Tag Archives: aca

Get Ready for $1,000 IUDs and $1,600 Colonoscopies Under Trumpcare

We’ve been living high on the hog these last few years: getting mammograms and colonoscopies whenever we need them, vaccinating ourselves against cancer-causing viruses for free, preventing unwanted babies from showing up in our wombs without having to spend our rent money to do so. But those days might be over soon,…

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Things Jimmy Kimmel’s Baby Should Have Done to Deserve Health Care, According to Republicans

Late-night host Jimmy Kimmel delivered a tearful monologue last night about his newborn son who was born with a heart defect and had life-saving surgery at just three days old. And today, Republicans are trying to get the votes to pass a health care law that will make it next to impossible for people like Kimmel’s…

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Obama’s Getting $400K for His First Private Speaking Engagement

After kitesurfing with Richard Branson and talking to youth leaders in Chicago, former president Obama has agreed to speak at an upcoming private engagement for a financial firm—for the going rate of $400,000, FOX Business reports.

Obama has reportedly agreed to talk at a healthcare conference for Cantor Fitzgerald LP—a Wall Street investment bank—in September. According to FOX Business, he's scheduled to be the keynote speaker at the luncheon, but the firm is just waiting to work out all the details before making an announcement. 

Obama, who condemned Wall Street after the 2008 financial crisis, may face some of the same criticism that Hillary Clinton did for giving private speeches for financial firms prior to her campaign. During his presidency, Obama referred to some bakers as "fat cats" and slammed their "irresponsible actions" that led to the Great Recession. Now he's accepting almost half a million dollars for a single Wall Street speaking engagement, double what Clinton was charging.

Still, it's pretty normal for former politicians to charge such high fees for private speeches. Former president Bill Clinton was once paid $750,000 for a single speech, and George W. Bush reportedly charges between $100,000 and $150,000. Even Sarah Palin managed to pull in $100,000 for a speech, according to Politico

But that all pales in comparison to what companies were shelling out to hear Trump talk—a whopping $1.5 million in some cases. Now, listening to Trump say "big league" (or is it "bigly"?) is just something the public gets to enjoy all the time for free.

How Many People Will Die if Republicans Pass ‘Trumpcare’?

In the days after Donald Trump's election as president, Americans suffering from chronic health conditions began to worry that they might be left for dead. Republicans had spent the past six years hammering Obamacare, and now that they controlled the White House and both houses of Congress, it seemed like only a short matter of time before they would ax it once and for all. Those fears were soon given voice by increasingly mainstream left-wing favorites like Bernie Sanders, who tweeted about a week before the inauguration that 36,000 people would die annually if Obamacare were repealed.

Of course, all that panic emerged before anyone had concrete information about what, exactly, Republicans were planning to pass in Congress. At the time, there were five competing GOP plans floating around. (A version of the repeal had actually passed in previous years, albeit mostly as a symbolic gesture, since President Obama was never going to sign a death certificate for his signature domestic achievement.) Republican leaders were finally in a position to kill their least favorite law ever but strangely decided to hide the repeal legislation in a basement, where no one could find it. Once it did see the light of day, the non-partisan Congressional Budget Office (CBO) had a chance to score the American Health Care Act (AHCA), the official Republican plan. But the CBO analyzed the law almost entirely for its effect on the budget, rather than life and death.

Although every think tank that works on health policy has taken a crack at guessing how many people could end up without health insurance if Obamacare went away, the CBO report gave us a go-to number of 24 million over the course of the next decade. That figure includes several broad categories of people who probably would have insurance ten years from now under current law but are much less likely to have it if the AHCA passes. They include people who would receive less generous subsidies to purchase insurance through insurance exchanges, people whose employers will no longer be incentivized to provide plans, lower-income individuals who benefitted from a more generous Medicaid program, and risk takers who probably won't buy a plan once the law stops requiring it. 

David Himmelstein is a physician who teaches at the City University of New York and Harvard Medical School and has spent decades studying the connection between healthcare and mortality. He told me that while it's impossible to reach a single definitive figure before a new law like this is finalized, we can get pretty damn close.

His method comes from tweaking data in an authoritative 2012 study in the New England Journal of Medicine (NEJM) that focused on those who benefitted from expanded Medicaid programs in New York, Arizona, and Maine. By applying the percentage change in that report to the average adult death rate, he came up with the estimate that for every 455 people who gained healthcare coverage, one person's life was saved.

"That's probably not a bad rough estimate for the population that would lose coverage with the replacement of the ACA because there'd be a lot of young people who'd lose Medicaid and also a fair number of older people who wouldn't be able to afford the coverage through the exchanges," he told me. "It's not an unreasonable assumption."

Meanwhile, Benjamin Daniel Sommers, a Harvard-based health economist who co-authored the NEJM report Himmelstein used for his calculation, suggested a different approach. He published a paper two years ago in the Annals of Internal Medicine on how death rates changed in Massachusetts after the state implemented healthcare reform in a program not too different from what Obamacare does nationally. Sommers says that data is more applicable to this hypothetical since it speaks to both public and private health insurance.

Although he hedges that—obviously—it's a messy extrapolation. But Sommers gave me a number from that paper to make a back-of-the-envelope calculation anyway. In Massachusetts, at least, one life was saved for every 830 people covered by the statewide expansion, according to his research.

Two more things to note here: Death from Obamacare repeal might be concentrated in states carried by President Trump in the election, and some liberal state governments might try to plug the coverage gap as best as they can. But it's unlikely that Democrats in any given state will be able to quickly pass something similar to what's already in place in Massachusetts––a plan Matthew Fiedler at the Brookings Institute calls "the exception that proves the rule" when it comes to the tricky politics of healthcare.

He says that much of "Romneycare"—as the state's health law was dubbed, after the Republican governor who signed it—was financed through a Medicaid waiver given by the federal government, and that it now relies heavily on Obamacare funding streams to keep plugging along. Places like New York and California have (relatively) high tax rates already, so it may not be viable for them to raise state income taxes to foot the bill for such a costly program. Perhaps more likely, if Medicaid expansion is clawed back by the feds, some states will fight back with lawsuits.

But assuming the CBO score is on point, Himmelstein's death estimate is 52,747 and Sommers's is 28,915—which is to say these are the experts' estimates for the number of deaths that would likely be avoided if Obamacare remained in effect. These are wildly different numbers, obviously, and it should be noted that there may be a difference in death rates when it comes to gaining insurance versus versus losing it. Still, two of the most prominent experts on the relationship between health insurance and morality stand by these figures, rough though they may be. 

"Neither of these data points are identical to the current circumstances, so both extrapolations are somewhat imprecise," says Sommers. "That said, I think it's a fair statement from our studies that tens of thousands of lives could be at stake with the ACA repeal debate and the proposed replacement."

Follow Allie Conti on Twitter.

What’s Going to Happen to My Insurance If the Obamacare Replacement Becomes Law?

We finally have some numbers on what the Republicans’ proposed replacement for the Affordable Care Act is going to do to health insurance coverage and costs. The estimate, from the Congressional Budget Office, says that 24 million of us will lose coverage, and the rest of us will probably see our deductibles go up.

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Obamacare Repeal Is Turning into a Big Hot Mess

Over the past few days, the Trump administration delivered a major blow to transgender rights, set back prison reforms, and revealed disturbing details on the practical implications of its immigration-enforcement measures. But for all this tumult, this week was (again) relatively quiet when it came to major news or developments on key campaign promises. Both Donald Trump and Republican House Speaker Paul Ryan have indicated this may soon change. Trump and VP Mike Pence have recently been promising that a full Affordable Care Act (ACA) replacement plan, arguably Republicans' biggest priority, is on its way, while Ryan said last week Congress would deliver a plan after its recess this week and should get it passed by late March.

This outward resolve may sooth a base increasingly frustrated by the slow pace of real action in the Trump era. However, looking at where replacement plans are today, these promises may just be bluster, destined to disappoint even Trump and the GOP's base.

Both elected Republicans and right-wing think tanks have floated several ACA alternatives since 2009. However, as a side-by-side comparison chart of recent major plans put out recently by the Kaiser Family Foundation shows, in all this time they've never developed a consensus plan. There are a few recurrent themes across proposals—creating high-risk pools that would partition chronically ill patients who need a lot of care from the market, allowing insurance sales across state lines, encouraging the growth of health savings accounts, and killing the mandate to buy insurance, to name a few. But a lack of unity on the specifics, especially more controversial elements like funding mechanisms or the fate of Medicaid expansion, explains why the GOP has failed to meet Trump's campaign promises on the speed of repeal and replacement, and blew through their self-imposed January 27 deadline for devising legislation as well.

On Friday, Politico received a leaked version of a two-week-old House Republican bill that ought to send chills down the spines of anyone who gets coverage through the ACA. In addition to ticking most of the aforementioned points of GOP consensus, like eliminating the mandate requiring people to get insurance, it would strike down the ACA's Medicaid expansion and replace income-based tax credits based on income with age-based credits. As Vox explains, broadly this is better for young healthy people who don't need much care and worse for older sick people as well as the poor. It would also defund Planned Parenthood, a threat Republicans have often made. And in a move economists will love but many Americans will find controversial, it would cap tax exemptions for employer-provided plans in order to pay for a lot of what it proposes.

Whether that bill represents the current state of a House Republican plan is unclear. House conservatives have in the past been uncomfortable with some of its elements. But the House itself is just one battleground—any replacement will have to pass the Senate as well, and that's a taller order.

"I have no idea what the Senate is doing," says Sabrina Corlette, a former House staffer who directs research projects at Georgetown University's Center on Health Insurance Reforms. However, she cautions, "It is not typical for the Senate to defer to the House and take whatever they come up with."

Some senators have proposed or backed plans that look quite different from the House's—most notably Kentucky Republican Rand Paul's predictably libertarian proposal. More important, many Republican senators may find it hard to swallow the House plan's Medicaid rollback. A whopping 20 Republican senators hail from states that opted for Medicaid expansion and are less disposed to jigger with the program's current status quo than their House counterparts. Alaska Republican senator Lisa Murkowski has strongly indicated she might oppose any swipes at Medicaid, and some expect moderate Maine Republican Susan Collins to join her, which would almost be enough to guarantee the House plan's failure on its own.

Combine these concrete intra-party wedge issues with broader concerns—caught on audio at a Republican retreat in late January—about the political risks involved with replacement, and you've got a pretty good recipe for continued timidity, aborted grand plans, and stalls.

"We don't have details, and the GOP has been slow to release any," says the University of Massachusetts, Amherst, healthcare economist Gerald Friedman, who has worked on and supported single-payer system proposals, "because every plan they have will hurt someone, and there are real differences of opinion within the GOP."

In theory, the White House could help Republicans unify around a plan, as Obama did for the Democrats when they passed the ACA. However, while Health and Human Services Secretary Tom Price has ostensibly been working with Congress—and was expected, in the run-up to his 10 February confirmation, to have significant influence on final legislation—it's unclear what exactly he could be working toward, or how effectively.

So, despite talk of a coming grand plan, Corlette says it's impossible to even say for sure what will be in a final bill. There are still too many opaque processes and moving parts.

Corlette adds that it's also unclear how Republicans will try to implement it. Their current strategy is to use the budget reconciliation process to pass repeal and ideally some kind of reform with a simple majority vote. However, Corlette notes, "the provisions in reconciliation have to directly affect federal revenue or spending," which may be interpreted to preclude measures like allowing the sale of insurance across state lines. This may force Republicans to push elements of their plan into piecemeal ancillary legislation, which could in turn face a Democratic filibuster in the Senate, leaving them dead in the water.

It is entirely possible for Trump, Ryan, and company to deliver a full ACA plan next week as promised, and it may resemble Friday's leaked draft. But the notion that it will be passed in March is borderline farcical. In fact, there's some acknowledgement within the GOP (even in the recent past from Ryan and Trump) that we may never see any sort of repeal—the most recent and notable recognition coming via former Republican House Speaker John Boehner's Thursday remarks that the notion of repeal was laughable. There is some acceptance that the ACA framework could be kept in place, but "repaired"—a necessary move, given the flaws in the existing system.

Unfortunately, for the GOP, any delay on its floated timetables could cause serious troubles. As I noted last week, Congress will soon be forced to turn to other issues, like the federal budget, which could take away ACA momentum and reopen further internal GOP disputes. Corlette notes that insurers also have to make their plans as to whether to stay in healthcare markets and how to price their plans soon—the recent exit of Humana and scale-down of Aetna from participation in ACA exchanges shows that the uncertainty of the current political climate has many providers spooked. Strong language and executive actions from the White House could calm insurers, thus alleviating some time pressures on a replacement plan. But that sort of action seems unlikely given Trump officials' actions to date and the spate of policy issues and scandals they are having to deal with on a day-to-day basis. The more time that goes by without a bill passing, the more pressure and protests Republicans will face from constituents afraid of losing their insurance. That could make plenty of congresspeople skittish.

"If they don't do it quickly, then they will be in trouble," says Friedman. "Their base wants ACA repeal, but the longer they wait, the more opposition will develop."

All of which is to say that there's a real fire under Trump and the GOP's collective ass right now to find true consensus legislation and push it forward. There's just no real sign they're making the progress they need to on untangling knotty issues—and it's not clear how long they can go before people start calling this a failure.

Follow Mark Hay on Twitter.