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“Playtime Is Over For Obamacare’s Foes”: And Still, Republicans Don’t Have A Serious Plan B

Friends of Obamacare, horrified that the Supreme Court has taken a case that could blow up the federal health insurance exchanges, should recalibrate their dread. While the health reforms were safely humming along, there was little political price for demanding their demise. Thanks to the Supreme Court, now there is.

Years of carpet-bombing assaults on Obamacare have left many Americans thinking that they don’t like the Affordable Care Act. But close down the federal exchanges covering 6 million people (so far) in 36 states and they may think otherwise. With a vengeance.

Here are the stakes in King v. Burwell: Should the justices strike down subsidies for coverage in the federal exchanges, only the very sick would hang in. That would be the end of the federal exchanges.

Donald Taylor, a health policy expert at Duke University, likens the Obamacare attackers to a dog chasing a car. “What’s the dog going to do if it catches the car?” he said to me.

Subsidies would be untouched in the 12 or 14 state-run exchanges (depends on how you define them), the majority of which are in blue states. Red-state politicians — oddly the biggest foes of a law that in effect transfers tax dollars from high-income liberal states to poor conservative ones — would have a mess on their hands.

“Some Southern states will be back up to 20 percent uninsured,” Taylor said, “and that doesn’t sound politically stable.”

The solution for Republicans would be a plan B. But they don’t have a serious plan B.

Republicans do have a proposal of sorts, composed early last year by three senators — Richard Burr of North Carolina, Orrin Hatch of Utah and now-retired Tom Coburn of Oklahoma. But it was written mainly as a political document with which to hit Obamacare over the head during the 2016 campaign — not as a ready-to-plug-in substitute.

Let’s look at the Republican plan that we aren’t supposed to examine too closely.

For starters, it would empower private insurers to play a bigger role in the relationship between you and your doctor — encouraging them to shrink the network of doctors and hospitals you may visit. So much for “choice.”

It also would cut government subsidies for many working stiffs who earn too much to claim poverty but too little to afford decent private coverage. And it would enable insurers to charge older people far more for their insurance. Obamacare lets them charge three times as much. The Republican plan would let them charge five times as much.

Gone would be the minimal coverage standards. That means the insurers could more easily deny payment for services that Obamacare considers basic. For all these gifts to private insurers, the industry actually prefers Obamacare because its subsidies create many more customers for their products.

The Republican replacement plan (as written so far) contains lots of other controversial elements pretty much ignored because few have taken it seriously. For example, it would tax employer-sponsored health benefits. (Obamacare’s “Cadillac tax” on luxurious coverage does some of that, for which it continues to take a beating.)

A group of conservative economists, led by Douglas Holtz-Eakin, has scored the Burr-Hatch-Coburn plan and claims that it would cut deficits by $1 trillion. These are reputable economists, Taylor says, but the text they were working with was “incredibly vague” on where the cap on the taxes would be put.

“The score is a number, and the text on which they did the score was ambiguous,” he said. “It shows just how hard this is.”

So now Obamacare won’t be the only piñata in town.

The Supreme Court will take up King v. Burwell in March. We do live in interesting times.

 

By: Froma Harrop, The National Memo, January 8, 2015

January 9, 2015 Posted by | Affordable Care Act, Health Exchanges, Republicans | , , , , , , | Leave a comment

“The Default Setting”: Why Your Employer Can’t Cut Off Your Contraception Coverage

On the Fourth of July, while you were stuffing your face with patriotic burgers and watching patriotic fireworks, the Supreme Court handed down an emergency injunction in a case involving Wheaton College’s objection to the Affordable Care Act’s contraception benefit, a decision that acted as an addendum to the Hobby Lobby decision. As I ranted over here, this is the decision that could really open the floodgates to thousands of claims from all kinds of organizations and companies that don’t want to let their employees get contraception. But after thinking and reading about it for a while, there’s something I think everyone seems to be missing, and it could mean that no one is actually going to lose their coverage, even temporarily.

I should say that it’s entirely possible that I’m completely wrong about this, and there’s some bureaucratic detail deep within the ACA that I’ve overlooked. But the first thing to remember is that the ACA requires that insurance plans cover a variety of kinds of preventive care, including contraception; this issue is about what exactly a company or organization has to do when they have an objection to contraception coverage. The Obama administration constructed an alternative arrangement, which until now was supposed to be used only for religiously affiliated non-profits but, after the Hobby Lobby decision, may have to be used for basically anyone, including for-profit companies. The way it works is that if your group doesn’t want to be tainted by the sin of contraception, there’s a form you file with the government stating your objection. You send a copy to your insurer or third-party administrator (TPA), and the insurer/TPA (I’m just going to say insurer from this point on) arranges for the coverage with the government, by getting reimbursed out of other funds.

The problem is that Wheaton College, along with dozens of other organizations that have filed suit, believes that just filling out this form and sending it to their insurer makes them complicit in sin, because doing so triggers the arrangement under which their employees will get coverage. Let’s leave aside the merit of this belief, but by granting the emergency injunction the Court’s majority essentially accepted that filling out the form and sending a copy to their insurer was indeed a burden on Wheaton’s religious freedom. This made Sonia Sotomayor absolutely livid, since just four days before the Court had used the existence of that very form as proof that there was a less restrictive alternative than the contraception mandate available.

So what Wheaton would prefer is that they not fill out the form and send it to the insurer. Instead, they want to send a letter to the government just stating their objection—a letter which wouldn’t have to inform the government of who their insurer is. In her dissent, Sotomayor warned that this could become a bureaucratic nightmare, because now the government has to figure out who the insurer is for every company that sends a letter, so they can get in touch with the insurer and arrange the alternate payment procedure for contraceptive coverage.

And this is where I’m puzzled. Because under the ACA, ordinary insurance coverage has to provide prescription contraception with no cost-sharing (meaning without copayment or deductable). That’s the default setting. So let’s say I’ve started a new non-profit aimed at educating America’s youth about the important cultural contributions of 1980s hair metal bands. I get health insurance for my employees, and because of the requirement in the ACA, it includes coverage for contraception. Then after spending an extended period listening to Stryper, I realize that contraception is sinful and try to deprive my employees of it.

Depending on the outcome of these cases, I may have a couple of options. I can file the original form with the government and send a copy to my insurer, in which case those two will arrange for my employees’ contraception coverage to continue. If I object to the form, as Wheaton College does, I’ll just send a letter to the government saying “I’ll have none of this!”

But since I don’t want to inform my insurer and thus trigger the alternate arrangement, my insurer has no idea that I object to contraception coverage. That means they’ll continue to provide it to my employees, as the law requires. If because of ordinary bureaucratic slowness it takes the government a while to find my insurer and inform them of my objection, my employees will still have contraception coverage in the meantime. Whether I’m active or passive the coverage continues, either because the alternate arrangement has been triggered, or because the insurer keeps doing what they’ve been doing because they don’t know of my objection.

To repeat, there may be something I’m missing here. But it seems that even if the Hobby Lobby and Wheaton cases impose more bureaucracy and make things more cumbersome for the government and insurers, as long as contraception coverage without cost-sharing is the default setting for insurance plans, people won’t actually have their coverage interrupted, no matter what the preferences of their employer.

 

By: Paul Waldman, Contributing Editor, The American Prospect, July 7, 2014

July 8, 2014 Posted by | Affordable Care Act, Contraception, Health Insurance | , , , , , | Leave a comment

“Told You So, Obamacare’s Back”: By Next Fall, HealthCare.gov Is Going To Be A Net Plus For President Obama And Democrats

If one looks just at the raw, bottom-line number the Department of Health and Human Services released Wednesday—365,000 citizens enrolled since October 1—one might be inclined to think it’s not so hot. And it isn’t. That’s 180,000 or so a month, and if you post that number against the stated goal of 7 million by next spring, the stated goal looks awfully chimerical, and the thing seems a disaster (180,000 times six months, the enrollment period, is just 1.08 million).

Dig a little deeper and things look considerably better. If we could graph it, the bar line of enrollment would make for a pretty impressive ski slope: After just 27,000 people signed up in the whole of October, The New York Times reported over the weekend, about 100,000 people signed up in November, and then, in the first week of December alone, 112,000 chose plans. The Los Angeles Times put out slightly different numbers Wednesday but agreed on the trend. From an obviously atrocious starting place, enrollment is essentially quadrupling. If that pace were to continue, the 7 million figure would be cleared in March.

I still wouldn’t quite bet on that. But I would definitely and unflinchingly bet on the central proposition I argued last week:  By next fall, HealthCare.gov is going to be a net plus for Obama and the Democrats.

Wishful thinking? You can call it that if you want to. But I warn you I’m not usually a wishful thinker. Like most partisans on either side, I tend to expect the worst. It’s usually a wise insurance policy; you’re rarely disappointed. I write such things only when I really think them, like the time in August 2012 when I wrote a column suggesting that Obama could very well win about 330 electoral votes. He won 332, which most anyone else would have said when I wrote that piece was crazy.

I had a hunch then, and I have one now. And my bet is based on a lot more than enrollment numbers. It’s based on the numbers of people who are benefiting and will benefit from aspects of the law. These aren’t in the thousands. They’re in the millions. About 70 million citizens will enjoy free—free—preventive care for a range of services that typically weren’t covered at all before or at best were covered and required a co-pay. About half of them are Medicare recipients (= old people = voters). Preventive care, as you may know, is something our system hasn’t been doing very well. Now it will.

More than 100 million Americans live with what the insurance companies would define as pre-existing conditions. Over these next few months, as their symptoms flare up or especially if they worsen, requiring lengthy hospital stays and intense treatment, they’re going to be seeing that they don’t have to fret about money or whether they’re going to continue to be covered anymore. Mental-health coverage is going to be improved dramatically for up to 60 million Americans. Nearly 7 million senior citizens are going to find in the coming months that they’re no longer screwed by the doughnut-hole prescription-drug problem that was created by the Bush Medicare Part D law of 2003 and corrected by Obamacare. It is saving these 7 million seniors an average of $1,000 a year, which for many of these folks is probably a reasonable chunk of their income.

I could go on. The thing is that all this isn’t going to make the papers and the cable channels much. There isn’t a lot of inherent news value in a free cervical-cancer screening or a prescription-drug refill. But these millions of people live real lives, not on TV, and they and their families and friends will know what has happened.

You see that I’m not making a Beltway/political argument. Washington, D.C., will, I can promise you, be the last city in the United States to change its mind about Obamacare. Once a notion becomes conventional wisdom in this town and rocks a president’s poll numbers the way the disastrous rollout so clearly has, it takes a typhoon to dislodge it. Or a hurricane—remember how Karl Rove was making the United States a conservative country until Katrina came along and sent Bush’s approval numbers down there in the range of curdled milk?

The rollout won’t be a hurricane. It will be a calm rain, a steady shower of reality across the country that may never achieve quite enough force to trump inside-the-Beltway perception but will be strong enough to change many people’s minds around the country.

Fixes still need to be made. But now, as opposed to a month ago, one can feel as if they will be made. And without excusing the bollixing up of the rollout, of which I’ve written very critically, one can also say now that in historical context, this is all happening pretty fast. Remember, the original Social Security legislation was passed in 1935. And when did the first check go out? Not until 1940. Can you imagine a five-year lag in today’s media world? Roosevelt, and more important the program itself, would have been torn to pieces. I think in two more years’ time, and indeed less than that, many millions of Americans will see that what they thought was decent health insurance before the Affordable Care Act was like gaslight before electricity. If that’s wishful thinking, it’s for their sake, not the president’s.

 

By: Michael Tomasky, The Daily Beast, December 12, 2013

December 13, 2013 Posted by | Affordable Care Act, Obamacare | , , , , , , , | Leave a comment

“Death By Ideology”: Among The Lying Liars, Mitt Romney Doesn’t See Dead People

Mitt Romney doesn’t see dead people. But that’s only because he doesn’t want to see them; if he did, he’d have to acknowledge the ugly reality of what will happen if he and Paul Ryan get their way on health care.

Last week, speaking to The Columbus Dispatch, Mr. Romney declared that nobody in America dies because he or she is uninsured: “We don’t have people that become ill, who die in their apartment because they don’t have insurance.” This followed on an earlier remark by Mr. Romney — echoing an infamous statement by none other than George W. Bush — in which he insisted that emergency rooms provide essential health care to the uninsured.

These are remarkable statements. They clearly demonstrate that Mr. Romney has no idea what life (and death) are like for those less fortunate than himself.

Even the idea that everyone gets urgent care when needed from emergency rooms is false. Yes, hospitals are required by law to treat people in dire need, whether or not they can pay. But that care isn’t free — on the contrary, if you go to an emergency room you will be billed, and the size of that bill can be shockingly high. Some people can’t or won’t pay, but fear of huge bills can deter the uninsured from visiting the emergency room even when they should. And sometimes they die as a result.

More important, going to the emergency room when you’re very sick is no substitute for regular care, especially if you have chronic health problems. When such problems are left untreated — as they often are among uninsured Americans — a trip to the emergency room can all too easily come too late to save a life.

So the reality, to which Mr. Romney is somehow blind, is that many people in America really do die every year because they don’t have health insurance.

How many deaths are we talking about? That’s not an easy question to answer, and conservatives love to cite the handful of studies that fail to find clear evidence that insurance saves lives. The overwhelming evidence, however, is that insurance is indeed a lifesaver, and lack of insurance a killer. For example, states that expand their Medicaid coverage, and hence provide health insurance to more people, consistently show a significant drop in mortality compared with neighboring states that don’t expand coverage.

And surely the fact that the United States is the only major advanced nation without some form of universal health care is at least part of the reason life expectancy is much lower in America than in Canada or Western Europe.

So there’s no real question that lack of insurance is responsible for thousands, and probably tens of thousands, of excess deaths of Americans each year. But that’s not a fact Mr. Romney wants to admit, because he and his running mate want to repeal Obamacare and slash funding for Medicaid — actions that would take insurance away from some 45 million nonelderly Americans, causing thousands of people to suffer premature death. And their longer-term plans to convert Medicare into Vouchercare would deprive many seniors of adequate coverage, too, leading to still more unnecessary mortality.

Oh, about the voucher thing: In his debate with Vice President Biden, Mr. Ryan was actually the first one to mention vouchers, attempting to rule the term out of bounds. Indeed, it’s apparently the party line on the right that anyone using the word “voucher” to describe a health policy in which you’re given a fixed sum to apply to health insurance is a liar, not to mention a big meanie.

Among the lying liars, then, is the guy who, in 2009, described the Ryan plan as a matter of “converting Medicare into a defined contribution sort of voucher system.” Oh, wait — that was Paul Ryan himself.

And what if the vouchers — for that’s what they are — turned out not to be large enough to pay for adequate insurance? Then those who couldn’t afford to top up the vouchers sufficiently — a group that would include many, and probably most, older Americans — would be left with inadequate insurance, insurance that exposed them to severe financial hardship if they got sick, sometimes left them unable to afford crucial care, and yes, sometimes led to their early death.

So let’s be brutally honest here. The Romney-Ryan position on health care is that many millions of Americans must be denied health insurance, and millions more deprived of the security Medicare now provides, in order to save money. At the same time, of course, Mr. Romney and Mr. Ryan are proposing trillions of dollars in tax cuts for the wealthy. So a literal description of their plan is that they want to expose many Americans to financial insecurity, and let some of them die, so that a handful of already wealthy people can have a higher after-tax income.

It’s not a pretty picture — and you can see why Mr. Romney chooses not to see it.

By: Paul Krugman, Op-Ed Columnist, The New York Times, October 16, 2012

October 17, 2012 Posted by | Election 2012 | , , , , , , , | 2 Comments

“Wrong Again Mitt”: Romney Says People Don’t Die Because They Lack Insurance

In an interview with the Columbus Dispatch in Ohio published Thursday, Mitt Romney repeated a claim that already got him in trouble once this cycle and has reflects an enduring belief among Republicans: that people in the U.S. don’t die because they lack health insurance.
“[Y]ou go to the hospital, you get treated, you get care, and it’s paid for, either by charity, the government or by the hospital,” Romney said. “We don’t have people that become ill, who die in their apartment because they don’t have insurance.”

It’s eerily reminiscent of a statement President George W. Bush made in 2007 that haunted Republicans during the 2008 campaign — “[P]eople have access to health care in America. After all, you just go to an emergency room.”

There’s just one problem: It’s not true.

Numerous studies over the past 10 years conclude that tens of thousands of Americans die each year because they lack insurance.

A 2009 study conducted at Harvard Medical School and Cambridge Health Alliance, and published in the American Journal of Public Health concluded that “[l]ack of health insurance is associated with as many as 44,789 deaths per year in the United States, more than those caused by kidney disease. … The increased risk of death attributable to uninsurance suggests that alternative measures of access to medical care for the uninsured, such as community health centers, do not provide the protection of private health insurance.”

A 2012 report by the health care reform advocacy group Families USA concluded that 26,100 people died prematurely in America in 2010 due to lack of insurance. That report extrapolated from a 2002 Institute of Medicine study — conducted when the uninsurance rate was lower — which concluded that 18,000 people died prematurely because they weren’t covered.

In a 2009 update, the IOM concluded that uninsured patients are at higher risk of mortality or poor health outcomes in the aftermath of both acute medical issues (heart attacks, serious injury, stroke) and chronic ones (cancer, diabetes).

In 2008, the Urban Institute’s Stan Dorn concluded that “[b]ased on the IOM’s methodology and subsequent Census Bureau estimates of insurance coverage, 137,000 people died from 2000 through 2006 because they lacked health insurance, including 22,000 people in 2006. Much subsequent research has continued to confirm the link between insurance and mortality risk described by IOM. In fact, subsequent studies and analysis suggest that, if anything, the IOM methodology may underestimate the number of deaths that result from a lack of insurance coverage.”

Conservatives have attacked these findings and methods and argued that, controlling for health status, there’s no difference in survival probabilities between insured and uninsured people. When the Families USA report came out, Avik Roy, a Romney health adviser, called its findings “statistical hogwash.”

To buttress his argument, he cited a thorough study by Richard Kronick — a University of Rochester health policy expert who served in the Obama administration and was a senior adviser to Bill Clinton during his push for health care reform. His conclusion? “[I]f two people are otherwise similar at baseline … but one is insured and the other uninsured, their likelihood of survival over a 2-16-year follow-up period is nearly identical.”

Further, I show that survival probabilities for the insured and uninsured are similar even among disadvantaged subsets of the population; that there are no differences for long-term uninsured compared with short-term uninsured; that the results are no different when the length of the follow-up period is shortened; and that there are no differences when causes of death are restricted to those causes thought to be amenable to the quality of health care.

However, Kronick conceded that “[g]iven the inherent uncertainties in inferring causality from the results of observational analyses, the results presented here are not able to provide a definitive answer to the question, ‘How many fewer deaths would there be in the United States if all residents were continuously covered by health insurance?’”

In an interview, Urban’s Stan Dorn praised Kronick but defended his and his colleagues’ conclusion.

“I’m aware of Rick’s study and he’s a great researcher. And I guess what I’d say is it’s an outlier,” Dorn said in an interview. “There’s a lot of research that goes beyond what we did, and it’s an outlier.”

Dorn noted that other studies focusing on particular ailments make the link between uninsurance and death quite clear. “We know that women with cervical cancer who are uninsured get their cancer detected later…. We know that people with heart disease don’t take their medicine because they can’t afford it…and sometimes die.”

And as Boston University health economist Austin Frakt noted when he engaged this same controversy in February 2010, “among recent studies in this area the evidence is greater than three-to-one in favor of an insurance-health outcome link, including mortality.”

In 2006, then-Massachusetts governor Romney himself agreed — at least to an extent. Though he did not address the mortality issue specifically, in an April 2006 presentation before the Chamber of Commerce he conceded that uninsured people who seek health care at emergency rooms experience worse outcomes.

“There ought to be enough money to help people get insurance because an insured individual has a better chance of having an excellent medical experience than the one who has not. An insured individual is more likely to go to a primary care physician or a clinic to get evaluated for their conditions and to get early treatment, to get pharmaceutical treatment, as opposed to showing up in the emergency room where the treatment is more expensive and less effective than if they got preventive and primary care.”

 

By: Brian Beutler, Talking Points Memo, October 12, 2012

October 14, 2012 Posted by | Election 2012, Health Care | , , , , , , , | Leave a comment

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