Health Care Reform

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Senate in a hurry

The Senate, that body that couldn’t seem to muster enough energy to do very much since 2010 except hold endless hearings about Hillary Clinton, has suddenly gotten busy.  Last night – or rather early this morning – they took the first steps toward repealing the Affordable Care Act.  The New York Times reporters wrote

The approval of the budget blueprint, coming even before President-elect Donald J. Trump is inaugurated, shows the speed with which Republican leaders are moving to fulfill their promise to repeal President Obama’s signature domestic policy achievement — a goal they believe can now be accomplished after Mr. Trump’s election.

The action by the Senate is essentially procedural, setting the stage for a special kind of legislation called a reconciliation bill. Such a bill can be used to repeal significant parts of the health law and, critically, is immune from being filibustered. Congress appears to be at least weeks away from voting on legislation repealing the law.

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Senate Minority Leader Sen. Charles E. Schumer (D-N.Y.) is leading the charge to make Hill Republicans own the Obamacare repeal process.

The Democrats staged a protest on the floor, taking turns speaking even while being ruled out of order.  The vote was 51 to 48.  So, what can someone who is opposed to repeal do at this point?  I found a New York Times Op-Ed Seven Questions About Health Reform to be a useful guide to the questions we should be asking any Senator or Congressperson who supports repeal.  The piece by Harold Pollack and Timothy S. Jost should be read in full, but here are what I think are the most important of the seven questions. (The numbering is mine not theirs. And they are not in the order of importance.}

First, “How many millions of Americans will lose coverage?”  Among the issues pointed out is

Proposals by Tom Price, Mr. Trump’s choice to run Health and Human Services, and by the House speaker, Paul D. Ryan, would repeal the expansion of Medicaid and replace the A.C.A.’s income-based subsidies with less generous tax credits. Another plan from the House Republican Study Committee would offer deductions. We particularly need to know how this would affect low-income Americans, to whom tax deductions are nearly worthless, and who would generally not be able to afford coverage under these plans.

Second, “Will people over 55 pay higher health premiums for the same coverage?”  If the repeal is paired with cuts to Medicare, all of us over 55 will be in trouble.  And younger folks who may not have saved much for retirement yet will find it impossible to save enough.

Third, “… how much more will those with costly illnesses or injuries have to pay in out-of-pocket costs?”

Critics of the A.C.A. often argue that the law has made health care unaffordable. But many Americans would pay much more without it. The A.C.A. capped out-of-pocket spending at $7,150 for individuals and $14,300 for families for 2017. Republican proposals appear to offer no protection from high deductibles and other cost-sharing.

This could be devastating to millions, including older Americans who often develop chronic illnesses.

Fourth on my list. “Will the new plan let insurers charge women higher premiums than men while offering them less coverage?”

Before the A.C.A. banned gender-based premiums, insurers in many states charged women more than men of the same age — some as much as 50 percent more. The A.C.A. also required all insurers to cover preventive health services without co-payments; for women, this includes birth control, Pap smears, mammograms and a host of other crucial services. Maternity care is fully covered as well. Republican replacement plans offer no such protection. And many Republicans want to defund Planned Parenthood, too, which would deprive women not just of coverage but also of care.

And, as we have learned, many men, particularly Republican men, have no idea of how a woman’s anatomy works.  For those opposed to choice on abortion, this could have the effect of increasing the number of abortions – legal and illegal.

I think there is time while President Trump argues with Congress and Congress argues with itself about what should be in any new law.  If your Senator and/or Congressperson favors repeal, call or write or visit and ask some of the seven questions.  And express your support for those that oppose wholesale repeal.  Should you agree with what is happening, leave me a message explaining why you think this is OK.

Photograph:  Alex Wong/Getty Images

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As the dust settles

on the first enrollment period of the new Affordable Care Act, we are learning that a lot more people than a lot of people predicted have signed up for insurance.  President Obama is claiming 7.1 million people signed up on the health insurance exchanges – along with unknown numbers of others who signed up directly with insurance companies.  There was a claim yesterday that 90% of the enrollees had actually paid a first premium, a crucial step to being able to actually use the insurance.  We all know that there will be hassles when people go to their medical provider, when insurance cards don’t arrive in the mail, when someone with expanded Medicaid goes to a doctor who doesn’t accept that plan, but then, there have always been hassles with health insurance.  This will be nothing new.  What will be new is the massive number of new people suddenly looking for a provider.  Adjustments will have to be made all around.

But the biggest losers as of this morning would seem to be the opponents of the ACA or Obamacare as they call it.  Here is Dan Wasserman’s cartoon from this morning’s Boston Globe.

obamacare wasserman

 

And then there is this story from Politico.

Back in the fall, conservatives seized on the flubbed Obamacare rollout as proof that President Barack Obama’s brand of liberalism doesn’t work.

Now, the law’s opponents aren’t about to say that critique was wrong — but they’ve lost the best evidence they had.

On Tuesday, Obamacare sign-ups passed 7 million, six months after the launch of a federal website that could barely sign up anybody. There are still a lot of questions about how solid that figure is, but the idea that the law could even come close to the original goal after such a disastrous start would have been laughable even a few weeks ago.

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That’s left the critics questioning the early numbers or changing the subject. It’s a reminder that the attacks on the website were more than complaints about technology, but a proxy for a much deeper argument about what government should do and what it can’t do

But the Republicans do seem to be suffering from a compulsion disorder.  Here is Representative Paul Ryan quoted in the Politico story

And House Budget Committee Chairman Paul Ryan, who on the same day released a budget plan that would repeal the law, wasn’t fazed by the enrollment news.

“I think Obamacare is a slow-rolling fiasco. I think it’s a Pyrrhic victory,” the Wisconsin lawmaker said during a conference call with reporters Tuesday, at the same time that Obama was giving his victory speech in the Rose Garden.

But it was so much easier when they could just say the federal government can’t tie its own shoelaces. Now, they have to acknowledge that the government fixed the problem — and enrollment came roaring back.

Louisiana Governor Bobby Jindal is set to release his health care plan – I guess he is running for President.  According to the Washington Post

Louisiana Gov. Bobby Jindal will announce Wednesday a plan to repeal and replace President Obama’s health-care law, an effort by the Republican to insert himself into the increasingly competitive early maneuvering for his party’s presidential nomination.

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In his 26-page plan, Jindal lays out a lengthy critique of the health law — which he refers to throughout as “Obamacare” — and reiterates his belief that it needs to be entirely done away with. In its place, he sets forth a bevy of ideas that have run through conservative thought for years, in some cases renaming them and in other cases suggesting new variations on old themes.

These themes appear to include giving those on Medicare a subsidy to buy private insurance and giving Medicaid money to the states to provide whatever care they decide on.  I have a feeling that this every-state-for-itself  idea will be proven to be a real problem as people in states that didn’t accept the expanded Medicare under the ACA are faced with citizens who won’t understand why Uncle Charlie can get health insurance subsidies and they can’t.  I don’t think this is a plan people will go for – especially after they get a feel for what is covered under ACA – but at least Jindal has something.

President Obama’s poll numbers are creeping up.  Democrats running for re-election would do well to be cautious about running away from the ACA, and optimistic me says that Nate Silver might just be wrong this time with is prediction that the Republicans have the edge in the mid-terms.  It won’t be easy for the Democrats:  They have to turn out their base in larger numbers than is usual for a mid-term, but it can be done.  Nate did favor Duke which lost in the first round of the NCAA men’s basketball tournament.

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The state of health care reform

As everyone knows, the rollout of the Affordable Care Act has been pretty bumpy what with website problems, Congress not providing funding for getting the word out, and states refusing expanded Medicaid even if it is free money.  There have been surprises also.  The red state of Kentucky with a Democratic Governor, Steve Beshear, is running a successful program.  Connecticut has an online program that it is thinking of selling to other states.  Massachusetts with the original universal health care program hired the same folks that messed up the federal website resulting in problem after problem resulting in a backlog in processing paper applications.

In the meanwhile, the Congressional Republicans would still like to either eliminate or defund the ACA, but as Greg Sargent wrote recently in the Washington Post people are beginning to move away from supporting those actions.

Obamacare is a disaster for Democrats, and a certain winner for Republicans. That’s what we keep hearing, anyway.

So why does it look as if the percentage of Americans who favor repeal may have actually shrunk since its rollout problems began?

That’s what the February tracking poll for the Kaiser Family Foundation suggests. To be sure, the new poll finds that opinion of the law is more negative than positive: 47 percent of Americans view the law unfavorably, while 35 percent view it favorably (though opinions have improved a bit since October).

But unfavorable views have not translated into support for the GOP position of repeal; indeed the repeal position may have lost ground since the October rollout problems, while a clear majority favors keeping and improving the law.

Some Kaiser survey results

Some Kaiser survey results

I think most people, including President Obama, would say that the ACA could be improved.  Any piece of legislation of that scope is going to have parts that don’t work well or have unintended consequences which need fixing.  And they need fixing in a systematic way and not just on the fly through delays and exceptions as the administration has been trying to do.  The poll results show support for making fixes.

The poll shows that 48 percent want to keep and improve the law, and another eight percent want to keep it as is — for a total of 56 percent who want to keep it. (50 percent of independents want to keep and fix.)

Meanwhile, 19 percent want to repeal the law and not replace it, while 12 percent want to repeal and replace with a GOP alternative — totaling 31 percent.

Back in October Kaiser found that 37 percent want repeal/replace or just repeal, versus 47 percent who want to keep/expand it. There was a temporary spike for repeal in December, at the height of the problems; now it appears to be back down to below where it was.

In fairness, the wording is not directly parallel. The new poll offers respondents the option of keep and improve, while the October poll offered folks keep or expand. But this underscores the point: When people are offered keep and improve — the Dem stance — support for keeping the law grows.

Paul Krugman pointed out in his last New York Times column that Republican attempts to find horror stories have so far not really succeeded.

Remember the “death tax”? The estate tax is quite literally a millionaire’s tax — a tax that affects only a tiny minority of the population, and is mostly paid by a handful of very wealthy heirs. Nonetheless, right-wingers have successfully convinced many voters that the tax is a cruel burden on ordinary Americans — that all across the nation small businesses and family farms are being broken up to pay crushing estate tax liabilities.

You might think that such heart-wrenching cases are actually quite rare, but you’d be wrong: they aren’t rare; they’re nonexistent. In particular, nobody has ever come up with a real modern example of a family farm sold to meet estate taxes. The whole “death tax” campaign has rested on eliciting human sympathy for purely imaginary victims.

And now they’re trying a similar campaign against health reform.

Krugman cites the Response to the State of the Union Address.

 In the official G.O.P. response to the State of the Union address, Representative Cathy McMorris Rodgers alluded to the case of “Bette in Spokane,” who supposedly lost her good health insurance coverage and was forced to pay nearly $700 more a month in premiums. Local reporters located the real Bette, and found that the story was completely misleading: her original policy provided very little protection, and she could get a much better plan for much less than the claimed cost.

Louisiana is running ads about people losing health care insurance with actors.

In Michigan, Americans for Prosperity is running an ad that does feature a real person. But is she telling a real story? In the ad, Julia Boonstra, who is suffering from leukemia, declares that her insurance has been canceled, that the new policy will have unaffordable out-of-pocket costs, and that “If I do not receive my medication, I will die.” But Glenn Kessler of The Washington Post tried to check the facts, and learned that thanks to lower premiums she will almost surely save nearly as much if not more than she will be paying in higher out-of-pocket costs. A spokesman for Americans for Prosperity responded to questions about the numbers with bluster and double-talk — this is about “a real person suffering from blood cancer, not some neat and tidy White House PowerPoint.”

Even supporters of health reform are somewhat surprised by the right’s apparent inability to come up with real cases of hardship. Surely there must be some people somewhere actually being hurt by a reform that affects millions of Americans. Why can’t the right find these people and exploit them?

The most likely answer is that the true losers from Obamacare generally aren’t very sympathetic. For the most part, they’re either very affluent people affected by the special taxes that help finance reform, or at least moderately well-off young men in very good health who can no longer buy cheap, minimalist plans. Neither group would play well in tear-jerker ads.

There is about a month left to sign-up before one has to pay a tax penalty for not having coverage for 2014.  The last number reported was 4 million sign-ups.  A priority:  Get the young and healthy to sign-up.

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Chart from Kaiser via the Washington Post

Picture of buttons from sites.tufts.edu

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Myths about the Health Care Law

I will likely be writing a lot about the health care law as the Supreme Court hears the case next week.   Walter Dellinger had a nice piece in today’s Washington Post dissecting five of the myths related to the Affordable Health Care Act or Health Care Reform.  I look at 3 of the myths.

Myth 1:  Everyone is forced to buy health insurance.  Dellinger writes

The law states that, beginning in 2014, individuals must ensure that they and their dependents are covered by health insurance. Taxpayers who do not meet this requirement will have to pay a penalty that the law calls a “shared responsibility payment.” It begins at $95 for the first year and never exceeds 21 / 2 percent of anyone’s annual taxable income.

A great majority of Americans, of course, have health insurance through their employers, Medicare or Medicaid and are already in compliance with this requirement. Given the relatively modest payment required of those who choose not to maintain insurance, no one is being literally forced to buy a product they don’t want.

The challengers argue that the mandate is a binding requirement that makes anyone who goes without insurance a lawbreaker. The government has determined, however, that those who pay the penalty, like those who are exempt from the penalty, are not lawbreakers. As a practical matter, the so-called mandate is just a relatively modest financial incentive to have health insurance.

Myth 3:  If the Supreme Court uphold the Affordable Care Act, Congress could force us to buy anything.

The health-care case is a test of Congress’s power under the Constitution to regulate commerce among the states. One way to defend the law is simply to say that a requirement to purchase insurance or any other product sold in interstate commerce is obviously a regulation of that commerce. President Ronald Reagan’s solicitor general, Charles Fried, and conservative judge Laurence Silberman have adopted this view.

The Obama administration is not relying upon such a sweeping argument, however, and its more limited claim would not justify any law that required Americans to buy products such as cars or broccoli.

Myth 5:  The Law is an extraordinary intrusion into liberty

Liberty is always said to be fatally eroded, it seems, when great advances in social legislation take place. The lawyers who urged the Supreme Court to strike down the Social Security Act of 1935 argued that if Congress could provide a retirement system for everyone 65 and older, it would have the power to set the retirement age at 30 and force the very young to support everyone else.

It was said that if Congress had the authority to create a minimum wage of $5 an hour, it would also be a regulation of commerce to set the minimum at $5,000 an hour. In 1964, critics argued that if Congress could tell restaurant owners not to discriminate on the basis of race, it could tell them what color tablecloths to use. None of these things happened.

Nothing in the health-care law tells doctors what they must say to patients or how those patients are to be treated. It only requires people to either have insurance coverage or pay a modest tax penalty.

I think this last is the argument you hear the most.  Change is always scary and many argue their fears.  One of the big arguments used against the Equal Rights Amendment by opponents was that it would require all bathrooms to be unisex.  In Virginia where I worked for the General Assembly to ratify the amendment, this was pretty potent especially with older women.  I think they envisioned a public rest room where men were lined up in full view using urinals!

How will the Court decide?  Hard to predict but there is one piece of hopeful new.  A moot court at the National Constitutional Center upheld Health Care Reform, 8 to 1.    The judges were:

Chief Judge: Timothy K. Lewis, Of Counsel at Schnader, Harrison, Segal & Lewis and former Judge, United States Court of Appeals for the Third Circuit

D. Michael Fisher, Judge, United States Court of Appeals for the Third Circuit

Thomas C. Goldstein, Partner, Goldstein and Russel, P.C., co-founder and publisher of SCOTUSblog

Kent A. Jordan, Judge, United States Court of Appeals for the Third Circuit

Theodore McKee, Chief Judge, United States Court of Appeals for the Third Circuit

Neil S. Siegel, Professor of Law and Political Science and co-director of the Program in Public Law at Duke University School of Law

Dolores K. Sloviter, Judge, United States Court Appeals for the Third Circuit

Patricia Wald, Judge, United States Court of Appeals for the District of Columbia Circuit

Richard C. Wesley, Judge, United States Court of Appeals for the Second Circuit

You can see video here.

 

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Understanding Health Care Reform

Health Care reform is coming before the Supreme Court soon and in an effort to really understand what it is all about I picked up a copy of Jonathan Gruber‘s book “Health Care Reform”

Health Care Reform: What It Is, Why It's Necessary, How It Works

It is a nifty graphic novel which does an excellent job of explaining why we need health care reformm what the reform will do and when, and how is will help reduce the deficit.  This last is the most complicated and I’m not sure I got it all in a single reading.

Gruber uses several characters in differing circumstances to illustrate the law’s impact.  On the whole, very nicely done and highly recommended if you want to understand what the Affordable Health Care Act is all about.  Gruber is an economist who worked first with Mitt Romney on reform in Massachusetts and then with President Obama and his team.