“Republican Alternative To Obamacare”: Pay More, Get Less, Put The Insurance Companies Back In Charge
Boy, can Democrats have fun with the new Republican alternative to Obamacare. It puts the health insurance companies back in charge and raises costs for almost all Americans. In particular, it substantially raises costs and threatens to cut coverage for the half of all Americans who get health insurance at work. Seniors, the group that Republicans have scared witless about Obamacare, would lose the real benefits they receive under Obamacare. The proposal from three Republican senators is a golden opportunity for Democrats to contrast the specific benefits of the Affordable Care Act (ACA) with what a repeal-and-replace agenda would really mean for Americans’ lives and health.
When it comes to the politics of health care reform, my first adage is “the solution is the problem.” That is because once you get past vague generalities, like lowering costs and making coverage available, to proposing specifics, people will look to see how the proposals impact them personally. This is why health reform is such a political nightmare. Unlike most public policy issues, the impact is very understandable and real.
With the ACA as the law of the land, in analyzing the Republican proposal we must compare its impact to the law it would repeal. The pre-ACA model of health insurance is irrelevant. Here is how the Republican plan would impact people, compared with the ACA:
People who get health insurance at work – bottom line: pay more for worse coverage.
Almost half of all Americans (48 percent), or 148 million people, obtain health insurance at work. The Republican plan would tax 35 percent of the average cost of health insurance benefits at work. This is a big tax increase on working people and is extraordinarily unpopular, as the Obama campaign used to devastating impact on John McCain. And while people would pay more, they would get less coverage, as the GOP plan would allow insurance companies to once again limit the amount of benefits they will pay out in one year and return to the day when employers could offer bare-bones plans.
While taxing health benefits would apply to all employer-provided coverage, the Republicans would give the 30 percent of people who work for businesses who employ fewer than 100 workers a tax credit. That might balance out the increased taxes for some people. However, doing so would create a huge set of economic distortions, as employers might seek to keep firm size under the 100-employee threshold.
Individuals who buy coverage on their own or who are uninsured – bottom line: insurance companies could again deny coverage for pre-existing conditions and offer bare-bones coverage, while the cost of decent coverage would go up for most people.
This is the group that the ACA is most aimed at helping, including the 5 percent of Americans who buy private health insurance and the 15 percent who are uninsured, totaling 64 million people. The ACA offers income-based subsidies to these people when they earn between 100 percent and 400 percent of the federal poverty level (FPL) and enrolls people under 133 percent of FPL in Medicaid, when states agree.
The Republican plan is toughest, in comparison with the ACA, on the lowest-income people and on the higher-income middle class, compared with Obamacare. But many families in between will do worse too.
The Republican plan would wipe out the expansion of Medicaid to people earning less than 133 percent of FPL, a provision the Supreme Court has made optional. It would cut back on Medicaid, ending the federal government’s offer to pay 90 percent of the cost of expanded coverage and replacing that with the federal government paying what it has paid historically, which is between half and three-quarters of the cost of Medicaid, with poorer states getting a bigger share. Crucially, the funding would only be for pregnant women, children and parents with dependent children who earn under the poverty level, as opposed to the ACA’s funding of all adults up to 133 percent of FPL. That means many fewer people covered and states getting less Medicaid money. Republican governors may not complain, but you can bet hospitals will. Adults without dependent children would not be covered by federal Medicaid, which means millions will stay uninsured or lose coverage they now have, unless states pay for coverage without federal support.
For individuals not covered by Medicaid or employees of firms with fewer than 100 workers, the Republican plan would replace the ACA’s sliding-scale subsidies, which now go to 400 percent of FPL, with a subsidy that is the same for everyone of the same age who is under 200 percent of FPL and lowersubsidies for people from 200 percent to 300 percent. In addition, the subsidies would be higher for older people than younger. The Republican plan also would take away the requirements that insurance plans offer decent benefits and free preventive care and charge women the same prices as men for coverage, along with every other consumer protection, with the exception of keeping in place no lifetime caps for covered benefits.
Comparing the value of the Republican plan subsidies vs. the ACA subsidies for the people who would still qualify depends on income, age, and family size. Generally, it appears that the Republican subsidies are much less than the ACA for people under 150 percent of the FPL ($35,000 for a family of four) and much less than the ACA for younger people, but more for older people. However, insurance rates for younger people would go down some at the expense of older people, who insurance companies could charge a lot more than under ACA. And families with incomes above $70,000 for a family of four would lose subsidies entirely.
Seniors and the disabled on Medicare – bottom line: seniors would pay more for prescription drugs and preventive care.
By repealing the ACA, the Republican plan would take away its two concrete benefits for seniors. One is that preventive care services are now free under Medicare (as they are under all insurance). The other is that the ACA is lowering drug prices for seniors by slowly closing the “donut hole,” under which seniors must pay the full cost of prescription drugs even though they are paying premiums for drug coverage. In other words, the Republican plan is simply bad news for seniors, the constituency that they have scared the most about Obamacare… groundlessly.
It is not surprising that Republicans have been reluctant to come up with a replacement for Obamacare. It’s much easier to throw darts – or bombs – at the ACA than to come up with a replacement that meets Republican ideological tenets of less regulation and less government. Any plan that meets the ideological test will be much worse for people in ways they can understand. It is our job to explain it to the public clearly: pay more, get less, put the insurance companies back in charge. This debate is not simply the political game Republicans want to make it. It is about our health and our lives.
By: Richard Kirsch, The National Memo, January 29, 2014
“Life Changing And Life Saving”: Remembering What Matters About The Affordable Care Act
On the Affordable Care Act front today, there’s very good practical news, and not-so-good political news. That gives us an excellent opportunity to remind ourselves to keep in mind what’s really important when we talk about health care.
Let’s start with the good news. First, as Marketplace reported this morning, a new report from PriceWaterhouseCoopers shows that the average health insurance premium on the exchanges is actually lower than the average premium in employer-sponsored plans. And it isn’t because the coverage is inadequate; according to a spokesperson, “even when you factor in all the out-of-pocket costs, the average top tier gold and platinum plans are similar to employer ones.” It’s hard to overstate what a success this is. If you’ve ever bought health insurance on the individual market before now, you know that if you could get covered at all, you were likely to get a plan that was expensive but had lots of gaps and lots of cost-sharing. The whole point of the exchanges was to give people buying insurance on their own the same advantage of pooling large numbers of customers that you get when you’re covered through your employer. If it’s working, then that’s something to celebrate.
Second, as Jonathan Cohn tells us, Wellpoint, one of the nation’s largest insurers, is reporting that exchange sign-ups are meeting their expectations; they have 400,000 new customers, and expect the number to rise to a million by the end of open enrollment. Even more critically, although their new customers are slightly older than the population as a whole, they expected this because people with a more pressing need for insurance would be the first to sign up, and they already incorporated that into their rates for this year. That means they’re unlikely to lose money, there is unlikely to be a huge rate spike next year, and the dreaded “death spiral” looks less and less likely.
This supports the contention I’ve had for some time, that in its first few years the Affordable Care Act is going to basically be fine—it may not create a health care paradise, but nor will it be the disaster conservatives are so fervently hoping for.
Before we get to sorting through what matters from what doesn’t, let’s look at the not-so-good political news. The Kaiser Family Foundation is out with their latest health care tracking poll, and there isn’t a lot to be glad about. More people have an unfavorable than a favorable view of the ACA. Most Americans are unaware that almost all the provisions of the law are now in force. And maybe most troubling, nearly half of Americans are still unaware of the law’s most popular provision, that insurance companies are no longer allowed to discriminate against people with pre-existing conditions:
Before you say, “Obama should have told people about it!” I must remind you that during the last four years you spent away from Earth, the administration and its allies did in fact repeat over and over and over again that the ACA prohibits insurance companies from denying you coverage if you have a pre-existing condition. There are many reasons why so many people haven’t yet understood, but you can’t say they didn’t try (you can read more about the myth of the bad sales job here).
In any case, here’s what we have to remember: On the scales of history, a person with a pre-existing condition who gets health coverage weighs much more than a person who doesn’t know that because of the ACA, people with pre-existing conditions can get health coverage. We spend so much time talking about politics that it’s easy to forget that politics are not an end in themselves, they’re a means to an end. Liberals advocated for comprehensive health insurance reform for so many decades not because it was politically advantageous (at some times it was, and at other times the voters didn’t seem to care), but because it was right. The fact that so many millions of Americans had no health security up until now was a moral obscenity. The ACA is beginning to fix things—slower and less completely than we might like, but it is a beginning. And if it never becomes the political boon you were hoping for, it was still the right thing to do.
That isn’t to say that political effects don’t matter, because they do. If the Republicans take over the Senate this fall, bad things would result, particularly if they also win the White House two years later, and if the ACA’s political troubles contributed to that turn of events, it would be unfortunate. But in the long run, what matters most is the effect on Americans’ lives. When you get distressed by a story about a Democratic member of Congress who’s in a tough race where her opponent is hitting her for supporting Obamacare, you can think of the families who never had health coverage before, but do now. For millions of people it will life-changing, and for many, literally life-saving. Try not to forget.
By: Paul Waldman, Contributing Editor, The American Prospect, January 30, 2014
“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
“Obamacare’s a ‘Bailout’ Now?”: Conservative Critics Are Getting Desperate
Conservatives used to say Obamacare is socialized medicine. Now they say it is a “government bailout” of insurers.
The new claim is just as misleading and cynical as the old one.
The latest conservative playing thing is a pair of previously obscure Obamacare features: “reinsurance” and “risk corridors.” Their mechanisms are a bit complicated to explain. (Read here if you want the details.) What matters is their shared purpose, which is to reimburse insurance companies that end up taking heavy losses—say, because the new marketplaces don’t attract enough young, healthy subscribers. Remember, insurers depend on premiums from people in good health to subsidize the costs of the sick. Without the right mix, the premiums insurers collect won’t be sufficient to cover the cost of clams. They’ll lose money, raise premiums in the future, drop out of the market altogether, or some combination of the three. In short, bad stuff will happen.
To Obamacare supporters, reinsurance and risk corridors are tools for stabilizing the insurance market and easing the transition from the old system to the new. (That’s why I’ve been calling them “shock absorbers.”) But the provisions started attracting scrutiny from the right in the fall, when policy watchers like David Freddoso of Conservative Intelligence Briefing first wrote about it. Now reinsurance and risk corridors are getting more sustained attention from the Weekly Standard, Fox News, and the conservative movement writ large. Republican Senator Marco Rubio has sponsored a bill to repeal the risk corridors. “Why should taxpayers have to bail out health insurance companies in the increasingly likely event that ObamaCare leaves them with financial losses?” Rubio wrote this week, in an op-ed for the Fox website. “This is government favoritism and corporate cronyism at its worst, and it’s taxpayers that will pay the price unless we stop it.” Insurers are sufficiently spooked that, as Buzzfeed’s Kate Nocera has reported, they are undertaking a lobbying campaign to keep the provisions in place.
The bailout analogy is potent. And it’s certainly accurate to say that, under Obamacare, some insurers may collect payments from the government to help offset losses. But the analogy breaks down after that.
Bailouts typically start with companies taking egregiously irresponsible actions and end with the government forking over mind-boggling sums of money to save them. Think of the savings and loans institutions misleading the public about the state of their finances in the 1980s—or the financial industry making those bad home loans and risky investments a decade ago. Each of those involved grievous management errors, frequently skirting the limits of legality. The federal outlays to save those banks were in the hundreds of billions of dollars.
With Obamacare, the situation is different. Projecting future insurance costs inevitably involves a little guesswork. With a brand new program like Obamacare, it inevitably involves a lot of guesswork. Even the smartest, most responsible actuaries might not get the numbers right, for reasons Sy Mukherjee of ThinkProgress explains:
Insurance companies were sort of shooting in the dark when they set premiums for Obamacare’s first year. They had to approximate how many people would enroll, how old the customers would be, how sick they would be, how much insurers would have to pay out in claims — but the whole enterprise was, ultimately, a series of educated guesses.
Will the guesses prove wrong? Humana officials told investors last week that the risk pools look a little worse than they had anticipated. But, as Sarah Kliff of the Washington Post just reported, officials at Wellpoint say their risk pools seem ok while the CEO of Aetna described the demographics as “better than I thought they would have been.”
Truth is, no insurer will be sure about its beneficiaries for many months, until the open enrollment period ends and the newly insured have a few months in which to file claims. That makes it impossible to know what kinds of losses, if any, insurers will take. But even if the losses are significant, the taxpayers won’t be in for another Wall Street-style bailout.
For one thing, the reinsurance money comes from the insurers themselves, who pay a tax on each beneficiary. It’s basically a transfer of funds, from all carriers to those companies inside the Obamacare marketplaces that end up with unusually unhealthy members. In this sense, it’s an insurance policy for the insurers—and one they more or less finance on their own.
The payouts from risk corridors are a little different, in the sense that those dollars come directly from government funds and have no actual limit. But the risk corridors also build up government funds—in effect, by claiming some of the profits from insurers who reap unexpected windfalls. The Congressional Budget Office, in its overall cost estimates for the Affordable Care Act, assumed that the inflow and outlfow would be roughly the same, so that the risk corridor program as a whole would be budget neutral. Even if CBO’s prediction is wrong, and the government ends up spending more than it raises, the difference is likely to be modest. The formula for payouts calls merely for government to share in high losses or gains, not to take them on completely. It’s enough to protect the insurers, the thinking goes, but not enough to cause a massive outlay. Meanwhile, lower-than-expected premiums are likely to save the government much more money than the risk corridors would ever pay out.
Conservatives might object to reinsurance and risk corridors on principle, regardless of amounts involved. That would be a perfectly legitimate argument, except for one thing: Reinsurance and risk corridors are already a feature of some government programs, most prominent among them Medicare Part D. The reinsurance and risk corridors in Obamacare and Medicare Part D are remarkably similar, except that Obamacare’s are temporary and Medicare Part D’s are permanent—which is to say, they are still part of the program.
What’s that? You haven’t heard Republicans attacking Medicare Part D as an insurer bailout? Maybe that’s because of one other, obvious difference between Part D and the Affordable Care Act. Only one of them was signed into law by a guy named Barack Obama.
Update: The Rubio bill would repeal only the risk corridors. Originally, I wrote that it would repeal both provisions. My apologies for the error.
By: Jonathan Cohn, The New Republic, January 16, 2014
“Obamacare And Emergency Rooms, A Bit Of Perspective Needed”: Oregon Study Doesn’t Undermine Affordable Care Act Claims
Headlines based on a study of emergency room visits by a few thousand Oregon Medicaid beneficiaries undoubtedly gave the Obama administration heartburn last week. Although the study predated the Medicaid expansion authorized by the Affordable Care Act — which began in some states on January 1 — many who wrote about the Oregon study jumped to the conclusion that the millions of newly enrolled Medicaid beneficiaries would make greater — not less — use of the ER for routine care.
I may be going out on a limb, but I for one don’t buy the idea that the Oregon study means emergency rooms are going to get even more crowded. And that’s because more Americans will finally have insurance.
Reform advocates have long suggested that getting folks out of the ranks of the uninsured should cut down on visits to the ER for noncritical medical care. Many people who lack coverage don’t have a primary care physician and all too often make trips to the ER when their illness or injury could have been treated more appropriately and inexpensively in a clinic or doctor’s office.
The Oregon study, which was published in the journal Science, would seem to disprove that theory.
In 2008, two years before the ACA was enacted, Oregon increased the number of Medicare beneficiaries in a novel way: by lottery. Many Oregonians who had been on a waiting list for the state’s Medicaid program got lucky when their names were drawn and they were added to the rolls.
The researchers who wrote the Science article studied the emergency room use of about 25,000 of the successful and unsuccessful lottery participants and found that those who won coverage actually made more trips to the ER over 18 months than those whose names were not drawn.
Headline writers were quick to draw their conclusions: Obamacare would not reduce unnecessary ER visits.
“Emergency Visits Seen Increasing with Health Law,” read the headline above the New York Times story last Thursday.
“Obamacare Medicaid Expansion to Worsen Hospital ER Burden,” said Bloomberg.
And Forbes gave us this: “New Oregon Data: Expanding Medicaid Increases Usage of Emergency Rooms, Undermining Central Rational for Obamacare.”
“For years,” wrote Forbes columnist Avik Roy, “it has been the number one talking point of Obamacare supporters. People who are uninsured end up getting costly care from hospitals’ emergency rooms. ‘Those of us with health insurance are also paying a hidden and growing tax for those without it — about $1,000 per year that pays for [the uninsureds’] emergency room and charitable care,’ said President Obama in 2009. Obamacare, the President told us, would solve that problem by covering the uninsured, thereby driving premiums down. A new study, published in the journal Science, definitively reaches the opposite conclusion.”
There is more than a bit of twisted logic in that paragraph. It is true that those of us with insurance pay considerably more for it because those who don’t have it often can’t pay for their ER care. That’s because the hospital shifts the cost of that “uncompensated care” to its insured customers. Researchers have estimated that people with insurance pay $1,000 more a year for it than they would if this cost shifting didn’t have to occur.
Bringing uninsured people into coverage eliminates much of that cost shifting. And that’s a good thing, considering that the vast majority of Americans with health coverage — even after the Medicaid expansion — get it through private insurance companies, either at work or on their own.
The actual increase in the number of visits per person among the newly insured in Oregon via the Medicaid lottery was 0.41. In other words, each new enrollee made 0.41 visits more on average during the 18 months than the 1.02 ER visits made by those who remained uninsured.
When you look at it from the perspective of those numbers, and the actual amount Oregon spent per person, as University of Chicago health policy expert Harold Pollack did in a healthinsurance.org post, this is far from a “sky is falling” disaster in the making. And it is actually reducing the cost shifting.
Also, as Pollack pointed out, “the emergency departments will be reliably paid for care they provide … (With coverage expansion) providers don’t have to fear the burdens or uncompensated care, and…they don’t need to cruelly pursue low-income patients over bad debts.
It’s also important to keep in mind that private insurers now manage most of the states’ Medicaid populations, and they will be vigilant in their efforts to steer their new Medicaid enrollees away from the ERs and to more appropriate and cost-effective settings. WellPoint subsidiary Amerigroup described in a recent policy brief, for example, how its efforts to reduce primary care-treatable ER visits among Medicaid beneficiaries resulted in a savings of more than 50 percent.
Rather than rushing to conclusions, let’s see how the Medicaid expansion under Obamacare actually plays out in the years ahead.
By: Wendell Potter, The Center for Public Integrity, January 6, 2014
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