“Let’s Not Forget Medicare Advantage”: Selective Outrage Over Federal Health Care Costs
Knowing I’ve been both a critic of insurance company practices and a supporter of efforts to reform the industry, a FOX news producer reached out last week to get my take on accusations by conservatives that Obamacare will actually result in a bailout of big insurance companies.
Under the headline, “Bailing Out Health Insurers and Helping Obamacare,” The Weekly Standard on Monday urged Republicans to insist that future debt ceiling increases contain a no-bailout provision. The magazine also cited Sen. Marco Rubio’s, R-Fla., bill to repeal a provision of the Affordable Care Act designed to limit potential initial losses of insurers selling policies on the new health insurance exchanges.
I reminded the FOX producer that Republicans have been supporting — and vigorously defending — a much more expensive transfer of taxpayer dollars to private insurers than the one Obamacare foes are now concerned about.
Here’s the issue:
Lawmakers who drafted the Affordable Care Act knew that insurers would be reluctant to participate in the new health insurance exchanges — also called marketplaces — if the government didn’t create a temporary program to protect them against what’s known in the insurance world as adverse selection.
Insurers were concerned, for good reason, that the first people to sign up for coverage through the exchanges would be folks previously shut out of the insurance market — people who were older and sicker than the population at large. Those people couldn’t afford to buy coverage previously because insurers were able to charge them far more than younger, healthier people.
In many cases, insurers refused to sell coverage at any price to prospective customers with preexisting conditions. That’s a big reason why the number of uninsured Americans had reached nearly 50 million when Congress passed the reform law.
So it wasn’t the least bit surprising that the first few million who have signed up for coverage since the exchanges opened on Oct. 1 skew older than many expected. People who have been denied coverage for years are far more motivated to get insurance — and fast — than anyone else. There is not the same pent up demand among the young and healthy.
In anticipation of this, drafters of the reform law established a $25 billion risk fund to insulate insurers from big losses during the first three years. Although the risk fund has always been in the law, conservative pundits apparently just became aware of it.
Yes, $25 billion is a lot of money, but it is pocket change compared to the enormous amount of taxpayer dollars that have been flowing to private insurance companies for nearly three decades to keep them in the Medicare Advantage program, which has had the unwavering support of Republicans.
Republicans have long supported efforts to privatize Medicare, and the Medicare Advantage program is one of the ways they’ve tried to do it. Medicare Advantage is billed as a private alternative to traditional Medicare. When Americans reach 65, they can enroll in traditional Medicare or in a private plan operated by an insurer. If they opt for a private plan, the federal government still picks up the tab and transfers money to the private insurer every month.
As the U.S. Government Accountability Office explains it, the Centers for Medicare and Medicaid Services (CMS) adjusts the monthly payments it sends to private insurers to account for each beneficiary’s health status. As part of this risk adjustment process, CMS assigns each Medicare Advantage beneficiary a risk score — “a relative measure of expected health care costs,” as the GAO puts it.
We’re talking a lot of money here. In 2012 alone, the GAO calculated that the federal government spent about $135 billion on the Medicare Advantage program. The problem for taxpayers is that, according to the GAO, the government has been more than generous over the years to private insurers, having paid them way more than it should have because of shortcomings in how the risk scores are developed.
Interestingly, but not surprisingly, there was no mention of that, or any reference at all to the Medicare Advantage program, the biggest champion of which are Republicans, in The Weekly Standard’s “bail-out” story last week. If they are sincere in their alarm that Obamacare might reward private insurers with an extra $25 billion between now and the end of 2016, they should be apoplectic about the ongoing bailout known as the Medicare Advantage program.
By: Wendell Potter, The Center for Public Integrity, January 20, 2014
“Becoming Increasingly Clear”: Despite What The Critics Say, Obamacare Is Working
Despite the treasured right-wing talking points, it’s increasingly clear that Obamacare is a success. Moreover, in places where Obamacare is not succeeding, it’s also clear that the right wing is to blame. Well, it’s clear to any who look at the state-by-state numbers of the newly insured. A whole lot of Americans will have to look, however, for the program’s success to redound to Democrats’ advantage.
Charles Gaba, an enterprising Web site designer, has taken it upon himself to track the number of Americans who have gained health insurance under the Affordable Care Act (ACA). Tallying those who have signed up on the state and federal exchanges (2.1 million), those who have obtained Medicaid coverage (4.4 million) and those who gained coverage through the law’s requirement that private plans allow parents to cover their children up to age 26 (3.1 million), he cites more than 9 million newly insured through Obamacare.
The meaning of that number is, to be sure, a little fuzzy. To begin, it’s a gross, not a net, increase. Some of the 2.1 million who purchased insurance on exchanges did so after their previous plans were altered or canceled. In some states, the increase in those insured through Medicaid does not distinguish between those not eligible previously and those who are simply renewing coverage.
All that said, whether the total is 9 million or 7 million, it’s a big number and it’s rising rapidly: December sign-ups far exceeded those in November, and the number is expected to continue growing through 2014.
Whether you can access the benefits of the ACA, however, depends on where you live. In states that set up their own exchanges and accepted federal funding for Medicaid expansion, the increase in the number of insured vastly exceeds that in states that declined to do either.
Theda Skocpol, a Harvard professor of government and sociology, has compared state totals of those who gained insurance through the exchanges and Medicaid with Congressional Budget Office projections of the number of enrollees in each state for the first year the ACA is in effect, as well as with the Kaiser Medicaid Commission’s projections of new Medicaid recipients in that first year.
In the three months since the exchanges opened, she wrote this week, the 14 states that established their own exchanges and accepted Medicaid funding reported increases amounting to 37.2 percent of the projected yearly exchange purchases and 42.9 percent of the projected Medicaid enrollments. In the 23 states that refused to establish insurance exchanges, refused to cooperate in making the federal Web site easily accessible and declined to expand Medicaid, exchange purchases were just 5.6 percent of the projected increase and Medicaid enrollments just 1.5 percent. (The 13 states that partially embraced the programs generally had increases lower than the 14 full implementers but higher than the 23 refusniks.)
Which is to say, the ACA is working as planned, perhaps a little better, in the states where governors and legislatures chose to implement it, such as California and New York. It is barely working in those states where governors and legislators have refused to implement it, such as Texas. Although the number of states declining any participation probably will diminish over time, as the tea party’s grip on the Republican Party wanes or as older white conservative voters die off, the resulting red-blue division between the states probably will be a feature of the nation’s political economy for some time.
Consider the implications: A larger share of Californians will be able to afford regular medical check-ups than Texans. A smaller share of Californians is likely to be bankrupted by the expense of major medical treatment than Texans. When the law’s tax penalties take effect, a smaller share of Californians will be subject to the penalties that come with the individual mandates than will Texans. In the coming years, a smaller share of California hospitals will face financial risk for indigent care than hospitals in Texas, where fewer of the sick and poor will be covered by Medicaid.
The conservative argument that the ACA is a disaster is true only when it’s a self-fulfilling prophecy: Most of the negative consequences that right-wingers have warned against have occurred only in those places where right-wingers have subverted implementation of the law. What supporters of the ACA must keep in mind, however, is that Americans who live in states where implementation has been stymied may continue to see the act as a failure and continue to blame President Obama and his party.
Only by publicizing the act’s manifest success in states where it has been implemented can supporters begin to change the public’s verdict.
By: Harold Meyerson, Opinion Writer, The Washington Post, January 8, 2014
“A Gaping Wound In The Republican Psyche”: Obamacare Is No Longer Doomed, It Will Become A Scandal
Obamacare — actual, real, Obamacare, with doctors and cards and everything — has been operational for nearly a week now. It has been … extremely boring. It does not look like Stalinist collectivization. There aren’t even any beheadings. It looks like regular medical insurance, except several million more people now have it than before.
How conservatives will respond next to this mundane new world has become the subject of combative speculation. Greg Sargent predicts Republicans will soon come to terms with the law and begin negotiating for incremental improvements. On the right, Conn Carroll angrily replies that the law’s demise remains “inevitable” and liberals will turn against the law, citing Michael Moore as a harbinger of pro-single-payer liberals who will help Republicans dismantle Obamacare, somehow.
I predict a slightly different outcome than either. Obamacare will neither collapse, nor will Republicans accept its legitimacy, but the nature of their opposition will instead slowly morph. Gleeful predictions of imminent collapse will give way to bitter recriminations at the nefarious tactics used to make the law work. Obamacare will cease to be the something certain to destroy Obama and become something Obama has gotten away with.
In recent weeks, it has begun to dawn on some conservatives that the actuarial death spiral they confidently predicted for years — in which the young and healthy shun the exchanges, leading to sicker and costlier patients and rising prices, in turn driving out the remaining healthy customers — may not actually transpire. It won’t for several reasons, one of them being a set of protections embedded in the law itself called risk corridors and reinsurance, which compensate insurance companies that wind up with a sicker customer base in the first three years of the law’s operation, thus preventing a death spiral.
Republicans, having just learned of these provisions, demand that they be abolished, to hasten the death spirals. Repentant immigration reformer Marco Rubio is at the forefront with a bill to strike them from the law. Obviously Obama would never sign such a bill, but Charles Krauthammer offers a solution: demand he sign it or else refuse to lift the debt ceiling. The program is “a huge government bailout,” argues Krauthammer. This is true in the sense that any cost overrun by a defense contractor is also a huge government bailout — which is to say, it’s not true.
But it feels true, and that is the important thing. The premise that Republicans will seek to alter Obamacare in conservative-friendly ways assumes that the policy design of health-care law is their primary motivating force. Everything about the history of Republican health-care thought suggests the opposite. Just five years ago, Mitt Romney was running on a platform of taking his Massachusetts plan, with its individual mandate, national, provoking only the mildest grumbling on the right.
Obamacare is a gaping wound in the Republican psyche, representing not only the rise of a majority moocher class but a potential symbol of a successful Obama presidency. Health-care reform, George F. Will has ludicrously if representatively declared, amounts to Obama’s “single” achievement. If it lives, it will vindicate his presidency as a liberal Reagan, rather than the reprise of Jimmy Carter (or George W. Bush) Republicans wish him to be.
If and when the law melds into the national fabric, the proximate Republican response will not be to adapt their policy ideas to it, but to denounce it as a kind of stolen law. You can see this spirit creeping out not only in Rubio’s proposal but elsewhere. Eleven Republican attorneys general have denounced Obama’s various administrative maneuvers to make the law functional as illegal. “It was powerful corporate America, with its influential lobbyists, that got an additional year to meet the insurance mandate — when individuals did not,” complains The Wall Street Journal columnist Kimberly Strassel, “It was the unions that got a reprieve from a health-insurance tax — when individuals and small businesses were left to pick up the tab.” The hapless Obamacare is slowly giving way to the devious Obamacare.
In the very long run, Obamacare may become a thing, like Social Security and Medicare, that Republicans initially predict will destroy the fabric of capitalism but eventually accept and then finally swear up and down they will not harm. In the shorter term, it will remain a bloody shirt. Obamacare will be Benghazi or the IRS scandal writ large.
By: Jonathan Chait, Daily Intelligencier, New York Magazine, January 5, 2014
“Can A Cure Be Found For Obamacare Brain Meltdown Syndrome?”: Putting The Lie To The Anti-ACA Talking Heads
As we launch into 2014, I must regrettably report that we have yet to develop a vaccine or cure that can assist those who have contracted the insidious Obamacare Brain Meltdown Syndrome (OBMS)–a tragic illness affecting roughly 50 percent of Americans who now lack all ability to review ACA data with any measure of balance and reason.
While we await the critically needed medical advances and discoveries that can bring relief to the afflicted—assuming such a program has not been ground into the dust as a result of sequestration cuts to medical research—we continue in the attempt to bring actual data to the attention of the long-suffering, in the hope that the rumors, half-truths and outright lies can be retired through the presentation of the facts.
One of the more pervasive rumors, half-truths and outright lies making the rounds these days is the meme that more people have lost their insurance as a result of Obamacare than have gained coverage thanks to healthcare reform.
As the story goes, some five million people have had their insurance cancelled because of the ACA while the numbers of those who have gained coverage currently stands somewhere around two million—and we don’t even know how many of those who have enlisted will actually bother to pay the first premium for their newly acquired insurance policy. Based on these numbers the math is simple—the law has hurt three million more than it has helped.
This line of reasoning makes for a terrific story as it is a tale both easy to understand and clear in its result.
The problem is, the story is clearly not true.
A report out this week from the Minority Staff of the House Committee on Energy and Commerce reveals that 99.8 percent of those who received an insurance cancellation can now either re-up their existing plans for another year, as a result of the changes made in recent weeks, or, alternatively, obtain a catastrophic coverage policy. As a result of these changes, the report finds that about 10,000 Americans —representing 0.2 percent of those who received cancellation notices—will actually find themselves without access to an affordable health insurance alternative.
That said, I recognize that the report was issued by the Democrats on the committee— making the study something less than the best possible authority for those suffering from OBMS. I also recognize that 10,000 people lacking the access they once had to affordable health care insurance are 10,000 people too many.
Accordingly, let’s just pretend that the Minority staff report never happened and that we are still working off the suggestion that five million people really have been left fully exposed as the metric that should be used for comparison.
With that as our comparison point, surely the argument suggesting that Obamacare has hurt more Americans than it has helped can be justified, yes?
Actually, no.
In fact, based on the hard data, we are now able to see that at least 9.4 million Americans have health insurance coverage as a result of Obamacare.
Let’s go to the numbers—
We know that approximately 2.1 million people have purchased a health insurance policy from either a health care exchange operated by the federal government or from one of the 14 state operated exchanges. Indeed, even the harshest ACA critics appear to have accepted this number—although they insist on noting that, somehow, many of these people went to the trouble of buying a policy but will refuse to pay the first premium by January 10th, as required.
While I don’t doubt that there will be a few purchasers who will fall into this category, it would require the most extreme case of Obamacare Brain Meltdown Syndrome to imagine that the number of those who went to the bother of signing up—but won’t pay up—will be statistically significant.
Next, I remind you that, as of November 30, 2013, 3.9 million new participants were enrolled in Medicaid as a result of the program’s expansion. These are 3.9 million who were not previously qualified. As reported by Michael Hiltzik over at the Los Angeles Times and Josh Marshall—using the data that has been compiled by Charles Gaba who has been carefully tracking the Obamacare math (I strongly recommend you review Mr. Gaba’s spreadsheet) since the beginning—the number of Medicaid sign-ups through the end of the year have now risen to a total of 4.3 million.
As you add up these numbers, you quickly arrive at 6.4 million Americans who now have insurance as a direct result of the ACA—a number, while in excess of the 5 million allegedly left without insurance coverage as a result of Obamacare, thereby disproving the meme—does not equal the 9.4 million Americans being served by Obamacare that I suggested earlier.
Clearly, this can only be the math of an Obama loving liberal, yes?
Or might you be missing something? Might that something be the roughly 3 million young Americans who have yet to reach 26 years of age who remain on their parents’ health insurance policy thanks to Obamacare?
Because this provision has been in effect for a few years, those afflicted with OBMS have managed to simply erase this number from their minds as if these young Americans either do not exist or simply do not “count”.
They very much do count as, prior to the ACA, these were precisely the people who were among the least likely to purchase a health insurance policy yet, thanks to the law, now have healthcare insurance. They are also the people who add the badly needed healthy participants to the insurance pools.
Add these people to the mix and you reach 9.4 million Americans with insurance as a result of the Affordable Care Act.
What’s more, the number is probably higher given that that we are not taking into consideration those who are purchasing their individual Obamacare policies off the exchanges by going to their insurance agent or directly to their insurance company. These are the folks who are not qualified for subsidies and, therefore, have no reason to deal directly with the exchange if they choose not to do so.
None of this data, by the way, proves that Obamacare is necessarily working. As I have long noted, success is far more tied to the composition of the insurance pools resulting from the ACA (the ratio of healthy to unhealthy) than it is tied to the raw number of sign-ups. This is data we do not yet have.
What this data does prove is that there are clearly far more Americans benefitting from Obamacare than those who are claimed to be losing coverage as a result of the law. The data also highlights that those with Obamacare Brain Meltdown Syndrome must fight through the fog that has descended upon them and try to face up to the actual numbers as, only then, can we continue a rational conversation about this law.
Until we find that cure for OBMS, we can only hope that those afflicted with this tragic illness will turn to that famous old saw that instructs, “then you will know the truth and the truth will set you free.”
By: Rick Ungar, Op-Ed Contributor, Forbes, January 4, 2014
“The Scourge Of The Wingnut Hole”: Coverage Totals Would Be Far Greater If Not For “Red” States Refusing Medicaid Expansion
We have a reasonably good sense of how many Americans have enrolled in the health care system in recent months, signing up for coverage made available through the Affordable Care Act. For a more ambitious tally, Josh Marshall includes exchanges, Medicaid, young adults staying on their family plans, and those who were able to bypass exchanges to buy ACA-compliant policies directly from insurance carriers, for a grand total of about 10 million.
But every time these numbers are culled, it’s worth remembering that the coverage totals would be far greater were it not for “red” states refusing to accept Medicaid expansion.
The original plan, you’ll recall, was to simply mandate the greater access. The U.S. Supreme Court, however, said states must have a choice as to whether or not to accept the good deal. Most Republican-led states, naturally, rejected the policy, leaving millions behind for no particular reason.
But how many million? The Associated Press published a report this week with a striking figure.
About 5 million people will be without health care next year that they would have gotten simply if they lived somewhere else in America.
They make up a coverage gap in President Barack Obama’s signature health care law created by the domino effects of last year’s Supreme Court ruling and states’ subsequent policy decisions.
This coverage gap clearly needs a name. Ed Kilgore started calling it the “wingnut hole” months ago, and it’s certainly a descriptive phrase. Ryan Cooper added the other day:
It’s worth remembering that the federal government will pay 100 percent of the cost of the Medicaid expansion through 2016 and 90 percent of the cost afterward. It could very well work out that refusenik states will not even save money because of additional spending on the uninsured in emergency rooms and elsewhere.
But regardless of the pitiful sums involved, make no mistake: This action is utterly gratuitous.
Quite right. In fact, as we’ve discussed many times, Republicans at the state level who refuse Medicaid expansion generally struggle to explain their position in any kind of coherent way.
What’s more, let’s not forget the irony of the larger context: congressional Republicans spent most of their waking hours complaining about a sliver of the population receiving “cancellation notices” through the Affordable Care Act because of changes to the individual market. Indeed, GOP officials routinely claim this will leave 5 million Americans behind with nothing (a total that appears to have been exaggerated by a factor of 500).
And yet, if their concern were genuine, wouldn’t Republicans necessarily be outraged by these 5 million Americans who are suffering because some red-state policymakers are acting out of petty partisan spite?
By: Steve Benen, The Maddow Blog, January 3, 2014
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