Repeal Failed but the GOP’s ACA Attack Continues; And Who is to Blame?

16831845_1116900401772951_1540332812797294563_nAs the midterm elections get closer and closer one wonders what the real effect of the GOP’s attack on Obamacare is and will be. Having failed in their effort to repeal the Affordable Care Act outright, the Trump administration and the Republican Congress are now waging a piecemeal assault on Barack Obama’s most significant domestic accomplishment. They have, of course, proclaimed its demise time and time again. But all that 2017 talk about how the law had failed or was starting to fail was just so much blather designed to justify their repeal efforts. However, the GOP’s multi-front assault on the ACA now appears to be having some effect. Last fall, the Trump administration ended the cost-sharing-reduction payments designed to help offset copayments and deductibles for low-to-moderate earners. That roiled the insurance markets. The administration also slashed the advertising and outreach efforts that encourage people to sign up for plans during the ACA enrollment period. The result is obvious and we are seeing presently, the fewer healthy enrollees, the higher the plan premiums.

Then, as part of its tax cut legislation passed on a party-line vote, the Republican Congress nixed the penalty for individuals who fail to buy health coverage, starting in 2019. Without a penalty, the requirement is toothless. (The mandate is hardly the only, or even principal, reason that people bought health care under the ACA; 90 percent of those polled earlier this spring by the Kaiser Family Foundation said they planned to buy insurance next year despite its de facto repeal.)

Meanwhile, the administration is finalizing regulations for short-term health insurance plans; because they needn’t meet ACA coverage requirements, those skimpier plans will be cheaper and thus may lure younger and healthier people from broader but more expensive ACA-compliant plans. And when it comes to having a sufficiently large risk pool to spread costs widely enough to keep premiums affordable, relatively small percentages can matter.

According to the Commonwealth Fund, another nonprofit that specializes in health care policy, the rate of working-age people without insurance has gone from 12.7 percent in 2016 to 15.5 percent today. That means about 4 million fewer people are covered. The Fund also found that 9 percent of those currently covered in the individual insurance markets say they won’t buy coverage next year. Larry Levitt, senior vice president for health reform at the Kaiser Family Foundation, notes that insurers are already citing the pool-depleting effects of impending short-term plans in order to justify price hikes for next year’s ACA-compliant coverage.

Meanwhile, congressional efforts to stabilize the insurance pools, either by re-establishing cost-sharing subsidies or helping states set up reinsurance plans to offset costs of the most expensive patients, have gone nowhere. Given the reflexive hostility Trump and congressional Republicans have for all things Obama, it’s hard to see these issues get worked out while Republicans retain control of both houses of Congress and the presidency.

But rising insurance premiums are likely to be an issue in the fall congressional campaigns. Voters who support the ACA need to hold the proper party responsible for the intentional slow-motion, beneath-the-radar screen effort to gum up the law’s works. And make no mistake, that’s the GOP.

Fact Check: ObamaCare, Not Trump, Is To Blame For the Rise In Uninsured In 2017

As some insurers angle for hefty premium hikes and concerns grow that more Americans will wind up uninsured, the federal health law is likely — once again — to play big in both parties’ strategies for the contentious 2018 election. Candidates are already honing talking points: Is the current dysfunction the result of the law or of GOP attempts to dismantle it?                                                                                                                The impact of changes to the law made by Republicans over the past year — modifications short of the “repeal and replace” they promised — is becoming clear. Initial announcements show health insurers in several states are seeking big increases in premiums for next year for people who buy their own insurance. That is renewing concerns about the potential for “bare” counties that will have no insurer selling coverage and hints that the number of uninsured Americans could again be on the rise.                                                                                                                                      “It’s sort of Insurance 101,” said Sabrina Corlette, a research professor at Georgetown University’s Health Policy Institute. Insurers “are facing a smaller and sicker risk pool as a result of both Trump administration and congressional action, and that means higher premiums,” she said.                                                                                                                           “A number of policy changes definitely impacted rates,” said Jeanette Thornton, a senior vice president for the trade group America’s Health Insurance Plans.

Among those changes is the elimination of the tax penalty for those who forgo insurance, included in December’s tax overhaul, and President Donald Trump’s cancellation of federal payments to insurers who provide discounts to some low-income customers.

Democrats say they will make sure voters know that Republicans deserve the blame. “Senate Democrats will be on the floor of the U.S. Senate every week talking to the American public about these rate increases and make sure they know about this campaign of sabotage,” said Sen. Chris Murphy (D-Conn.).

Republicans, however, say Democrats are at fault for blocking bipartisan legislation, which might not even have had enough GOP votes to pass. The effort sought to stabilize the Affordable Care Act’s marketplace through measures such as setting up reinsurance funding to help keep an individual insurer from facing devastating losses and guarantees for insurers to help pay their share of the out-of-pocket expenses for low-income customers.

“Democrats could have worked with us to lower premiums by as much as 40 percent but instead choose to cling to an unworkable law,” Sen. Lamar Alexander (R-Tenn.), chairman of the Health, Education, Labor, and Pensions Committee, said on the Senate floor Tuesday. “So if you have an insurance premium that is going up 40 percent next year, on top of an over 105 percent increase since 2013, you can thank a Democrat.”

The heightened political rhetoric comes after the first two states unveiled insurance company premium requests for policies on the individual market for 2019. These are not final rates, but they give an idea of what premiums for next year might be for people who don’t get insurance through their job or the government and buy their own coverage on the individual market.

That market included about 15.6 million people, both inside and outside the ACA insurance marketplaces, in the final quarter of 2017, according to the consulting firm Mark Farrah Associates.

State deadlines for filing next year’s rates run from May through July. Once insurers have made their initial premium requests, state regulators negotiate final rates before open enrollment begins in the fall. In Virginia and Maryland, insurers are seeking a wide range of significant increases, from about 15 percent for some plans up to more than 91 percent for one Maryland PPO.

Analysts are not surprised by the requested rate hikes and predict more to come. The first requests in past years have often moderated before being finalized, but this year’s political uncertainties could play a bigger role.

The Congressional Budget Office estimated that the elimination of the tax penalty for people without health insurance, which was included in last December’s tax law, by itself, would result in premium increases of around 10 percent per year. That’s because, without the prospect of a fine, healthier people would be more likely to forgo coverage, making the pool of people who continue to buy insurance sicker and more expensive for insurers.

Separately, Trump roiled the individual insurance market by canceling federal “cost-sharing reduction” payments for moderate-income insurance buyers.

The administration is also trying to extend the availability of short-term insurance plans, which frequently offer only bare-bones coverage, and “association health plans,” which can provide cheaper alternatives for those who are considered healthy. But such plans don’t include all the benefits of ACA plans. Analysts say both types of options would draw even more healthy people out of ACA plans..

The insurance industry acknowledges the actions have boosted next year’s rates. Chet Burrell, the CEO of CareFirst Blue Cross Blue Shield, which serves both Maryland and Virginia markets, told The Washington Post that “continuing actions on the part of the administration to systematically undermine the market … make it almost impossible to carry out the mission.”

AHIP’s Thornton cautioned that it is still early in the process and many things could change. Maryland, for example, has passed legislation to create a “reinsurance” pool that could substantially lower premiums for next year. It still requires formal permission from the Trump administration, however.

And while Congress could still help ameliorate next year’s increases, that appears increasingly unlikely. In a sign that the bipartisanship that characterized the effort last fall has broken down, Alexander said in his Senate speech that he plans to move on to other health issues, including ways to address the opioid crisis.

“Given Democrats’ attitude, I know of nothing the Republicans and Democrats can agree on to stabilize the individual health insurance market,” he said. Sen. Susan Collins (R-Maine), who was promised a vote on her bipartisan bill by Senate Majority Leader Mitch McConnell (R-Ky.) that never materialized, now blames Democrats. In a column she wrote for her home-state Portland Press-Herald late last month, Collins said Democrats refused to accept additional restrictions on abortion funding. “Although federal funding has not been used to pay for elective abortions for decades, some Democrats reopened the long-settled debate on the Hyde Amendment in order to block these much-needed insurance reforms,” she wrote.

Democrats, however, say it was Republicans who reopened the abortion debate by demanding language to create new, permanent restrictions that could eliminate abortion even in private insurance plans. Even so, some say they still hope consensus may be reached.

“Patients and families deserve better than the higher costs and dysfunction they are getting under Trumpcare by sabotage,” Sen. Patty Murray (D-Wash.) told reporters Tuesday. “And as soon as Republicans are ready to work again in a bipartisan way and act actually to lower families’ costs, Democrats will be at the table.”

Health Care: The ranks of the uninsured climbed last year. So, naturally, President Trump is taking the blame because of his attempts to repeal ObamaCare. The fault, however, lies not with Trump, but with ObamaCare itself.

A new Gallup report shows that the ranks of the uninsured climbed from 10.9% in Q4 2016 to 12.2% by Q4 2017. At first blush, it makes sense to point to Trump, given that this increase came during his first year in office.

As Huffington Post put it: “Trump’s sabotage of the Affordable Care Act appears to be working.”

But a closer look at the data and a review of recent history shows that Trump had nothing to do with the increase in the uninsured last year. The factors that did were baked in the cake in the summer of 2016 — when President Obama was sitting in the White House and Hillary Clinton was busy measuring the Oval Office drapes.

Let’s review the facts.

Insurers had to announce their proposed 2017 premiums in mid-2016, which then got reviewed by state regulators. The result was a massive 25% increase in average ObamaCare premiums nationwide. In Pennsylvania, premiums shot up 33%. In Illinois, they climbed 44% and in Oklahoma premiums climbed by 76%!

That was after two previous years of historic rate hikes. And insurance companies fleeing ObamaCare markets marked each year.

At the time, Democrats and the press dismissed skyrocketing ObamaCare premiums, saying that they really didn’t matter since most people enroll in an ObamaCare exchange get generous subsidies, which means their actual premiums would remain unchanged.

But that overlooked the millions who buy coverage in the individual market but who aren’t eligible for any ObamaCare subsidies. Thanks to ObamaCare’s mandates and regulations, basic insurance was fast becoming unaffordable.

Trump and the GOP had nothing to do with these failures. The changes they did enact had only a modest impact on 2018 premiums.

What’s more, open enrollment in the exchange for 2017 closed on January 31, 2017 — one week after Trump took the oath of office. So the fact that enrollment in the exchanges dropped in 2017 also had nothing to do with Trump. Enrollment in the ObamaCare exchanges came in well below forecasts every year since they opened in 2014.

The combination of declining ObamaCare enrollment and skyrocketing premiums ended up pushing more people out of the insurance market in 2017.

What’s more, Gallup’s survey found that the uninsured rate had essentially bottomed out in early 2015, when it hit 11.4%. By the end of that year, it was back up to 11.9%. It dipped down to 10.9% during the last half of 2016, before resuming its upward trend in 2017.

Even if Hillary Clinton had been president, the ranks of the uninsured would have started climbing again last year as ObamaCare’s years of massive rate hikes priced more and more people out of the insurance market.

In fact, Seema Verma, the administrator of the Centers for Medicare & Medicaid Services, lashed out during a recent meeting at critics of the Trump administration’s changes to the Medicaid program and the Affordable Care Act (ACA), also known as Obamacare.

“I take exception to those out there who have made claims that we have tried to sabotage the healthcare of the American people, particularly when it comes to the healthcare exchanges,” she said here at the World Health Care Congress. “Obamacare was failing long before Donald Trump became president and I became CMS administrator.”

The reality, said Verma, is that health insurers have fled the exchange markets “after losing millions of dollars,” adding that with only one insurer offering policies, “half the counties in America, and 10 states in our country, don’t even have a choice of a health insurer.”

Verma went on to detail some of the problems with the ACA’s insurance marketplaces. “We were promised that Obamacare would lower premiums by up to $2,500 for a typical family, but the reality is that premiums more than doubled since its inception,” she said, noting that in states such as Arizona, premiums rose by an average of 190%, and in Oklahoma, they rose 201%.

“These are plain, clear facts,” said Verma. “The stark reality was that when we came into the market, we were faced with health exchanges that were pricing Americans out of the system … and punishing them with penalties for being unable to afford government-mandated coverage.” In December, Congress repealed the individual mandate, which required all Americans to acquire health insurance or pay a penalty.

Supporters of the ACA have blamed Republicans in Congress for the exchanges’ increasing premiums, citing Congress’s failure to continue funding the “risk corridors” that would have helped health insurers pay for higher-cost patients; providing that funding, they say, would have encouraged more insurers to offer policies on the exchanges and made the marketplaces more competitive. They also are critical of the Trump administration’s canceling of the cost-sharing reduction payments the federal government had been making to help lower-income enrollees with their copays and deductibles.

Verma said the administration would “refuse to stand idly by while Americans are suffering,” so officials are “cleaning up regulations to provide states with more flexibility … to create more choice and competition to help drive down costs.”

“We have also proposed to expand the use of short-term insurance to now be used as an affordable option for people caught between individual market premiums they can’t afford and no coverage at all,” she said. These short-term plans are not required to include all of the benefits mandated by the ACA and can, therefore, be sold more cheaply than plans on the exchanges.

In addition, “it’s impossible to address Obamacare without addressing the strain it put on the Medicaid program,” Verma said. For patients who are severely disabled, and for their families, “Medicaid is more than a safety net — it’s a lifeline, one that needs to be preserved and protected for those who truly need it.”

However, the ACA’s Medicaid expansion has resulted in the addition of able-bodied adults to the Medicaid rolls, and with increased reimbursement rates for this population. “That stretches the safety net for fragile populations who are still on the waiting lists for [services like] home care,” argued Verma, and puts millions of people “into a program that wasn’t designed to meet their needs.”

The Obama administration was resistant to efforts aimed at allowing states to tailor their programs to better serve this population, said Verma. The Trump administration is remedying this problem by allowing states to require able-bodied Medicaid recipients to either work, take classes, or volunteer — a mandate known as “community engagement.” Three waivers for community engagement have already been approved, she said, “and we have 11 more we should be making decisions on pretty soon.”

Currently, eight in 10 adults who are receiving Medicaid are in families in which at least one family member is working, according to a report from the Kaiser Family Foundation. In total, 60% of Medicaid recipients are working themselves; of those who aren’t working, most cite impediments such as a disability, illness, or caregiving responsibilities as the reason, the report found.

“I hope it’s clear to everyone in this room that through all our actions we start with the goal of putting patients first,” Verma concluded. “We need to work together to create a healthcare system that pays for value, not merely volume.”

Do I think that the Democrats and the GOP will work together? Not a chance. We are dealing with politicians who are still confused and angered. Bernie and most of the Democrats are looking at some type of single-payer health care system and point to the Europeans and Canada as the models for a health care system. I have already pointed some of the frustrations in the European systems and the way that they pay for their system and some of the limitations. So, what would our model look like and will it work in a free-market society?

I promise that next week I will start putting together the single-payer option; what it is, what it looks like and will it work?

And most important-Happy Mother’s Day to all the Most Important People out there! Thank you for all that you have done for all of us and thank you for your continuous support and love!

Also, remember to check out our new book The Search for Excellence in Clinical Practice: A Handbook on Clinical Process Improvement for Providers, Sentia Publishing Company.

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