Archive for the ‘ACA’ category

Death Spiral

May 9, 2017

A “go to” line through out Donald Trump’s campaign was to characterize the Affordable Care Act as caught in a death spiral. (House speaker Paul Ryan likes that line too.) The inference was that insurance companies were losing money and would need to raise rates so much that individuals could not afford to purchase coverage. At some point candidate Trump predicted insurance companies would simply stop participating and there would be no insurance available in the exchanges. Hmmm.

As normal for the course, Trump and other Republicans failed to mention that the GOP had consistently opposed any further government aide for insurers, as envisioned in ACA. Now, the use of “death spiral” is serving as a handy crutch to divert attention from the GOP House debacle, the American Health Care Act.

Over the weekend, several GOP Congress members tried to put a positive spin on the House AHCA by pointing out that Obamacare was about to fail (Death Spiral) and AHCA would come to the rescue. When listeners complained about the AHCA’s weakened “pre-existing condition” coverage and huge Medicaid funding reduction, GOP speakers reminded listeners that most Americans would not be in jeopardy of AHCA.

These Congress members said that most Americans had employer provided healthcare (group plans with no denials for pre-existing conditions), Medicare, and Medicaid.
While this is a true statement, I wonder what these Republicans really meant?

  • Does the GOP think Americans shouldn’t worry about the other 20-50 million without healthcare coverage?
  • Does the GOP think Americans are naive enough to overlook the possibility that even if employed today, in a recession or just normal course of business, they might be furloughed and suddenly have no healthcare insurance?
  • And what exactly does the GOP think are “pre-existing conditions”?

Libertarian GOP members are intellectually the most honest GOP faction. Libertarians reject government welfare in all forms and providing at tax payers expense healthcare insurance just doesn’t cut it with real libertarians. Then again, Social Security, Medicare, and Medicaid don’t make the Libertarian cut either. Hmmm.

The GOP is moving into dangerous voter territory. While not of their making, the continued, rise in healthcare costs (greater than the rate of inflation) will not suddenly change if Republicans prevail and pass the watered down AHCA.

The US healthcare delivery system is seriously flawed. EpiPens did not increase 400% in price due to the Affordable Care Act. Mylin’s decision to raise prices was a pure exercise of capitalism in the healthcare market. And Mylin’s actions are not an isolated exception. Almost all drug companies are driving up prices to see what the market will bare. And why is it one can buy the same prescription drugs substantially cheaper in Canada than in the US?

As frustration continues to mount, sooner or later, Americans are going to ask, “do other countries have this same cost problem?” Most Republicans know this, yet many Republicans continue to march further out on a limb, probably blinded by the tax cut appeal associated with the repeal of ACA.

ACA has opened Americans eyes to how precarious their insurance coverage is and how the widening income distribution inequity combined with rising healthcare premiums are putting the American dream further out of reach.

Will the current fight over ACA be a death spiral or a rebirth of hope for universal healthcare?

Assessment After The House Vote

May 5, 2017

Yesterday the Republican controlled House of Representatives voted narrowly (217-213) to pass the American Health Care Plan which in their eyes is a “repeal and replace” healthcare option. Amazingly, the House rushed to vote with no “official” (CBO) estimate of the cost or impact.  Hmmm.

When the vote was announced, Republican leaders including Vice President Pence stood before photographers applauding each other. Was it a day of rejoicing or a day which will bring telling consequences?

The AHCA retains much of Obamacare but has reduced its benefits and scope. Senator Rand Paul has aptly called AHCA “Obama-lite”. What the AHCA is not light about is the individual mandate and the mix of revenue offsetting taxes designed to make the keep federal budget revenue neutral, they are gone. I wonder whether that is what the GOP leaders were cheering about?

There will be passionate speeches about what the House AHCA version does and does not do. And, until the bill actually goes into effect, no one can be 100% sure. What can be sure is that without the additional income generated by the individual mandate and the special taxes, is that the GOP replacement will (1) swell the deficit since the government must make the insurers whole in some way, (2) Republicans will be content to allow the marketplace to price some Americans out of the market bragging that these fellow Americans made patient centered choices, or (3) some combination of both.  The AHCA is less coverage for more money for fewer people.  Hmmm.

Do the math. Minimum wage is $7.50 per hour, 40 hours (if one is lucky to find work) per week is $300. Therefore in a year this low wage American is earning $15,600. According to published reports, individual purchased family insurance cost $1021 per month, or $12252 per year. Hmmm, $15,600 before food and shelter, and healthcare of $12,252 which must come off the top. Do you think there will be incentives to offer less insurance coverage in order to get the yearly individual market coverage decreased?

How can a major party sleep knowing that its proposal will treat Americans of limited financial means (which could include full time, minimum wage earners) destine for less basic healthcare than more wealthier Americans? Would anyone think that we should ration basic sustenance for water or food based upon ability to pay?

The House vote marks a dark day for Republicans. All the masterful rhetoric the GOP will surely muster will not change the directional outcome. The American Health Care Act now heads to the Senate where it will meet another test.

Some GOP Senators think the House version is far too rich and would advocate an even stingier act. Others are more moderate and find the House version onerous. Regrettably most Republican Senators are likely to find the House bill as no obstacle to a good nights rest.

With a two seat Senate majority, the outcome is too close to call.

Will It Be This Week, What Republicans and Democrats Won’t Tell

May 3, 2017

Here it comes again. More hints (maybe even boasts) about the repeal of the Affordable Care Act and the replacement with the American Health Care Act. The spotlight remains on the House of Representatives where Republicans hold a firm majority so one might be excused not understanding what obstacles lies before an easy Republican victory. Here’s what a closer look reveals.

Republicans have campaigned against the “job killing”, “train wreck”, “big government” healthcare law known as Obamacare (the ACA). Being against things has become a Republican art form and while Republicans have advocated lustily for many things, they have not been for anything for which they would actually be responsible implementing and having to deal with the consequences. Times have changed.

The Affordable Care Act (Obamacare) is far from perfect legislation. In concept, Obamacare represents a noble step forward by sharing America’s wealth with those less fortunate, specifically providing health insurance to more Americans. (“Noble might be too literary a word since over two dozen other modern countries already provide all their residents healthcare at half the US per capita expenditure with better outcomes!!!). Never the less, Obamacare did represents a giant step forward for the US.

Healthcare is not free. So, Obamacare had to find ways to help Americans “buy” insurance coverage. A combination of mandatory enrollment (for those who game the system by not buying insurance when they are young and healthy), “exchanges” where Americans could buy basic insurance coverage even with pre-existing conditions, a complex system of subsidies the government could provide exchange members, and Medicaid expansion to catch the remainder.

So how would this program be paid for?

Democrats had to come up with a dog’s breakfast of taxes to cover the portion of insurance the new insurance holders could not afford. The individual mandate and these new taxes became the rallying cry for Republicans. Take away the taxes, the additional expense necessary to add coverage to 20+ million more Americans, the cost would flow straight to America’s credit card, the Federal Deficit.

Republicans stood tall, said they had a better plan, and said they would give Americans their freedom back. Hmmm.

Back to this week. Republicans have offered the American Health Care Act to replace Obamacare. Almost unbelievably, the Republicans have discovered that those previously without health insurance like Obamacare’s features (like pre-existing condition coverage, basic services coverage, children on parent’s policies until age 26, and for many, financial assistance to subsidize buying coverage). The American Health Care Act offers much less insurance protection while giving generous tax cuts to the wealthy (not the Americans needing coverage). Hmmm.

To make matters worse for Republicans, they recognize that if they offer the same benefits as Obamacare (and just rename it), there is still the problem of paying for the expanded coverage. Moderate Republicans and conservative budget hawk Republicans cannot agree upon cuts which would lower the AHCA cost nor can they agree upon how to fund an Obamacare look-alike. Hmmm.

Democrats have chosen to hold their fire until the House passes AHCA and fight it in the Senate. Most pundits do not see the current AHCA passing a Senate vote. Time will tell.

The bedrock issue that is not being discussed by either party is whether basic healthcare is a right or a privilege. (Apparently, this comparison does not poll well, republicans do not want to be associated with denying healthcare coverage to Americans. Republicans would prefer to say some Americans choose not to buy insurance or prefer to buy a stripped down policy, and that is their right. Hmmm.)

Astute GOP leaders must be thinking how they can minimize a loss on this issue. Republicans are simply on the wrong side of history. Too much of the modern world has already solved the healthcare problems, and it is unlikely Republicans will wish to boast, “Among third world countries, American offers the best healthcare coverage”.

The issues at hand are not Obamacare versus AHCA because Obamacare has some serious shortcomings and frankly does not insure all Americans. And, the AHCA covers less Americans with less coverage. That doesn’t make it either.

Democrats and Republicans appear content to remain silent on the real elephant in the room.

A Week Of Eye Opening

March 26, 2017

This past week has been an eye opener for what a new Republican Congress stands for. How about “for everything” and “for nothing”? Or, maybe “for effective government” and “for ineffective” government? Or, maybe “for sincere government” and “for insincere government”? Hmmm.

This first revelation was striking. Republicans had passed legislation to repeal Obamacare about 80 times during the past 6 years and had campaigned in 2016 for the complete repeal and replacement of Obamacare. Yet when the opportunity was there, Republicans had no replacement plan.

The GOP had many plans, all disingenuous, but there was no one plan Republicans could agree upon. Hint: do you realize GOP candidates lied about their intentions?

The most popular refrain the GOP used was lowering the premium costs which “Americans” are experiencing. To some degree, in some places, this claim seems justified but Republicans were happy to leave this claim unclear. Americans receiving healthcare coverage from their employer, Medicare, or Medicaid, received no staggering premium price increases. These Americans were shielded from the increases some individuals in certain areas experienced.

So why would Republicans make such a claim? Could it be that most all Americans experience some form of uncontrolled healthcare cost increases (as they did yearly before Obamacare) and don’t understand why hospitals, doctors, and drugs cost so much?

Few, if any of our politicians called out for a universal, single payer system to replace Obamacare. Shamefully, Republicans instead called for changes to Obamacare which were designed to reduce cost increases pressure by insuring less people! How do those politicians sleep at night?

But simply reducing coverage was not good enough for some Republicans. The “Freedom Caucus” members sought to change Medicaid from an entitlement for the most needy to a capped block grant which would become the sole responsibility of States in a few years.

The “Freedom Caucus” wants to deconstruct the Federal Government and healthcare seemed an opportune way to begin the process. “Freedom Caucus” members represent a clear and present danger to modernity.

Most Americans have little skin directly in the healthcare game. Next up on Congress’ docket is likely to be “tax reform” where almost all Americans have an opinion.

While there is much good that can be achieved (like eliminating or vastly reducing the number of tax loopholes, exemptions, and deductions), changes which will lower the overall tax revenue or the progressive nature of the tax code, are sinisterly designed to reward the wealthy and to starve the Federal Government and its ability to function.

With tax reform, even more than with healthcare, it will be critical to study what any proposed changes might accomplish before voting upon any bills. The devil will almost certainly be in the details.

This past week revealed a White House and a Congress whose intentions are hidden.   On one hand, the Republicans seem unfit to govern and on the other hand, seem not a friend to the average American.

I wonder whether this GOP leadership will have learned anything that might restore faith in their intentions? I really wonder whether the White House or the Freedom Caucus care?

Free Market Health Care

March 23, 2017

The Republican sponsored “American Health Care Act” is floundering in Congress. The replace portion (as in repeal and replace Obamacare) is in trouble for curious reasons given that Congress and the Presidency are both in Republican hands. The political farce which is unfolding casts a sharp light on the undeniable fact that there is no Republican Party united around a core set of principles. Rather today’s Republican Party is a party of convenience which unite around not being Democrat or progressive.

The shallowness of this union shows through in the Republican argument over repealing Obamacare and trying to agree upon a replacement. Maintaining “no pre-existing condition” or “no life time benefit limits” exclusions along with keeping children on parent’s policies until age 26 showed the world Republicans were caring and compassionate (or so they said).

But doing away with the individual mandate and dropping certain taxes has brought into focus the difficult task of how to pay for these benefits and keep the same number of Americans on the insured roles. The inescapable GOP conclusion is that insurance costs will not come down unless, Republicans say, the free market kicks in. If this mysterious free market does not bring down the cost of insurance, then individuals and Medicaid will see large increases in cost.

The most conservative Republicans, true believers in everyone should have access to the best healthcare they can afford, are now proposing to eliminate the 10 healthcare benefits mandated in Obamacare. Hmmm.

  1.  Outpatient care—the kind you get without being admitted to a hospital
  2. Trips to the emergency room
  3.  Treatment in the hospital for inpatient care
  4.  Care before and after your baby is born
  5.  Mental health and substance use disorder services: This includes behavioral health treatment, counseling, and psychotherapy
  6.  Your prescription drugs
  7.  Services and devices to help you recover if you are injured, or have a disability or chronic condition. This includes physical and occupational therapy, speech-language pathology, psychiatric rehabilitation, and more.
  8.  Your lab tests
  9.  Preventive services including counseling, screenings, and vaccines to keep you healthy and care for managing a chronic disease.
  10.  Pediatric services: This includes dental care and vision care for kids

It shouldn’t take a genius to realize that without some requirement like these 10, insurance companies can price policies high and steer customers to stripped down version such as  catastrophic coverage. Moderate Republicans, especially those representing poor or inner city districts, see a huge backlash coming in the next election if the ultra conservatives prevail.

Conservatives are quick to counter, “doesn’t everyone have the right to buy only as much insurance as they want? Why would a single young man want to pay for pre and post natal coverage if he is not married?”

That strikes right to the heart of the matter. Healthcare costs, are generated by hospitals, doctors, and drug companies and don’t change simply because of insurance changes. The number of pre- and post natal visits will be the same regardless of whether a young man chooses to carry broad coverage or just a stripped down policy. The implication, however, should not be lost, everyone else will pay more if the young man is allowed to buy stripped down policies. That is the definition of insurance.

Republicans are ringing their hands over this dilemma. Conservatives say they will vote against the American Health Care Act if the bill looks too similar to Obamacare and Moderates say without certain coverage and federal assistance (like tax credits and Medicaid) they will vote against it.

Congress members appear to be living in a make believe world. If somehow Congressional leaders along with President Trump can work out a compromise and pass the American Health Care Act, then just looking at the reduce insured numbers and the fewer services many Americans want (and need), Republicans will lose in 2018.

“Americans” Expect Us To Act

March 22, 2017

How many times have you heard GOP leaders repeat ad nauseam the mantra “the American people elected us to X or Y”, or “the American people want this or that”? The correct terminology  would be “Some American people…” with emphasis on “some”.

This type of honesty and absence of hyperbole would diminish the pomposity and self importance GOP elected officials want to present. (I fear this is a Republican disease today simply because Republicans are in the majority and in truth, Democrat leaders might fall under the same spell if roles were reversed.)

No better example of the misleading nature of “Americans expect” is the current healthcare debate. Republican Congressional leaders are moaning about those Republican Congress members who are threatening to vote against the American Health Care Act (the replace plan for Obamacare). “Americans expect us to pass this bill” leaders cry while all sorts of non-partisan studies point out that the replacement bill will maintain some popular Obamacare benefits but at the end of the day provide less coverage and insure fewer people.  No more appropriate subject does “some Americans” apply than here.  “Most Americans” are not impacted as a benefit recipient by Obamacare

For some Republican Congress members, the AHCA does go far enough in rolling back entitlements and for others, it goes too far. Hmmm, I wonder what Americans really want?

Senator Rand Paul elaborated today on his proposal which could gradually eliminate Medicare expansion and streamline the individual market. Paul has proposed creating a pool of all uninsured and the allowing the “free market” to drive down price through competition amongst insurers.  As lower policy prices emerged,  government supports would decrease until they disappeared. Hmmm.

Paul deserves credit for proposing a clever way out of the box Republicans have created for themselves. His proposal, of course, has it own set of pitfalls, the most obvious of which is whether “for profit” insurance companies will want to offer policies at prices the pool will demand and people can afford. None the less, Paul proposal deserves a careful review.

The irony of the current healthcare repeal and replace drama is that greedy Republicans are far more interested in diving into “tax reform”. We will hear again that “Americans expect us to lower taxes” when in fact “some Americans”, like the top 1 or 2% wealthiest Americans will alone reap huge benefits. Most American will see little impact and no benefit. More insidious will be the knock on effects of such a large tax cut. Where will the Government get revenues to pay its expenses?  Think there will be more cut in government services?

The Republican tax reform odyssey will make “searching for a free lunch” dinner time conversation.

Supreme Decision

February 1, 2017

With the nomination of Federal Appeals Court Judge, Neil Gorsuch, a difficult decision lies in front of Democrat Senators. Do they oppose his confirmation at all costs or do they object but in the end allow him to be confirmed? And more to the point, why in either case?

Judge Gorsuch claims to be someone who interprets the Constitution as the framers intended and reads laws in the context of how they were created, not how they would impact the future. Judge Gorsuch as been described as “Scalia-esq” without the bombastic-ness Antonin Scalia employed. So does Judge Gorsuch deserve a hearing?

It should be very understandable if Democrats chose a “tit for tat” response reflecting Mitch McConnell’s decision to not even give hearings to Merritt Garland. On this basis alone, a logical refusal to confirm could be based.

Over time, however, political sentiment shifts back and forth from conservative to progressive and back. It should therefore not be overlooked that in the future as the recent past, progressives have been nominated. (Judge Garland’s treatment, unfortunately, hurts this argument).  Never the less, a complete stonewall of Gorsuch would only serve to dignify McConnell’s dysfunctional behavior.

Assuming there is a hearing, what questions should be asked? And what type of answers will indicate Judge Gorsuch is not “out of the mainstream”?

Judge Gorsuch calls himself an “originalist” in the Antonin Scalia mold.  Questions around social issues and religious rights represent places where (IMO) “originalists” are the furtherest out on the limb and may be seen as out of the mainstream.

For example, supporting the Little Sisters of the Poor’s or Hobby’s decision not to provide all of Obamacare’s benefits to women for religious reasons runs dead smack into the 14th Amendment (equal protection). The Affordable Care Act required no one to use any birth control method, ACA simply made it available to any woman who so chose. Does Judge Gorsuch believe exercising religious liberty can over ride the 14th Amendment?

Another social issue involves individual gay rights such as employment discrimination and same sex marriage. Does freedom of religion allow someone with “deeply held religious beliefs” to fire or refuse to hire someone, or to withhold services to a customer on the basis of sexual orientation?

And of course, does any government have the right to interfere with a women’s choices on her reproductive health, and by extension, does a person with deeply held religious views or any religious institution have standing in denying any women such rights?

Judge Gorsuch’s beliefs in other areas such as tort, tax, and corporate law, while important, are less relevant since the Judge’s opinions are well known to be the conservative side.

It is instead the social issues which are dividing the country and are not to be found in thoughts of our founding fathers.

A simple principle might be, “believe what you want, live personally your beliefs, do not require others to follow your beliefs”.