Tag Archives: ACA

Sabotage

While the media and the country are being distracted by the daily crazy/sleazy coming from Washington, the Trump Administration is working feverishly behind the scenes to dismantle the rules: rules that protect us from dirty air and water, from discrimination in housing and education, and rules that guarantee us access to health care, among others.

The unremitting attack on the Affordable Care Act has been particularly effective. The GOP may not have been able to repeal it outright, but regulatory sabotage has been the next best tactic. Thanks to the administration’s actions–neutering and threatening to eliminate provisions of the ACA that were included in order to keep premiums affordable, health insurance rates continue to rise.

According to Larry Levitt at the nonpartisan, respected Kaiser Foundation,

New analysis: Insurers did very well in Q1 of 2018 in the individual market under the ACA. If not for looming repeal of the mandate penalty and expansion of loosely-regulated plans, we’d be looking at modest premium increases and even decreases for 2019.https://www.kff.org/private-insurance/issue-brief/individual-insurance-market-performance-in-early-2018/ …

Evidently, however, the administration has decided that killing affordability by raising costs was too incremental; a recent article from The Washington Post reported on a much more direct attack.

The Trump administration took another major swipe at the Affordable Care Act, halting billions of dollars in annual payments required under the law to even out the cost to insurers whose customers need expensive medical services.

In a rare Saturday afternoon announcement, the Centers for Medicare and Medicaid Services said it will stop collecting and paying out money under the ACA’s “risk adjustment” program, drawing swift protest from the health insurance industry.

Risk adjustment is one of three methods built into the 2010 health-care law to help insulate insurance companies from the ACA requirement that they accept all customers for the first time — healthy and sick — without charging more to those who need substantial care.

As the article goes on to explain, two of the three methods were temporary;  risk adjustment, however, was to be permanent. Federal health officials are supposed to annually calculate which insurers had relatively low-cost consumers, and which had more expensive customers. Those with the lower-cost customers would make an adjustment payment to those whose customers were more costly.

This idea of pooling risk has had significant practical effects: encouraging insurers to participate in the insurance marketplaces the ACA created for Americans who cannot get affordable health benefits through a job.

In its announcement, CMS said that it is not going to make $10.4 billion in payments that are due to insurers in the fall for expenses incurred by insurers last year.

The announcement that payments due under the law would simply not be made is just the most recent measure taken by the Trump administration to demolish a law the GOP was unable to repeal legislatively. (It’s a tactic Trump is undoubtedly comfortable with–throughout his “successful” development career, he routinely stiffed architects, engineers and contractors. Wheelers and dealers who are willing to ignore the terms of contracts to which they are party are unlikely to have qualms about ignoring the obligations imposed by laws to which they are subject. But I digress.)

The administration has taken a number of steps to dismantle the ACA through executive powers.

Last year, health officials halved the length of the annual sign-up period for Americans to buy ACA health plans and also slashed by 90 percent the federal funds for advertising and other outreach efforts to urge people to enroll. Last October, the president ended another important subsidy to insurers: cost-sharing reduction payments, which cushioned them from the law’s requirement to provide discounts on deductibles and other out-of-pocket costs to low-income customers.

This year, the Department of Labor and HHS have worked to make it easier for people and small companies to buy two types of insurance policies that sidestep benefits required under the ACA and some of the law’s consumer protections.

There have been a couple of lawsuits in the lower courts over past calculations of these payments, with inconsistent results, and the administration blamed the withholding of funds on one of those decisions–a transparently trumped-up excuse. (Pun intended.)

“Risk adjustment is a mandatory program under federal law,” said Scott Serota, president of the Blue Cross Blue Shield Association. “Without a quick resolution . . . this action will significantly increase 2019 premiums for millions of individuals and small business owners. . . . It will undermine Americans’ access to affordable coverage, particularly for those who need medical care the most.”

Matt Eyles, president of America’s Health Insurance Plans, noted in a statement that the timing of this latest move could be particularly disruptive, because this is the season during which insurers around the country decide whether to take part in ACA marketplaces for 2019 and, if so, what rates to charge. “This decision . . . will create more market uncertainty and increase premiums for many health plans,” Eyles said.

Of course it will. That’s the whole intent.

And if thousands of people are bankrupted or die as a result? Too bad. They weren’t Republican donors anyway.

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As The Bullets Find Their Mark..

I will never understand the GOP obsession with repealing Obamacare.

I could certainly understand efforts to improve it, or even replace it with a different mechanism (not the smoke and mirrors sort of replacement that Trump yammered about but was unable to describe, but a different way to deliver actual healthcare).

It is hard for me to accept that there are people who genuinely believe poor folks aren’t entitled to medical care, that being unable to afford a doctor means you don’t deserve one. On the other hand, I recall that telling–and chilling– moment in a GOP debate when Ron Paul was asked what should be done with people who don’t have insurance, and the audience members yelled “let them die.”

So there’s that…

Even though Paul Ryan and his cronies couldn’t manage a complete repeal of the Affordable Care Act, they did manage to make it less workable. They didn’t kill it–they just made it more incoherent and costly.

According to Michael Hiltzik in the L.A. Times,

Those fiscal geniuses in the White House and Republican-controlled Congress have managed to do the impossible: Their sabotage of the Affordable Care Act will lead to 6.4 million fewer Americans with health insurance, while the federal bill for coverage rises by some $33 billion per year.

Also, by the way, premiums in the individual market will rise by an average of more than 18%.

These figures come from the Urban Institute, which on Monday released the first estimate of the impact of two GOP initiatives. The first is the elimination of the individual mandate, which is an offshoot of the GOP tax-cut measure signed by President Trump in December. The measure reduced the penalty for not carrying insurance to zero as of next Jan. 1.

The second is Trump’s plan to expand short-term insurance plans, which don’t comply with many of the ACA’s essential benefits requirements and allow insurers to reject or surcharge people with preexisting medical conditions or histories.

Both of these provisions siphon younger, healthier people out of the insurance pool–an entirely foreseeable (and indeed, widely foreseen) consequence. When the pool of insured individuals contains older, sicker participants not offset by as many young healthy ones, insurers must raise premiums.

Because government premium subsidies rise in tandem with premium increases, the cost of subsidies borne by the government will rise by $33.3 billion next year, or 9.3% — to $391.4 billion from $358.1 billion under existing law.

It isn’t only taxpayers who will get hosed by the changes Trump is so proud of. The article goes through a variety of ways in which people needing health insurance will get screwed over, and I encourage you to click through and read the whole analysis.

It’s hard to disagree with Hiltzik’s conclusion:

The damage estimate can’t be restricted to the immediate impact on individuals and families, the researchers observed. “As healthier enrollees exit for short-term plans, insurers will by necessity reexamine the profitability of remaining in the compliant markets. This may well lead to more insurer exits from the compliant markets in the next years, reducing choice for the people remaining and ultimately making the markets difficult to maintain.”

In other words, the Republican sabotage will continue to undermine health coverage in the U.S. The only alternative, it becomes clearer with every day, is some form of single-payer, Medicare-for-all coverage. That’s increasingly becoming part of Democratic Party orthodoxy, and it’s about time.

One more reason why we need a wave election in November.

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Another Last Straw

Every morning since January 20th, Americans have awakened with foreboding: what new attack on reason and sanity has our tweeter-in-chief launched today? And what excuses for inexcusable behavior will spineless GOP Senators and Representatives offer this time?

Optimists wil predict that this (insert latest outrage) will be the final straw. Realists respond that, given the invertebrates in Congress and the ship  of fools that is the cabinet, it won’t be.

Yesterday, we woke to discover that Trump unilaterally and abruptly ended the Obamacare subsidies that make health insurance affordable for millions of Americans. Every single health-care organization in America opposed this action, but if there’s one thing we’ve learned about Donald Trump, it’s that he’s a know-nothing unwilling to listen to people who actually know something.

Congress failed to “repeal and replace” the ACA, so Trump has evidently decided to simply destroy it. The fact that many people will die is obviously of no importance to Mr. Me Me Me. In his zeal to destroy the ACA (and all vestiges of Obama’s legacy), he had already cut the enrollment period for 2018 in half, cut 90% out of the advertising budget and eviscerated the so-called “navigator program” that helps people through the ACA enrollment process.

At the Washington Post, Catherine Rampell warns that Trump’s sabotage is likely to destroy the system.

President Trump has made a lot of promises on health care.

Somehow, though, I don’t remember him promising stadiums of cheering fans that he’d take away protections for preexisting conditions, increase deductibles, spike premiums, eliminate basic coverage requirements and, more generally, destabilize the individual health-insurance market.

After explaining what yesterday’s Executive Order will and will not do, Rampell concludes that this impulsive and destructive act was “pretty much on brand for this nihilistic president: When you can’t come up with a new system that works, just blow up the old one.”

One of the most maddening aspects of Trump’s Order is that withdrawing the subsidies will actually cost the federal government money. A lot of money. The Kaiser Family Foundation has estimated that “savings” of 10 billion dollars would be offset by a rise in premium tax credits to 12.3 billion. In other words, the federal government will be paying  2.3 billion dollars more by making health insurance unaffordable once again for untold numbers of Americans.

The CBO projects that cutting off the subsidies will cause premiums to rise 20 percent by 2018 and 25 percent by 2020, and will increase the budget deficit by nearly $200 billion by 2026.

It’s really expensive to screw over the American public, but don’t expect the man with the tacky gold toilet to worry about budgets.

A number of people have compared Donald Trump to Richard Nixon. Admittedly, there are parallels:  Nixon was also mentally ill, also a bigot, and also willing to sacrifice American lives for political advantage.  However, despite his paranoia and some truly unforgivable–even treasonous– decisions, Nixon was intelligent and informed. He knew how government worked and what it was for, and he made some good decisions, including creation of the EPA and opening relations with China.

Trump is profoundly ignorant of government and policy, is clearly uninterested in learning, and is the loosest of loose canons. In ten short months, the man Rex Tillerson has (accurately) described as a “fucking moron” has made America an international laughing-stock, and his irrational behaviors toward North Korea and Iran have brought us dangerously close to nuclear war.

With Trump, I worry that the final straw will be a mushroom cloud.

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If You Can’t Defeat It, Sabotage It

During the ongoing saga of the Senate’s inability to formally eviscerate the Affordable Care Act, “President” Trump has tweeted out several threats: to fund primary opponents of Republicans who refused to support repeal,  to punish Alaskans for the votes of their Senator, and implicitly, after the measure failed, to sabotage the Affordable Care Act to ensure that it will fail.

Nice guy–as no one ever has said.

The Washington Post, among many others, has reported on the methodology behind the madness. (Madness used here in both senses of that term…)

Blue Cross Blue Shield of North Carolina has announced that it intends to try to raise premiums by 22.9 percent next year. The company says it would have tried to raise them by only 8.8 percent, but it is going for the larger increase because the Trump administration has not said whether it will continue paying the law’s so-called “cost-sharing reductions” (CSRs) to insurance companies, which subsidize out-of-pocket costs for lower-income people who get insurance on the individual markets. Democrats in Congress want to appropriate money to cover these subsidies, but Republicans have not done so….

Trump has repeatedly threatened to cut off the CSRs. Doing so could cause many insurers to exit the market, potentially costing millions their insurance, while causing others to dramatically hike premiums. The administration paid them for May, but officials continue to refuse to saywhether the payments will continue after that. The CSRs are tied up in court: House Republicans sued to stop them under Barack Obama, whose administration appealed the decision, and the payments continued pending the appeal, but the Trump administration has not said whether it will continue the appeal (dropping it would cause the payments to halt) and recently asked for a 90-day delay from the court while it mulls their fate. But this has only injected further uncertainty, and while some congressional Republicans have said they think the funds must be appropriated to stabilize the situation, there’s no sign whether they actually will.

Anthem Insurance, based here in my home city of Indianapolis, has withdrawn from participation in several of the exchanges due to the lack of CSR certainty.

The Center on Budget and Policy Priorities has actually added “Sabotage Watch” to its webpage; it tracks administration actions taken to undermine the Act, month by month, since Trump’s inauguration. Here’s the entry for July:

July 20

The Trump Administration ends contracts with two private firms to provide in-person assistance in states using HealthCare.gov for marketplace enrollment.  Since the first open enrollment period in 2013, Cognosante LLC and CSRA Inc. have provided one-on-one assistance for people enrolling in marketplace plans and applying for subsidies.  The loss of this assistance is especially likely to affect enrollment for 2018 coverage because the Administration has already shortened the open enrollment period to six weeks.

July 20

The Department of Health and Human Services (HHS) continues its public relations campaign attacking the ACA. HHS has released 23 videos featuring individuals explaining how the ACA has harmed them.  HHS has also used its twitter account to amplify anti-ACA messages and removed website content promoting the ACA, including the popular ACA provision enabling young people to stay on their parents’ plans until they turn 26.

A number of publications have reported on the Administration’s efforts to undermine “Obamacare.” The following explanation from New York Magazine is typical.

By threatening to stop paying out those so-called cost-sharing reductions — while also threatening not to enforce penalties on those go without insurance — the White House sowed uncertainty that chased insurers out of Obamacare.

In mid-April, several of America’s largest insurance companies descended on Washington to seek the White House’s assurance that Trump’s rhetoric about withholding the subsidies was just a bluff. Seema Verma, Trump’s head of Medicare and Medicaid Services, informed the insurers that it couldbe a bluff — if they agreed to publicly support the president’s health-care bill.

The insurers found little comfort in this exchange. Nor did Trumpcare’s sudden revival calm their nerves. To protect themselves from a diverse array of very-bad-case scenarios, many jacked up their premiums and wound down their participation in the Affordable Care Act.

It’s hard to find words to describe this behavior. Unconscionable, despicable and disgusting come to mind….

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Deconstructing The Rhetoric

A week or so ago, an Indiana legislator–a Republican– posted a comment to Facebook about the current effort to “repeal and replace” the Affordable Care Act. I know this particular Republican to be thoughtful and well-intentioned; he’s not one of the mean-spirited or rigidly ideological partisans who populate our Statehouse.

His “logic,” however, defied reality.

He began by saying that we are not debating healthcare–we are debating access to health care via insurance coverage and that government  should “let the insurance market work.”  (Why he thought the distinction significant mystifies me, but okay.)

I am a huge proponent of markets–in areas of the economy where they work. Most people recognize that healthcare is an area where markets do not work; market transactions require a willing buyer and a willing seller both of whom are in possession of all information relevant to the transaction. That definition doesn’t characterize doctor-patient interactions, and it also doesn’t characterize the health insurance “marketplace.”

Even if you assume that all citizens understand the complexities and “fine print” of the policies offered by health insurers, that they all understand the technical terminology employed and are able to make considered opinions about the nature and extent of their desired coverage, you are left with several major problems that cannot be solved by “market magic.”

First of all, most Americans get their health insurance through their employers. They don’t get to participate in the choices involved. (This coupling of insurance and employment is problematic for lots of reasons unrelated to the subject of this post; for one thing, it makes American businesses less competitive in the global economy. But that’s a subject for another day.)

Second, significant numbers of people who do not get their insurance through their jobs–either because they don’t have jobs or their employer doesn’t offer it–cannot afford the coverage they need. (That’s why we have Medicare and Medicaid.) In the U.S., non-governmental health insurance policies are priced to cover expenses that include not just the expected payouts to providers, but the costs of marketing, profits and taxes. Private insurance overhead also includes very substantial salaries paid to insurance companies’ management, costs not incurred by Medicare and Medicaid. Last time I looked, Medicare overhead averaged around 3% while private insurance overhead averaged around 24%.

Third, and most important: markets, by definition, are voluntary. (That “willing” buyer and seller…). Insurance works by spreading risk. If younger, healthier people decide they aren’t “willing” buyers–if only the elderly and sick and people with pre-existing conditions participate in the market–the whole system comes crashing down. Insurers have to charge higher and higher premiums, and policies become more and more unaffordable. That’s why the ACA’s mandate was an essential part of the law.

If we accept the premise that access to healthcare is a human right–and I am well aware that most Republicans do not accept that premise–then people who cannot afford insurance must be subsidized. For the reasons I’ve listed, providing access through “market forces” would add enormously to the costs of the insurance and thus to the amount of the subsidies.

There is a reason other developed nations have pursued a variety of ways to nationalize health insurance; it’s the only way to make universal access cost-effective.

When you deconstruct Paul Ryan’s rhetoric about giving people the “freedom” to go uninsured, and the GOP’s reverential references to “market economics,” what you get is what the Congressional Budget Office described: millions of Americans losing insurance entirely, and millions of others paying much more for much less coverage.

Eventually, Americans are going to have to decide between a system like “Medicare for All,”  that pays for actual healthcare, and our current, unsustainable and immensely more expensive insistence upon subsidizing the bottom lines of Big Insurance and Big Pharma in the name of “the market.”

The purchase and sale of health insurance in today’s U.S. can be called many things, but a genuine market isn’t one of them.

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