The Republican party’s direction for health care has become the proverbial circus car with 20 clowns inside, none of them driving. President Trump is on the roof, shouting conflicting directions to no one.
The ACA is the GPS.
Donald Trump is now our country’s President. Despite the efforts of the Democrat party to gain control of the Senate, it remains in the hands of the Republican party, along with the House of Representatives. The reality is that for the third time since 1945, the conservative party has control of the Presidency, the Senate and the House (1). Since President Trump ran with an overwhelming number of campaign promises solely designed to gain voter support, we will likely find that a lot of what he promised will not happen.
The future of the Affordable Care Act (ACA) is now under attack.
From the start of the 8-year term of President Barack Obama in 2008, he was met with Republican opposition to almost everything he tried to accomplish (2). This has been particularly true for the ACA, which became law in 2010. The Republicans in the House of Representatives have voted over 60 times to repeal it, at a cost to taxpayers of $87 million (3). 19 states still refuse to expand Medicaid to include all of their working poor under the ACA, despite the ACA reimbursement of 100% for three years and the enhanced federal match of 90% to cover the costs. The ACA has met with great opposition, more than any other piece of health care reform in our country’s history. That political opposition has hindered its success more than anything else.
One of the most important things the ACA did was to reorganize the entire health insurance market for people who buy their own insurance. This included the establishment of online health care exchanges where people could shop for competitive prices for policies that fit their needs. Those same exchanges are where they
could find out if they were eligible for tax credits based on their income that has helped discount the cost of insurance. The ACA set new standards for health insurance to protect people from buying policies that were previously overpriced and provided little actual coverage of value.
The changes to the insurance industry brought about by the ACA were indeed disruptive. It left some people who were required to buy insurance upset and angry. Ineligible for subsidies because their incomes were too high, they feel they were forced to buy insurance with high deductibles to save money. They don’t feel the value of what they bought was worth it. (8)
Most people are pleased with the ACA
Most Americans are quite happy as they realize the value of the insurance they now have. The Commonwealth Fund, a Washington think tank, recently surveyed Americans on this issue. They have found that 77% of adults with marketplace plans purchased under the ACA and 88% of those newly enrolled in Medicaid were satisfied with their health insurance. When asked to rate their insurance, 66% of marketplace enrollees and 77% of new Medicaid enrollees said their coverage was good, very good, or excellent.
They also found that 7 out of 10 enrolled in a marketplace plan or newly enrolled in Medicaid said they had used their coverage to go to a doctor, hospital, or other healthcare provider or to fill a prescription. 6 out of 10 of them also said they would not have been able to access or afford this care prior to getting their new coverage. Among those who were previously insured, half said they would not have been able to access or afford this care before getting their new insurance. (9) The majority of self-insured Americans are happy with the ACA, and millions of people now have insurance they did not have a decade ago and are using it.
The number of uninsured is at an all times low, down to 8.6% from 9.2% last year, and from 15.7% before the ACA. This is the lowest uninsured rate in 45 years. Millions of lives have been extended and saved by newly found health insurance, particularly among our country’s poorest people in the 31 states that did expand Medicaid under the ACA. Households with incomes below $500,000 also benefited greatly from the ACA, their uninsured rate dropped as well to an all-time low of 7.4%. Health insurance premiums on average are actually 32% lower now than they would have been without the ACA if you account for annual historical increases and the higher benefit of the plans. (16)
The ACA is a success
The quality of care has improved, and the cost of health care is starting to stabilize as the expanded markets lower the rate of increase each year since the ACA was passed. People with pre-existing illnesses can get insurance now. Insurers can not drop you if you become sick. They can not cap your benefits annually or over your lifetime. Parents can keep their children on their insurance until they are 26. We have more rights when appealing insurance company denials. Businesses that offer health insurance to their employees get tax breaks. Subsidies help lower income families afford to buy their own insurance. (18)
The ACA also expanded Medicaid in 31 states that agreed to do so, bringing health insurance to over 10 million people, who are mostly the unemployed and working poor of our country. These are people who work in jobs that do not provide insurance and who do not make enough money to qualify for subsidies. They are also the children of poor parents, disabled people who weren’t eligible before the ACA, and people who have chronic health problems that limit their ability to work full time. Because of the ACA, they now have access to health care that provides them with a physician, diagnostic testing, and preventative care that will ensure they live longer, healthier and happier lives. (10)
All of these gains have come from the Affordable Care Act. Without the laws’ protection for those with pre-existing conditions and financial supports for those having trouble affording it, many Americans will find themselves without health insurance again. The Congressional Budget Office (CBO) has predicted the outright appeal of the law would increase the number of uninsured Americans by 22 million, and defunding the parts that make it work would likely have the same effect. (11)
Insurance Companies Will Become Broken
If Republicans are allowed to repeal the ACA, they would need to have an effective replacement to ensure the health insurance industry does not collapse financially. The ACA was a compromise that included insurers as partners, allowing them to stay profitable by increasing the risk they provide insurance for across a wider, healthier population. That’s how insurance works… the more people who have insurance, the cheaper it becomes for everyone.
If the individual mandate is repealed, millions of Americans will simply cancel their health insurance. Because they are healthy, they don’t think they should be forced to buy something they don’t need. What they do not understand is that the risk they take is that a single illness or accident can drive them into medical bankruptcy. They risk finding their care limited to emergency rooms and urgent care centers instead of the primary care physicians and the extended networks of specialists that insurance gives. Without preventative care, such as annual physicals and diagnostic screenings, they risk losing the benefits of early detection of often fatal illnesses, which decreases their chances of survival.
If healthy people stop buying health insurance, hospital costs will rise dramatically when some of them become ill or injured and they can not afford to pay their bills. Hospitals use cost-sharing practices to pass that cost on to insurers. Insurers will be forced to drastically raise premiums to cover those who still have insurance. As premiums go up, the number of enrollees will decrease, creating a feedback loop that will cause what is called a death spiral. The American Health Insurance Plans (AHIP), the health insurance industry’s largest trade group, has predicted that “That same dynamic would play out across different age groups, in different states, and in different low- and middle-income brackets. The ACA’s tools for balancing the risk pool would be ineffective, and, would resemble the ‘death spiral’ phenomenon accompanying the failed state reform efforts of the 1990s”. (12)
Medicaid will be block granted into oblivion
The Republican plan includes radical changes designed to force states to cut or limit enrollment in Medicaid. States that have not expanded Medicaid would no longer be eligible for ACA funding to expand. All states would have to choose between a block grant or a per capita cap that would severely limit federal reimbursement.
The latest version of the plan being drafted would phase out by 2020 the Medicaid expansion that has covered millions of people under the ACA. Instead, states would begin to receive a set dollar amount for each person covered by the program, a drastic change from the open-ended entitlement the program is now. (29)
The current plan is to replace the existing Medicaid program with grants to the states that let the money be spent with little if any, federal oversight. This is a long-term attempt to deprive the poor of the health care that Medicaid now provides. The grants amounts will likely be determined at a set rate of money per person living in poverty within each state.
A major problem with this is the lack of any provision to increase that rate as the cost of health care continues to increase in the future, effectively limiting state’s abilities to maintain their programs or increase the number of people covered in the event of a recession. State’s will be forced to do less for its poor, in fact, the Republican plan acknowledges it by stating that enrollment caps and waiting lists for new enrollees will be allowed. Medicaid will quickly become “dead on the vine”, and one of our country’s greatest safety nets for the poor will be torn to shreds.
The destruction of Medicare as we know it
The other federal program that provides health insurance is Medicare, which insures seniors over the age of 65 directly without state involvement. The ACA made significant improvements to Medicare, by eliminating a great deal of the existing fraud, waste, and abuse. This saving, estimated at $716 billion so far, has been reinvested back into Medicare to improve care for seniors. This included closing the Medicare Part D “donut hole”, which has saved Medicare recipients $11.5 billion since 2010 in prescription drug payments. Over the next 10 years, each Medicare beneficiary will save about $4,200 due to lower drug costs, free preventive services, and reductions in the growth of health spending (14). Either repealing or defunding the ACA will eliminate these savings to our nation’s elderly and those who are disabled.
Additionally, Republican Speaker of the House Paul Ryan has been pushing to phase out Medicare and replace it with private insurance for several years. Since the election, Ryan has stated “What people don’t realize is because of Obamacare, medicare is going broke, medicare is going to have price controls because of Obamacare, Medicaid is in fiscal straits. You have to deal with those issues if you are going to repeal and replace Obamacare. Medicare has serious problems because of Obamacare. Those are part of our plan.”
This is simply untrue. The ACA is not the problem with Medicare. In fact, the savings created by the ACA have extended the solvency of Medicare by at least ten years. Leftover from his failed run for Vice President with Mitt Romney four years ago, Ryan’s plan to privatize Medicare is not only unpopular with seniors it is also built on false assumptions. What do Republicans mean when they discuss plans to phase out Medicare?
According to Ryan’s website, “For younger workers, when they become eligible, Medicare will provide a premium-support payment and a list of guaranteed coverage options – including a traditional fee-for-service option – from which recipients can choose a plan that best suits their needs.” (15) Allow me to translate that for you…. If you have Medicare now, you’ll keep it. If you aren’t old enough yet to be on Medicare, when you become 65 you’ll get a check that will allow you to buy health insurance from those same providers that are about to either drastically increase premiums or simply go out of business if they repeal or defund the ACA.
The GOP healthcare backpack is empty
The GOP plan is also short on the details that are necessary to develop an accurate estimate of its cost to taxpayers. The Congressional Budget Office (CBO) could determine the actual future cost of the Republican plan if they provided sufficient details about how it would be implemented, but they are deliberately not doing so. We have no idea whether or not what they propose will actually save any money, but we do know it will harm the poor. Speaker of the House Paul Ryan has stated, “Our proposal is like a health-care ‘backpack’ that provides every American access to financial support for an insurance plan chosen by the individual and can be taken with them job-to-job, home to start a small business or raise a family, and even into retirement years.” For anyone looking closely at their plan, the “backpack” appears to be empty, void of detail and substance. (13)
If you’ve followed this so far, by now you understand that the simplistic three-word promises of a campaign (“Repeal and Replace”) can not solve anything. The Democrat platform had a plan that would have repaired much of what was wrong with the ACA. Ranging from enhanced enticements for states that have not yet expanded Medicaid to tax credits to help Americans with high insurance deductibles, those options are gone now. All we can do now is protect the progress we have made in the last six years by defending the ACA.
President Trump speaks to Congress about the ACA
In his first Congressional address last week, President Trump made the following statements (19). I’ll explain how each and every one of them is patently false and deliberately misleading.
“Tonight I am also calling on this Congress to repeal and replace Obamacare with reforms that expand choice, increase access, lower costs, and at the same time provide better health care. Mandating every American to buy government-approved health insurance was never the right solution for our country. The way to make health insurance available to everyone is to lower the cost of health insurance, and that is what we are going to do. Obamacare premiums nationwide have increased by double and triple digits.”
The ACA includes a mandate that everyone should have health Insurance, but that mandate actually only affected a small percentage of Americans. In 2015, 49% of Americans get health care insurance through their employers, and 20% receive Medicare because they are either retired or disabled. This did not change much because of the ACA. 14% of Americans receive health insurance because they are income eligible for Medicaid, about 9% purchase their own insurance, and another 9% are uninsured. About half of those without insurance would be Medicaid eligible if their states expanded their programs to include the poor under the ACA. Lowering the cost of health insurance will not change those numbers. As I said before, the ACA has actually slowed the rate of health insurance premium increases by 32% if compared to what they would be without the ACA. What is meant by “lowering the cost of health insurance” is removing the minimum standards defined by the ACA and letting insurers sell inferior plans across state lines to employers and the self-insured that do not cover as much, have higher deductibles and impose limits on the care one can receive, both in terms of the actual care and the quantity of care.
“As an example, Arizona went up 116 percent last year alone. Gov. Matt Bevin of Kentucky just said Obamacare is failing in his state — and it is unsustainable and collapsing. One-third of counties have only one insurer, and they are losing them fast. They are losing them so fast, they are leaving, and many Americans have no choice at all. There is no choice left.”
Is this true? Yes and no. According to CNN, “The Department of Health and Human Services confirmed the Obamacare premium increases for 2017 in the final months of the Obama administration — an average of 25% in states served by the federal Obamacare exchange, healthcare.gov. Arizona was slated to see an average 116% premium increase, the highest of any state by far. These hikes are for the benchmark silver plan upon which subsidies are based.” (20) The premium increases cited by President Trump are before federal subsidies are accounted for, and for many middle and lower income families, the premium increase will be less than 2%. The ACA subsidies were designed to offset premium increases for those who could least afford them. (21)
As to the number of counties with “only one insurer”, although this is true it is deliberately misleading. The number of counties with just one health insurer selling on Healthcare.gov did rise from 182 counties in 2016 to 960 counties (out of a total of 3,142) in 2017. (22) Once again, remember that this affects only the 1 out of 10 Americans who purchase their own insurance plans. More importantly is the question of why insurers have dropped out of these state exchanges, and the answer to that has little to do with the ACA.
UnitedHealth announced in April that it would stop selling on the marketplaces after suffering more than $1 million in losses. Aetna followed in August, reducing the number of states where it sells from 15 to four. Although UnitedHealth’s decision to drop out seems based solely on profitability (24), Aetna’s decision has been found by a Federal judge to be a response to a federal lawsuit blocking its proposed $34-billion merger with Humana. Aetna threatened federal officials with the pullout before the lawsuit was filed, and followed through on its threat once it was filed. (23)
The ACA is having growing pains, but it certainly not imploding or failing. Despite all of the uncertainty being created by the rhetoric of the GOP, 12.2 million Americans signed up for coverage this year. Couple with Medicaid expansions in 31 states, these two arms of the ACA has brought health insurance to over twenty million people. (29)
“Remember when you were told that you could keep your doctor and keep your plan? We now know that all of those promises have been totally broken.”
Yes, before and during the roll-out of the ACA President Obama made this statement repeatedly. It was inaccurate but the reason why a very small number of people found their plans canceled by their insurers was because the insurers decided to cancel them. The ACA actually included provisions that allowed those plans to be grandfathered, basically exempting them from complying with the new law. That exemption also included a provision that grandfathered plans could not be altered. Once insurers decided to offer only plans that complied with the ACA standards, they canceled the plans.
Obama’s “promise” was intended to convey that those who already had insurance through their job or through Medicare would not be forced into the new health-care exchanges. At the same time, his statement did not convey the fact that those with skimpy coverage would likely be required to purchase upgraded plans that complied with the standards set by the ACA. (25)
Keep in mind that 3/4 of medical bankruptcies occurred with people who had health insurance plans that not only excluded people with preexisting conditions but also imposed caps on coverage, the very things that the ACA eliminated to protect patients from insurers. To put this in perspective, the best estimate of how many people were affected by this is around 2.6 million, about 10% of the 22 million people who buy insurance on the marketplace. That’s less than 1% of the 320 million people with insurance, and over half of them were likely eligible for federal subsidies because of the ACA. (26)
Let us look at the five guiding principles also mentioned by President Trump in his address.
“First, we should ensure that Americans with preexisting conditions have access to coverage, and that we have a stable transition for Americans currently enrolled in the health care exchanges.”
Access to coverage does not mean access to affordable coverage. Access to coverage does not mean a right to have coverage. Both as President and as a candidate for President, Donald Trump repeatedly pledged that his plan to replace Obamacare would involve “insurance for everybody.” What he did not say to Congress was that he wants to ensure that health plans can’t discriminate against Americans with preexisting conditions. Instead, he says he wants to make sure that those people have “access to coverage.”
In fact the leading plans on Capitol Hill, which require insurers to offer coverage to everybody, also lets health plans charge higher prices to people with preexisting conditions who have a break in coverage. That is a lot of people: Before the ACA, the Commonwealth Fund in the mid-2000s estimated that about 36 percent of Americans had a gap of coverage at least one month long in an average year. Although the Republican replacement plan for the ACA may include some protections for those with preexisting conditions, it will be weaker than what exists now, under the ACA. (27)
“Secondly, we should help Americans purchase their own coverage through the use of tax credits and expanded health savings accounts. But it must be the plan they want, not the plan forced on them by our government.”
The ACA already includes tax credits (and subsidies) to help make coverage more affordable for low- and middle-income Americans. The tax credits are on a sliding scale, giving more financial help to the Americans who earn the least. Republicans are battling amongst themselves on this issue. Centrist congressional leaders favor continuing the tax credits, though some would favor basing them on age rather than income. Other more conservative republicans in Congress are opposed to any tax credits. They worry that this will create another level of entitlement programs, without doing anything to decrease insurance premiums. This is the currently the biggest battle going on within the Republican party. President Trump’s comment to Congress is a deliberate attempt to shift that battle, but it remains to be seen how responsive to it the conservatives will be. (28)
“Thirdly, we should give our state governors the resources and flexibility they need with Medicaid to make sure no one is left out.”
Medicaid now provides health insurance to 73.5 million Americans in all 50 states. Medicaid expansions in 31 states funded by the ACA have brought health insurance to 14.5 million people, 3 million of which were already eligible for Medicaid before the ACA but just did not know it. The President’s language is deliberately vague, as many Republican Governors and Senators are pushing to maintain the Medicaid expansions. If Medicaid is altered, the leading plan likely to gain majority support is the conversion to block grants I mentioned before.
Changing how Medicaid functions and how money is brought to the state level by the federal government is an incredibly complex and politically risky issue. Currently, the feds reimburse states for a certain percentage of their state Medicaid expenses. Only those new enrollees (11 million people) are reimbursed at a higher rate (90% in 2020) under the ACA. The other 64 million people covered by Medicaid are reimbursed by the feds using a percentage that varies from state to state, depending on economic factors.
Looking at how that money is currently spent is a glimpse into how complicated it would be to simply convert the program to block grants that would “make sure no one is left out”. Breaking down Medicaid’s $530 billion annual budget shows us that 42% goes to managed care organizations (Health Maintenance Organizations and Prepaid Health Plans), 30% goes directly to fee for service acute medical care (hospitals and doctors), 21% goes to fee for service long term care (nursing homes). A small percentage goes to Medicare (3%) to pay for Medicare premiums for those enrolled in both programs, and Direct Hospital Subsidies (3.5%) are paid directly to hospitals which provide large amounts of charity care to those with no insurance. (30)
Converting this program to a simple per capita block grant system will be a complete disaster. States are currently required to contribute between 30% and 50% of the money their programs use, and under a block grant-style of federal funding, those requirements would certainly be weakened. Coupled with the lack of flexibility in block granting the funds into the future to match unexpected growth during times of economic recession or drastic increases in health care costs due to an unstable health insurance system, it is a recipe for disaster.
“Fourth, we should implement legal reforms that protect patients and doctors from unnecessary costs that drive up the price of insurance and work to bring down the artificially high price of drugs, and bring them down immediately.”
The first part of this point seems to be a reference to medical malpractice reform, which actually has not been a major part of the Republican effort to replace the ACA. The Congressional Budget Office does not even score medical malpractice reforms like capping payments to patients as meaningful in lowering health care premiums in any fashion.
The second part, regarding the cost of prescription drugs, is interesting. Previous statements by President Trump have included “We’re the largest buyer of drugs in the world. And yet we don’t bid properly. We’re going to start bidding.” Unfortunately, the prescription drug coverage provided by Medicare Part D, which was passed under President Bush in 2003, does not allow Medicare to bid or negotiate drug prices with pharmaceutical companies. This was partly resolved by the ACA when a 55% discount was negotiated for Medicare Part D recipients with the pharmaceutical providers that includes most medications. Also, because of the ACA, the infamous “donut hole” where recipients are required to pay high prices for medications until huge annual deductibles are reached is being closed and will be gone by 2020. (31) In the meantime, the “Extra Help” program was implemented as part of the ACA to provide financial assistance for those Medicare recipients making less than $13,000 a year and provides up to $4,000 of help annually in purchasing medications. (32) Simply put, repealing the ACA will actually result in higher prices for drugs for Medicare recipients.
“And finally, the time has come to give Americans the freedom to purchase health insurance across state lines, which will create a truly competitive national marketplace that will bring cost way down and provide far better care. So important.”
Since the start of his campaign, President Trump has called for an end to the ACA restrictions that prevent health insurers from selling insurance across state lines. He has repeatedly stated that he wants to be able to allow insurers in one state to be able to sell insurance in other states, even if the plan they are offering does not meet the other states mandates and regulations. This does not really make any sense, since health insurance plans rely heavily on having a local network of providers, both hospitals, and doctors, in order to keep costs lower and profit high. There is zero evidence that this would bring down costs or actually increase consumer options. Most state level officials do not even like the idea, as it would limit their own ability to regulate the market within their own states. (28)
What President Trump did not say to Congress
He didn’t say anything about how this would be paid for. Repealing the ACA means repealing the funding mechanisms that were a part of it. More importantly, he did not even mention the most controversial and contested part of the ACA- the mandate that everyone should have health insurance. The currently proposed Republican plan disguises the mandate as a requirement maintain continuous coverage or face much higher costs for pre-existing conditions if they don’t. (28) President Trump’s choice of Tom Price to head the Department of Health and Human Services gives us an idea of what they have planned. As a Senator, Price has proposed to change the pre-existing conditions exemption in the ACA to a qualified restriction that allows insurers to deny or charge more for anyone who has had a break in insurance coverage in the previous 18 months. This means that losing your job can not only lose your employer provided insurance, but if you develop a “pre-existing” condition you will be once again at the mercy of insurers who will likely deny you insurance. It will change the right to insurance guaranteed by law under the ACA to a penalty imposed on people who become sick.
Before the ACA, 30% of all adults under the age of 65 were uninsured due to conditions like cancer, heart disease, diabetes, and obesity. Millions more had premiums that made their insurance unaffordable. Women were routinely charged more than men for the same health insurance. The ACA ended all of this, by requiring that everyone must have insurance. This spread out the cost of insuring those with illnesses or other reasons for higher costs across a larger, healthier population. This allows insurers to provide the insurance required to cover everyone and still stay profitable. We can not have guaranteed coverage for everyone regardless of pre-existing conditions without the mandate that everyone has insurance, one can not exist without the other. (33)
So now you hopefully see what I meant at the beginning…. The Republican party finally has the ability to repeal and replace the ACA, but they are hesitant. Now that it is within their grasp, all they really need is leadership. All they are getting is confusion and conflict. Their party leadership shouts turn right, the President shouts turn left, and all those satisfied voters are shouting go straight ahead.
It is up to us to tell them to turn on the GPS and follow the directions set by the ACA. We need to be united in telling them we, the people, think America is already great. Equal access to health care is where we begin, and we are almost already there.
We can do better. Together, we will.
How you can help protect the ACA
First of all, share this blog. Follow it so you can get updates.Talk about it with your friends and family.
Follow the links I’ve included below and learn more about the different parts of this issue.
Most importantly, schedule a few minutes this week to make a few phone calls to your state senators and representatives. Better yet, if they hold a Town Hall meeting go and ask them questions.
Tell them you will hold them accountable if the ACA is repealed or defunded. They are the ones who actually can make or break President Trump and Speaker Ryan’s plans to damage Medicare, Medicaid and the ACA.
Let your elected leaders know that you are promising to vote against them in 2018 if they do not stand with you.
They respond to this threat, in fact, it is the one thing that motivates them the most… our votes.
Send postcards to them as well. Buy a card that has your state name on it, or buy the ones I’ve created at CafePress (see below). Write them a short message, letting them know you will not vote for them and their party at the next election if they repeal or damage the Affordable Care Act.
And if you live in one of the 19 states that have not expanded Medicaid, call you Governor and elected state congresspeople and tell them to start caring for the working poor of your state… and fight to be able to expand Medicaid for the working poor in your state! Thousands of people across the country are literally dying from preventable diseases and illnesses every year that they use this issue for partisan purposes.
Find out who your congresspeople are, along with their addresses and phone numbers.
To find Town Hall meetings near you that you can attend.
I am leaving comments on for this post. If you have questions, ask. I’ll answer.
If you prefer to do so privately my personal email is firstname.lastname@example.org.
Keep Your Hands of Our Healthcare!
Let them know you want them to
Repair the ACA!