Are We Any Closer to Repeal and Replace of Obamacare?

17201136_1131265140336477_6000204883258090829_nMaybe????? So, where does the GOP health care bill stand presently? The Republican plan backed by President Donald Trump to overhaul the U.S. healthcare system cleared its first hurdles in Congress on Thursday, but its chances for passage looked uncertain and top Republicans scrambled to bring disgruntled conservatives aboard.

In the face of opposition by Democrats, healthcare providers and many conservatives, two House of Representatives committees approved the legislation that would undo much of the 2010 Affordable Care Act, popularly known as Obamacare, moving it closer to a vote before the full House.

The Energy and Commerce Committee voted 31-23 along party lines, with Democrats unified against it, to back the plan after marathon proceedings lasting 27 straight hours. Hours earlier, the tax-writing Ways and Means Committee similarly voted 23-16 before dawn to approve it after working 17 straight hours.

House Speaker Paul Ryan sought to bolster support among conservatives in his own party, Senate Majority Leader Mitch McConnell said fellow Republicans must get in a “governing mode” while Trump denied the bill was in trouble. “Despite what you hear in the press, healthcare is coming along great. We are talking to many groups and it will end in a beautiful picture!” the Republican president said on Twitter.

The bill would replace Obamacare’s income-based subsidies with a system of fixed tax credits to help people buy private insurance on the open market, while ditching the Obamacare expansion of the Medicaid insurance program for the poor. It would also end penalties for not having insurance, though insurers would be given permission to impose a 30 percent surcharge on customers who let their coverage lapse for more than two months and then seek to renew.

Hospital stocks, which have fallen after the plan was unveiled on Monday, ended broadly higher on Thursday, with Tenet Healthcare up 3.4 percent. Shares of health insurers were mixed, with most large insurers modestly higher and Medicaid-focused insurers ending negative, including Molina Healthcare’s 3.3 percent drop.

While Republicans have been itching for seven years to dismantle Democratic former President Barack Obama’s signature domestic policy achievement, the party has failed to coalesce behind the plan put forth by House Republican leaders. Republicans control the White House and both houses of Congress for the first time in a decade, but passage of the legislation was not a foregone conclusion.

Conservative lawmakers and lobbying groups have lambasted it as too similar to Obamacare. They have sharply criticized its proposed tax credits as an unacceptable new government entitlement program and have called for a quicker end to the Obamacare Medicaid expansion.

The measure is the first major legislative test for Trump and his fellow Republicans amid questions about whether they can govern effectively after years spent as an opposition party under Obama. Ryan, with his shirtsleeves rolled up and using a video screen with facts and figures, held what he called a “townhall-style” presentation for reporters on the proposal. But his intended audience appeared to be fellow Republicans, and he said his party must “actually make good on our word.” “The time is now,” said Ryan, who long has been the target of criticism of some conservatives. “This is the closest we will ever get to repealing and replacing Obamacare,” Ryan added. McConnell had a similar message, saying, “We need to get into a governing mode and start thinking about actually achieving something rather than just kind of sparring.”

Democrats denounced the bill as a gift to the rich that would force millions of people off of insurance rolls. Republicans said it was needed to roll back the government’s “nanny state” role in the more-than-$3 trillion U.S. healthcare system. “Trumpcare is a loser for just about all of America, unless you’re in the top 1 percent,” Senate Democratic Leader Chuck Schumer said.

The House Budget Committee next Wednesday is due to merge the provisions approved by the two committees into one bill to be voted on by the full House before it goes to the Senate. Republican leaders are eyeing April for congressional passage of the bill.

In a series of tweets early on Thursday, conservative Republican Senator Tom Cotton urged his House colleagues to pull back, saying their measure could not pass the Senate without major changes. “What matters in long run is better, more affordable health care for Americans, NOT House leaders’ arbitrary legislative calendar,” Cotton wrote.

But White House spokesman Sean Spicer expressed confidence in the legislation’s prospects. “We’re not jamming this down people’s throat,” Spicer said. “This bill will land on the president’s desk. He will sign it. We will repeal Obamacare.”

The Brookings Institution think tank forecast that the nonpartisan Congressional Budget Office, expected early next week to release its closely watched assessment of the bill’s cost and coverage implications, would conclude that at least 15 million people would lose health insurance. Credit rating agency Standard & Poor’s earlier estimated 6-10 million people could lose health insurance coverage.

Before the Energy and Commerce Committee vote, conservatives at the request of the panel’s chairman withdrew an amendment sponsored by Republican Joe Barton that would move up by two years, to next Jan. 1, the end of the Medicaid expansion. Barton said he planned to try to offer the amendment on the House floor. Committee Chairman Greg Walden hailed the unanimity of Republicans on the committee in approving the bill.

Remember, Obamacare enabled 20 million previously uninsured people to obtain coverage. About half came from the Medicaid expansion. We previously discussed that the bill’s proposed changes in Medicaid funding could hurt smaller, less diverse health insurers, Fitch Ratings said, and the unintended, unforeseen consequences of a bill this size are likely to create uncertainty for all health insurers.

With doctors, hospitals, seniors, health plans, Democrats, some governors and conservative Republicans against the bill, it may not make it out of the House, Mario Molina, chief executive of managed care company Molina Healthcare, said in an interview. “If it does, I think the Senate is going to slow things down and really take a good look,” Molina said. “We are going to have to hope that the Senate is more moderate.”

What is the next big battle in the GOP’s repeal and replace the Affordable Care Act? The White House foretold the next big battle over health care reform this week, in a strange attack on a government agency that’s actually one of the most competent in Washington.

During one of his daily briefings, White House spokesman Sean Spicer assailed the credibility of the Congressional Budget Office, the nonpartisan group of professional analysts that estimates the cost of proposed legislation. What’s up with that?

Here’s what: The CBO is in the process of “scoring” the health-reform bill officially unveiled this month by House Speaker Paul Ryan, which is supposed to repeal portions of the Affordable Care Act and impose new laws instead. Trump backs the Ryan plan and recently tweeted that the Republican effort to repeal and replace the ACA will end with “a beautiful picture.” He has also promised that every American will have insurance under his plan.

But the picture is going to get uglier before it gets prettier. The Ryan plan would eliminate all the new taxes passed under the Affordable Care Act, aka Obamacare, which almost certainly means it will add more to the national debt. Obamacare, by contrast, essentially paid for itself through those taxes. The Ryan plan would still provide subsidies to help lower-income Americans buy health insurance, but they’d be less generous than those offered under Obamacare. That means fewer people will use subsidies to buy health insurance. The Ryan bill would also cut federal spending on Medicaid, the health care program for the poor, pushing even more people off health insurance.

Some private analyses have attempted to predict what the CBO’s much-awaited predictions will be. The Brookings Institution, for instance, thinks the Ryan plan will reduce the number of Americans with health insurance during the next decade by 15 million or more. The Committee for a Responsible Federal Budget points out that the tax cuts in the Ryan bill would deplete federal coffers by about $60 billion per year. The CBO is usually considered the official arbiter of such estimates, with sound accounting principles meant to assure credible numbers when it comes to the use of taxpayer dollars.

Spicer, presumably anticipating bad news, tried to argue that the CBO was way off on its Obamacare estimates back in 2010, when the law passed. “If you’re looking at the CBO for accuracy, you’re looking in the wrong place,” Spicer said. “They were way, way off the last time in every aspect of how they scored and projected Obamacare.” By that logic, the CBO’s estimates on the Republican replacement ought not be credible, either.

But Spicer’s wrong; the CBO actually did a pretty good job on the ACA, especially considering that the law endured unanticipated Supreme Court challenges, years of bad publicity and dreadful technical glitches when it first rolled out in 2013. In 2015, the nonprofit Commonwealth Fund analyzed the CBO’s predictions regarding the ACA from a few months before the law passed in 2010. “Despite the many unforeseen factors surrounding the law’s rollout,” Commonwealth found, “the CBO’s forecast was reasonably accurate.”

CBO predicted, for instance, that 7 million Americans would sign up for subsidies to help purchase insurance during the ACA’s first year. The actual number was 6 million. So CBO overshot by 17%. But it was still the most accurate of 5 major estimates. As for cost, CBO estimated the price tag for subsidies in the first year would be $19 billion; the actual cost turned out to be $15 billion: Again, too high, but only one of the four other projections was closer.

Spicer says the White House’s own projections on the Republican plan are likely to be more accurate than the CBO’s. But this would be the same White House that has made dubious claims about federal wiretaps on Candidate Trump last year, and peddled myriad other alternative facts—on voter fraud nobody else can find, an escalating murder rate that in reality is declining, terrorist attacks that didn’t happen, and the “biggest electoral college win since Ronald Reagan,” even though Obama won by bigger margins, twice.

So the next phase of the Obamacare repeal will pit good-faith estimates on cost and coverage from the CBO against alternative facts from the Trump White House. Where the Ryan legislation goes from there probably depends on whether there’s a public backlash once the CBO figures are out. Ryan already faces blanket opposition to his plan from Democrats and select opposition from some Republicans, with passage far from guaranteed.

A key factor is whether Trump can use the persuasive powers of the presidency to unify Republicans and neutralize doubt among voters. Trump relishes conflict, and he might think that picking a fight with the CBO will pay off among the portion of voters who distrust everything about the government. But we have to believe something when it comes to actual legislation that will affect real people, and GOP efforts to repeal Obamacare could turn out to be a test of the power of alternative facts. Starting any moment.

That next question is what is up President Trump’s sleeve if the GOP can’t pass their own health care plan? President Donald Trump told conservative groups that if the GOP leadership’s American Health Care Act did not pass, he would allow Obamacare to collapse and blame its failure on Democrats.

Trump revealed his strategy during a meeting with the conservative groups FreedomWorks, Club for Growth, Heritage Action, Americans for Prosperity, and the Tea Party Patriots at the White House on Wednesday. His comments were first reported by CNN’s Jim Acosta and were confirmed to Business Insider by a source with knowledge of the meeting. After the meeting, the heads of the various groups in attendance struck a conciliatory tone but still expressed concerns over the new bill.

“We shared our concerns with the bill, including the refundable tax credit, continued enrollment under Medicaid expansion, the likelihood of a ‘doc fix’ scenario of Medicaid expansion as it winds down in 2020, the continuous-coverage language, and remaining regulations in the bill,” FreedomWorks’ president, Adam Brandon, said.

“The concerns that have been raised by Sen. Paul, Sen. Lee, and members of the House Freedom Caucus are real, and we believe that we can negotiate on these provisions, address them in a substantive way, and get to ‘yes’ on this bill and throw Obamacare into the dustbin of history,” he added.

David McIntosh of the Club for Growth said the president “listened” to the groups concerns. “The president wants to get something done, and he urged us to stay supportive,” a statement from McIntosh said. “We laid out our major concerns about the lack of free-market reforms in this bill, the continuation of the Medicaid expansion, and the refundable tax credits.” At the same time, more Americans appear to have warmed to Obamacare, with polls showing the Affordable Care Act hitting its highest level of popularity ever.

Trump has long said allowing the law to remain unchanged would lead it to collapse, which would allow him to easily pass a replacement bill. The president said while that would be the politically easier path, he wanted to be proactive about a replacement. Health-policy experts, however, have said Obamacare has not fallen under the technical definition of a “death spiral” that would indicate a collapse.

I thought that it would be interesting to hear what some of the physicians, including some in private practice, around the country think about this bill. While responses from hospitals and physician societies were largely critical, the proposal has since gained momentum, with the Ways and Means and the Energy and Commerce committees approving a mark-up of the bill on Thursday. Here’s a sample of the initial reactions:

Darrell S. Rigel, MD, New York University Medical Center: It looks like it is a significant improvement over the ACA. The insurances in the exchanges have such high deductibles and thin coverage that many “insured” suffer. Hopefully, this will be materially improved. But what will really matter will be what the implementation regulations that this replacement will need will actually turn out to be.

Jerris R. Hedges, MD, University of Hawaii: This is a large and very complex bill. It will require much review, but contrary to when the ACA was first provided, there is substance that can be reviewed before the bill is passed.

Williams O’Neill, MD, Henry Ford Health System: I think the Republicans are making the same mistake the Democrats made by not having any semblance of bipartisan support. No matter what bill they pass, if it’s entirely Republican, it becomes a major campaign issue again in two and four years.

Eve Higginbotham SM, MD, University of Pennsylvania: This bill will not make healthcare better for Americans and will increase the number of uninsured, particularly in vulnerable communities.

Victoria I. Paterno, MD, private practice, Los Angeles: As physicians we are taught to do no harm. The GOP bill does harm to our patients in many areas but is most egregious and mean-spirited in the area of women’s health. As a physician who was taught to analyze data and has read extensively the pros and cons of the ACA, as well as the proposed healthcare bill, it is clear that the overall parameters that measure health in this country will be worse if this bill passes.

How it Benefits Clinicians                                                                                                        Paterno: It appears that the GOP plan will primarily benefit clinicians financially at the expense of patients. Wealthier Americans (which includes most physicians, particularly the subspecialists) are the ones who will be able to take advantage of health savings accounts, deductions of their Cadillac health insurance policies, and other tax deductions that are touted as part of the plan.

O’Neill: Having worked for Centers for Medicare & Medicaid Services for TAVR, mitral clip and Watchman procedures, I hate having them as insurers. The National Coverage decisions are often arbitrary and rigid and there is no arguing with them about coverage. Any private system is better than government run coverage.

Improving Coverage and Costs for Americans                                                                        Anees B. Chagpar, MD, MSc, MPH, Yale Cancer Center: As healthcare costs continue to skyrocket, the resulting financial hemorrhage needs to be addressed. It is unclear whether the plan will address the root cause of these costs and whether it will ensure affordable access to high-quality care. As subsidies and tax credits that would have allowed the least fortunate to gain access to coverage are rolled back, and as the individual and employer mandates are repealed, one wonders whether there will be a surge in the number of patients who are uninsured or underinsured.

Higginbotham: It is unclear not only how this revised plan will be funded, but more fundamentally how much will it cost. Removing the personal mandate will eliminate the incentive for healthy individuals to sign up for insurance and [thus it may] keep those with chronic conditions concentrated in the pool. If there is less coverage than perhaps that will reduce premiums in the short run. However delays in getting treatment and progression of disease processes will end up costing more money for individuals.

Hedges: There are a lot of assumptions in the current ACA and (I presume) the proposed alternative bill regarding the ability of insurance companies to assure service, access, and quality. I believe most of those assumptions are unfounded.

Debra Johnson, M.D., the ASPS President stated, “Without question, there is a long way to go before the American health system fully meets the needs of patients. The legislation introduced this week and marked-up by key House committees has some elements that will bring us closer to meeting that promise. Ultimately, though, it needs to go much further.”                                                                                                                                                       “Our patients deserve better access to care through affordable coverage,” Johnson continued. “The American people should have the time to deliberate the merits and drawbacks of the American Health Care Act with an independent Congressional Budget Office analysis of its cost and impact on insurance coverage in place.”                                   The principles that we physicians do and should espouse focus on providing access to high-quality care from the appropriate provider; strengthening the physician/patient relationship by stripping away regulatory box-checking that gets in the way of patient care; and improving the independent private practice environment through medical liability reform, preventing draconian cuts by repealing the Independent Payment Advisory Board, and restructuring federal quality and delivery reform efforts so they work better for specialty providers.. These principles have been identified areas that must be addressed in order to fulfill the potential of the American health system. We all believe in these principles, and we are confident legislation that satisfies them will create a dramatic improvement over the status quo. Congress needs to adhere to these principles as it continues its health care reform effort. If they don’t then the new health care bill will also be a failure!

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