cadillac tax on high-value insurance plan, a change that will substantially increase the federal deficit.

Unforeseen implications – job loss

There’s been far too little coverage of one of the most important impacts of AHCA – the loss of close to a million jobs if this is signed into law. While employment would increase over the very-near term, over the next few years it will drop as fewer people have insurance and thus can’t get care.

What does this mean for you?

Millions of Americans will lose their health insurance, smaller hospitals will close, and cost shifting will explode as providers try to stay in business.

I don’t see the bill – in it’s current form – passing. But we are close to ACA’s death than we were a few weeks ago.

Why are Senate Republicans hiding their health care bill?

OK, let’s set aside the partisanship to objectively consider that question.

Senate Republicans are writing a bill in secret that would:

  • change one-sixth of our economy,
  • cause at least 20 million Americans to lose health insurance,
  • eliminate thousands of jobs in healthcare, and 
  • significantly change the insurance many of the rest of us have.

Many Republican Senators have yet to see the bill. HHS Secretary Tom Price has not seen the bill. The President has not seen the bill. The Wall Street Journal is upset with the process. The Conservative Review reports Orrin Hatch (UT), the second-highest ranking Republican Senator hasn’t seen the bill.

Senate Majority Leader McConnell has crafted a process to repeal-and-replace ACA that:

  • eliminates Senate requirements for debate,
  • doesn’t allow members of his own party or any Senate committee to review the bill before it hits the floor, and
  • avoids an accurate assessment by the Congressional Budget Office.

When ACA was passed back in 2009, there was:

  • 25 days of open public debate on the floor of the Senate
  • 13 days of open committee hearings
  • consideration of hundreds of amendments
  • months of meetings of the Gang of Six – three Republican and three Democratic Senators

Then-Minority Leader McConnell had this to say about ACA’s passage in 2009:

“This massive piece of legislation that seeks to restructure one-sixth of our economy is being written behind closed doors, without input from anyone, in an effort to jam it past not only the Senate but the American people…”

What does this mean for you?

Are you OK with this?

AHCA and the circular firing squad

Senate Republicans are not going to pass the AHCA.

Here’s why.

credit NYTimes

23 million Americans would lose their healthcare over the next decade.

14 million of those lose their coverage next year – an election year.

Anyone who’s been elected to the Senate is smart enough to know that taking benefits away from your core supporters is political suicide – and make no mistake, AHCA does precisely that.

Core Republican voters are those most hurt by AHCA; lower-income seniors would see their health insurance premiums explode, jumping almost ten times to $16,100.

But it’s not just about coverage – it’s about employment; healthcare systems, doctors offices, insurers and other businesses would shed 1.8 million jobs by 2022. These are well-paid positions, averaging well over $55,000.

That’s $99 billion in wages alone sucked out of the economy.

Here’s what I see happening.

Senate Republicans know they’re screwed if they pass AHCA as is. So, they may claim they’ve delivered on campaign promises to repeal-and-replace “Obamacare” by passing  some legislation – any legislation – that lets Republicans claim they tried to repeal “Obamacare”.

Then, when the House rejects their bill, the Republican Senate can blame it on House Republicans.

Doesn’t matter if you’re a Trump Republican or a Bernie backer, the cold hard political reality is there’s no way to lower premiums, cut budgets, and improve coverage. Anyone with any experience knew that, and knows that.

What does this mean for you?

The circular firing squad is forming.

 

What’s in the House version of AHCA?

Here’s the quick summary of the Republican bill. Lots of details here.

Net is the bill attempts to give states much more leeway in establishing and regulating health insurance policies and programs – sort of returning to the world we had pre-ACA.

While the bill was passed without a CBO evaluation/score, it is similar enough to the original bill. My guess is we could expect at least 15 million people will lose insurance coverage under this bill…but remember it’s not going to pass the Senate.

  • It replaces income-based subsidies (basing financial subsidies on a person’s income) with age-adjusted tax credits of fixed amounts.
    This means – wealthy and near-poor people of the same age get the same $ amount
  • Eliminates the individual and employer mandate
    This means – no requirement that people have health insurance.
  • Increases premiums for older people and reduces them for younger folks who get their insurance from small employers or in the individual market
    This means – more young people may sign up, more older folks will find insurance unaffordable
  • Ends funding for Medicaid expansion and caps future federal Medicaid payments
    This means – fewer low-income people will have coverage, states will have to come up with more money.
  • Penalizes individuals and families that don’t maintain continuous insurance coverage
  • Allows states to let insurers drop coverage for different types of medical care
    This means – consumers may not be able to get coverage for their condition or the type of care they need (e.g. drugs, behavioral health, maternity)
  • Eliminates taxes and tax increases from ACA
    This means – Medicare will run out of money in a couple of years instead of 10+

This is just what’s in the actual bill – which is already under fire by Senate Republicans; Portman, Heller, Graham, Scott, and Snowe have all voiced objections.

Instead of adopting or modifying the House Bill, expect an entirely new bill from the Senate. If the Senate bill is passed (which may – or may not – require 60 votes), then the House and Senate will have to figure out how to move forward and which bill is the vehicle.

 

 

ACA Deathwatch: No, AHCA is not going to pass Congress

AHCA is not going to become law.

IF it passes the House, there’s no way it gets enough votes in the Senate.  Two reasons.

  1. Senate Republicans are opposed to the bill.
  2. Enacting AHCA without massive changes would alienate core Trump voters.

Passing AHCA – without drastic changes – would be political suicide for politicians who voted for passage. And while pre-existing condition coverage is a big issue, the big issue is loss aversionmillions of Trump voters would lose coverage under AHCA.

The biggest winners – young, healthy people – don’t vote.

Oh, and AHCA keeps current ACA subsidies and protections for Congress and Congressional staff while chopping both for regular Americans

This from Nate Silver:

Republicans whose families make less than $30,000 a year were nearly three times more likely than those in families making at least $75,000 to say it was the government’s responsibility ensure Americans had health care coverage.

And from Jonathan Cohn – voters who stand to lose the most in insurance subsidies under AHCA are – by a wide margin – Trump voters…

Subsidy amounts lost by voters in 2016 election

AHCA drastically cuts assistance to older, lower-income Americans in rural areas, a demographic that overwhelmingly supported Trump. And, most of these voters earn too much to qualify for Medicaid, so they’ll be left:

  • with far lower subsidies
  • without coverage for pre-existing conditions
  • facing insurance premiums that are much higher than today’s because AHCA allows insurers to charge older folks much higher premiums.

Some may cynically hope AHCA passes as it will doom the GOP in the 2018 elections. But the cost of that political calculation is far too high; the millions will lose coverage are those most in need of healthcare coverage.

Of course, Congress won’t suffer – they keep subsidies, pre-ex coverage, and all the other goodies.

Congressional Republicans win; ACA repeal is NOT going to happen.

It’s official – Republicans’ efforts to repeal and replace ACA are done.

Finished.

Over.

And boy are they relieved!

I don’t know why anyone is surprised by this.  Only in the world of fantasy that exists inside the Washington Beltway would one think that changing legislation to appease far-right Freedom Caucus types wouldn’t cost votes from somewhat-more-moderate Republicans.

The latest defection is a big one – Fred Upton of Michigan said “I cannot support the bill with this provision (eliminating protection for individuals and small groups with pre-ex medical conditions) in it…”

What’s truly bizarre is this happened about the same time that Speaker Ryan was telling reporters “There are a few layers of protections for pre-existing conditions in this bill,”

Leaving aside the fact that the Speaker is wrong, think about the political implications for Republicans if they passed this legislation.  Their core voters in many states would find health insurance unaffordable, if available at all.

This isn’t liberal blather, it’s reality.  The best thing that can happen to Congressional Republicans is this bill isn’t going to pass.

And that’s before one contemplates the fate of the proposed bill in the Senate; if the House passes the AHCA repeal bill, their members will be hanging way out on a political limb as there’s no way the bill would ever get thru the Senate.

What does this mean for you?

Ignore the pundits.  AHCA is deader than this guy…

ACA Deathwatch – A Zero-Sum game

The ACA repeal movement may have gained a bit of momentum this week…The quick take – odds are this momentum will peter out as changes wanted by some Republicans are anathema to others.

My take is the hands on the Deathwatch Clock just moved back – not forward.

Here’s what’s going on.

The White House continues to push for a vote in the House by the end of this week, apparently to give President Trump a “win” in his first 100 days.

Hard-right Freedom Caucus Republicans have apparently agreed to a rough outline of a repeal plan. (details below)

Somewhat-more-moderate Republicans have publicly weighed in on the outline, and there’s a good bit of concern over coverage for pre-ex conditions and other provisions.

While the challenge faced by the Republicans is pretty straightforward, the solution is anything but. Put simply, changes that get support from the hard-right reduce support from more-moderate Republicans; It’s a zero sum game.

And that’s before it gets to the Senate, where it will die because Senate Republicans are loathe to pass anything remotely resembling AHCA.

Details on the latest legislation

Healthcare is brutally complicated, a reality that’s becoming increasingly apparent to GOP negotiators. To get to some sort of agreement between hard-rights and more-moderates, the latest repeal legislation includes:

  • waivers that allow states to set insurance premiums for older people 5 times higher than younger folks
  • ability for states to let insurance companies eliminate or limit coverage for different types of medical care – drugs, therapy, behavioral health, nursing home care, etc.
  • ability for insurance companies to “medically underwrite” individual and small group insurance again – in English, let insurers decide whether to cover you, and how much to charge, based on your medical history and risk factors.  To do this, states will have to provide high-risk insurance pools to help offset losses (this is a really complicated solution that hasn’t ever worked)

I won’t bore you with the nitty-gritty details, you can read them here.

What’s becoming increasingly apparent to Republicans in DC is they have a Hobson’s choice.

There is no way they can deliver on their campaign promise to repeal ACA and replace it with anything that won’t piss off a lot of their supporters.

But if they don’t repeal ACA, that will really piss off a lot of their supporters.

Add a President who doesn’t care what legislation does or doesn’t do, but cares a lot about “winning”, and we now understand why they are in the mess they are.

What does this mean for you?

The GOP has yet to transition from opposition to governing party.

Republicans channelling Monty Python

Why the President and Congressional Republicans are still trying to do healthcare legislation is truly a puzzle. Unhappy with their initial effort to completely blow up the insurance markets (and their political future), they’ve re-engaged in a pointless effort that is destined to fail – and wound themselves in the process.

Pointless because every concession to win votes from the Freedom Caucus guys costs votes from those slightly more moderate.  So, it’s a zero-sum game – win an arch-conservative’s support, lose a less-conservative vote.

perhaps they’re thinking the initial AHCA no-vote debacle wasn’t much of a concern…

To be fair, in the disastrous AHCA non-vote they ONLY lost one of their arms.  This time they’re looking to lose more appendages.  This is one of those “if you don’t laugh you’ll cry” moments, because ACA does need significant improvement, but – at least for now – improvements are being ignored as politics prevail.


There are a lot of reasons this is political suicide…

The President and Republican candidates committed to keeping coverage for pre-existing conditions.  The plan being discussed today would gut this entirely, leaving over a quarter of us without coverage for pre-ex.  Ignore claims to the contrary; the combination of changes to what’s covered (essential health benefits) and removal of restrictions on premiums would mean anyone in the individual or small group markets would be subject to medical underwriting (absent state regulations to the contrary).

A close friend and lifelong Republican (including experience working on Capitol Hill) emailed me this morning about this latest “reform the reform” effort using language that would peel the paint off a battleship.

Most Americans now believe the GOP “owns” health reform.  A just-published Gallup poll finds 61% of respondents said “any problems with the law moving forward are the responsibility of Trump and Republicans in Congress…”

Interestingly, ACA is now polling higher than ever, at 55% approval. That’s up 13 points since the election…

I think the Freedom Caucus guys understand their ideological purity means millions of Americans will lose insurance coverage – and thus healthcare. 

And when they do, every mother, father, aunt, uncle, and grandparent will be incensed beyond measure that their wife/husband/child/grandchild won’t get the care they need.

How that is a winning proposition escapes me, but good for the Freedom Caucus for standing up for what they believe in.

Of course, you need to have legs if you want to stand.

 

UPDATE – looks like the Freedom guys and their Republican opponents can’t agree on what the White House said the new bill would include.  Either that or the WH folks told the two parties different things.

AHCA has failed – what’s the next step?

AHCA has failed, and with it the Republicans’ efforts to repeal ACA.

Despite President Trump’s threats, cajolery, and bribing the Freedom Caucus, the attempt to repeal ACA is, for now and probably for the long term, dead.

(Please allow me this opportunity to point out that I predicted three months ago that ACA would NOT be repealed)…OK, chest pounding interlude is over…

What does the future hold?  While we all wish Congress would adopt sensible solutions to fix ACA, that’s highly unlikely. Steps such as

  • increasing the penalty for not carrying insurance to levels originally recommended by the Heritage Foundation,
  • fully funding the risk corridors and co-op support measures
  • fixing the “family glitch”
  • require insurers to operate in broad areas so they don’t cherry-pick only the most profitable locations, and
  • requiring full transparency from all medical providers

would help a lot, and that’s not even adding a Medicare-for-all option. As I noted in a previous post, Democrats helped fix G W Bush and the GOP’s Medicare Part D plan when it was cratering.

Unfortunately, it’s more likely the administration will do everything it can to hamstring ACA – refuse to enforce the mandate, end premium support, defund the federal Exchanges, you name it.  In the process, they’ll likely blame the prior president, or Democrats, or whatever. And in so doing, they will hurt businesses, taxpayers, individuals, patients.

What’s most likely is a concerted and persistent effort to defund Medicaid.  This will be described as allowing states more flexibility, as refusing to use federal funds for abortions, as reducing the federal deficit, but make no mistake, the real priority is to shrink funding for the poor, elderly, kids, and disabled.

Lest you think that’s harsh, recall that those are precisely the people Medicaid helps.  It remains to be seen if Republicans will be successful, or if they will come together and heal the fractures so visible within the party.  If they do, they will likely find Democrats willing to work with them, perhaps using the Cassidy Collins bill as a starting point.

There’s been a lot of energy focused on blocking or passing AHCA.  Let’s take a few days to let the smoke clear, and then try to get Congress to work together to fix ACA.

Because it isn’t going to be repealed.

ACA Deathwatch: Damned if they do…or don’t

GOP Representatives are being strong-armed by President Trump and wooed by House leadership, and nowhere is the stress more intense then where I live – upstate New York.

While Trump blusters and leadership cajoles, wheedles, and bribes, Katko, Tenney, Faso et al (upstate GOP Congresspeople) are facing furious constituencies livid at the possibility that they and their neighbors will lose coverage – and that their state is being held hostage.

photo credit WSKG News

New York is the only state that requires counties to pay a chunk of Medicaid expense – 13% to be precise.  In my home county, Onondaga, that amounts to just over $100 million, and costs the average  homeowner about $600 annually in property taxes. In an effort to bribe/force upstate’s Republican Representatives to support AHCA, the bill was modified to specifically force New York to eliminate counties’ financial requirement and shift it to the state.

In Onondaga, 80,000 people, one out of six residents, is covered by Medicaid.  There are 26,000 healthcare jobs in the county paying $58,000 each.  If the AHCA passes and Medicaid expansion funding disappears, we’re going to lose over a thousand jobs – and $60 million in wages. Sure property taxes will go down, but state taxes will have to increase.

Syracuse – the biggest part of the county – has the highest minority poverty rate in the nation, and the lowest economic opportunity of any municipality as well.  Other upstate communities are better off – but not much.

If AHCA passes, an already desperate economic and health situation will get immeasurably worse.  That’s why Katko won’t hold town halls and is avoiding any and all public appearances; he knows that a NO vote on AHCA will cause a tweetstorm while a YES vote will likely cost him his seat.

That’s the dilemma facing all House Republicans, even those in “safe” seats. While Freedom Caucus members don’t know it yet, passing AHCA would cost many their seats. Voters HATE losing things they already have, and now that they have health coverage, and were promised the replacement will be better/cheaper/with lower deductibles and more access, when that proves to be false they are going to be really pissed off.

Medicaid cuts will result in their parents losing coverage for nursing home stays, neighbors’ disabled kids losing medical care, friends losing jobs in healthcare, and hospitals in rural America closing.

Fortunately, it’s extremely unlikely AHCA will pass, as several Republican Senators are strongly opposed to AHCA and will not be intimidated by Trump tweets.

What does this mean?

Elections have consequences – and so do votes.

If upstate Republicans vote to overturn ACA and the bill doesn’t pass the Senate, they are going to pay a very heavy price from voters on both ends of the political spectrum.