Trump administration wants to get rid of protections for pre-existing conditions

Let’s see the Trump administration’s latest attempt to help the average American:

The Trump administration said in a court filing late Thursday that it will no longer defend key parts of the Affordable Care Act, including the requirement that people have health insurance and provisions that guarantee access to health insurance regardless of any medical conditions.

Both President Trump and leading Republicans have said they support protections for people with pre-existing conditions, but this was done with his knowledge:

Attorney General Jeff Sessions said in a letter to Congress on Thursday that Trump, who campaigned on repealing the law and nearly did so his first year in office, approved the legal strategy.

And it  affects a huge number of people:

It confirms that a large fraction of non-elderly Americans have pre-existing health conditions: at least 23 percent of Americans (61 million people) using a narrow definition based on eligibility criteria for pre-ACA state high-risk pools, or as many as 51 percent (133 million people) using a broader definition closer to the underwriting criteria used by insurers prior to the ACA.

Between 2010 and 2014, when the ACA’s major health insurance reforms first took effect, the share of Americans with pre-existing conditions who went uninsured all year fell by 22 percent, meaning 3.6 million fewer people went uninsured.

And the effect is pretty bad:

a 2009 survey found that, among adults who had individual market coverage or shopped for it in the previous three years, 36 percent were denied coverage, charged more, or had exclusions placed on their policy due to pre-existing conditions. A report by the Government Accountability Office estimated that, as of early 2010, the denial rate among individual market applications was 19 percent, and the most common reason for denial was health status.

It’s part of a long term strategy (notice the post is from February):

Already in recent weeks, the Trump administration has shown little interest in enforcing Obamacare’s guarantee that healthy and sick people get access to the same type of health insurance.

For example, it hasn’t intervened in Idaho, where regulators recently told insurers they can simply disregard many of the Affordable Care Act rules and sell new “freedom plans” that discriminate against sicker enrollees.

The rules the Trump administration rolled out Tuesday relate to “short-term” health plans, coverage that is meant to fill gaps between more permanent policies (for someone who takes a few months off between jobs, for example).

Short-term coverage is allowed to skirt several of the health care law’s core provisions: Plans can deny people insurance based on their medical history, charge them higher premiums because of their preexisting medical conditions, and craft skimpy benefits packages that will appeal mostly to young and healthy people.

So, as usual, Trump claims he’s trying to help people as he makes things much worse for them.

Insurance companies and Medical Providers join forces to increase healthcare costs

It would seem that insurance companies and hospitals would be adversaries since, you would think, insurance companies want to pay the hospitals as little as possible. It seems that’s not true:

The Affordable Care Act kept profit margins in check by requiring companies to use at least 80 percent of the premiums for medical care. That’s good in theory but it actually contributes to rising health care costs. If the insurance company has accurately built high costs into the premium, it can make more money. Here’s how: Let’s say administrative expenses eat up about 17 percent of each premium dollar and around 3 percent is profit. Making a 3 percent profit is better if the company spends more.

And, of course, this means the typical patient gets screwed:

But Frank was startled to see that Aetna had agreed to pay NYU Langone $70,000. That’s more than three times the Medicare rate for the surgery and more than double the estimate of what other insurance companies would pay for such a procedure, according to a nonprofit that tracks prices.

Fuming, Frank reached for the phone. He couldn’t see how NYU Langone could justify these fees. And what was Aetna doing? As his insurer, wasn’t its duty to represent him, its “member”? So why had it agreed to pay a grossly inflated rate, one that stuck him with a $7,088 bill for his portion?

It’s not just out of pocket expenses:

Economist Priyanka Anand of George Mason University said employers nationwide are passing rising health care costs on to their workers by asking them to absorb a larger share of higher premiums. Anand studied Bureau of Labor Statistics data and found that every time health care costs rose by a dollar, an employee’s overall compensation got cut by 52 cents.

The reason they can do this is it’s almost impossible to get the actual cost of medicine beforehand:

Patients who want to know what they’ll be paying — let alone shop around for the best deal — usually don’t have a chance. Before Frank’s hip operation he asked NYU Langone for an estimate. It told him to call Aetna, which referred him back to the hospital. He never did get a price.

This is starting to be solved by sites such as Healthcare Bluebook and state laws mandating medical cost transparency. Hospitals and others are pushing back, such as filing a lawsuit in Ohio to stop the implementation of a transparency law or they often ignore a law such as one passed in Massachusetts.

 

The Trump budget

Let’s look at some of the highlights of the Trump budget:

For example, the budget would cut $554 billion from Medicare spending over 10 years.

It also would make changes to Medicaid, the health program for lower-income Americans that is funded by the federal government and states. It would create a “market-based health-care grant” that could fund programs in addition to the traditional Medicaid program, a change that would lower Medicaid spending by about $250 billion over 10 years.

One program that would face the biggest reduction is the Supplemental Nutrition Assistance Program, which is a version of food stamps run by the Agriculture Department. The White House proposes cutting $214 billion from the program over 10 years, although Congress often fights about changing SNAP and rarely has enacted changes.

Kevin Drum adds in some more:

The Post Office loses $4 billion, primarily by giving them “the ability to address their expenses—including the cost of personnel.” In other words, by slashing pay and pensions. Low-income energy assistance is eliminated. Foreign aid is cut $5 billion. PBS funding is eliminated. Ditto for the National Endowment for the Arts and the National Endowment for the Humanities. HUD loses $9 billion, including a $4 billion cut in rental assistance. Etc. etc.
On the mandatory spending side, the budget proposes cuts of $266 billion to Medicare over ten years. SNAP loses $213 billion. Obamacare is eliminated, of course. “Waste and abuse” will generate savings of $187 billion. Farmers lose $47 billion. Subsidized student loans go away, as does the student loan forgiveness program.

And yet it still increases the deficit by a lot:

The White House projects a large gap between government spending and tax revenue over the next decade, adding at least $7 trillion to the debt over that time. In 2019 and 2020 alone, the government would add a combined $2 trillion in debt under Trump’s plan.

And even to get that they assume very rosy projections that are unlikely to happen.

On the one hand this budget is meaningless since the recently passed budget doesn’t follow this plan, on the other this tells us what the Trump administration wants: massively increase defense spending even though the US easily has the largest defense budget in the world already; cut almost all domestic spending, especially that which goes to the non-rich and science; pass large tax cuts that mostly go to the rich and big corporations even if it explodes the deficit.

 

Punish the poor

Hmm, should there be work requirements for Medicaid?

Conservatives like to assert that Medicaid somehow suppresses the desire to work, but that appears to be a fantasy. Studies have found no evidence for it. For example, a study published in the journal Health Affairs in 2016 found that “Medicaid expansion did not result in significant changes in employment, job switching, or full- versus part-time status.”

What the evidence does show, however, is that work requirements attached to social programs are ineffective. The best research involves TANF, or Temporary Assistance for Needy Families program, which replaced traditional welfare and added a work mandate. Several studies have shown that TANF recipients who are able to work do so whether or not they’re subject to the requirement, which suggests that it’s not necessary. Those who find employment end up in low-wage jobs, typically earning about as much as the TANF and food stamp benefits their earnings replaced.

Work had not lifted them out of poverty or increased their income relative to what they had received from TANF and food stamps,” one study found, contrary to Verma’s aspirational language. The work requirements failed to reflect that many of the program enrollees faced social, educational or physical barriers to employment, conditions that are likely to be replicated among unemployed Medicaid recipients.

Moreover, the work requirements added bureaucratic burdens that affected program administrators as well as enrollees, sometimes severe enough to discourage enrollment.

Those studies aren’t politically correct so the Trump administration ignores them and says:

Verma tried to put an uplifting spin on the new policy on work requirements: “We owe beneficiaries more than a Medicaid card,” she tweeted; “We owe them the opportunity and resources to connect with job skills, training and employment so they can rise out of poverty.”

Now that’s something the Republicans can believe (but they won’t actually increase funding for job training). Really they just want to punish the poor but they can’t say that so they make stuff up.

Who needs evidence?

Well, this is surprising if by surprising you mean completely expected:

The Trump administration has abruptly halted work on a highly regarded program to help physicians, families, state and local government agencies, and others separate effective “evidence-based” treatments for substance abuse and behavioral health problems from worthless interventions.

The program, called the National Registry of Evidence-Based Programs and Practices, was launched in 1997 and is run by the Substance Abuse and Mental Health Services Administration. Its website lists 453 programs in behavioral health — aimed at everything from addiction and parenting to HIV prevention, teen depression, and suicide-hotline training — that have been shown, by rigorous outcomes measures, to be effective and not quackery. The most recent were added last September.

It seems there were problems with registry:

In fact, a recent paper in the International Journal of Drug Policy found the registry contained programs with limited studies evaluating them or studies with very small sample sizes to accurately measure their success.

So there was a good reason to look at it and try to make it better, but this is the Trump administration:

However, no specific details regarding when the new program will begin and when results will be made public were provided. The current registry will remain online as of now, but will not be updated.

SAMHSA’s statement was the first public response it had provided since the email it sent out two weeks ago announcing the registry would be frozen. That announcement took mental health advocates by surprise. “It came with such a blinding speed,” said Richard Yep, CEO of the American Counseling Association. “People were initially really shocked by the whole thing.”
Without any additional information from SAMSHA, Yep said mental health professionals were left to speculate what was next and why the registry had stopped.
Yep admits that the program wasn’t flawless but said “it has stood the test of time.” He questioned why a replacement wasn’t up and running to take over the work and called the decision to freeze the registry short-sighted. “Why didn’t you start that system up and compare it side-by-side? Instead, to just cut it off, it makes no sense professionally.”
The Trump administration is, by its nature, sloppy and that’s what you get here.

Children’s Health

Ok, this is stupid:

CBO and the staff of the Joint Committee on Taxation (JCT) have completed a preliminary estimate of the budgetary effects of extending funding for the Children’s Health Insurance Program (CHIP) for 10 years using specifications provided by your staff. Under those specifications, the provisions of S. 1827, the Keep Kids’ Insurance Dependable and Secure Act of 2017 (KIDS Act), would be extended. In particular, all of the provisions that would be in place in 2022, the final year of funding under that Act, would continue unchanged for the remainder of the 2023-2027 period. The agencies estimate that enacting such legislation would decrease the deficit by $6.0 billion over the 2018-2027 period.

And yet:

Some states will run out of money by February 1 if an agreement is not made, according to estimates from Georgetown University’s Health Policy Institute based in Washington, D.C., but more conservative estimates from the U.S. Centers for Medicare and Medicaid Services (CMS) suggest several states risk burning through the federal funds by January 19.

What’s the problem?

In December, Congress provided short-term finances for CHIP, but lawmakers have not moved to give the program another five-year allotment because Democrats and Republicans disagree on how to finance it. Republicans wanted to pull money from public health programs—like Medicare—and Democrats refused. The minority party’s votes will be necessary for Republicans to pass a solution, and some politicians have predicted a deal will be struck next week before the January 19 deadline.

Now that the CBO says it will save the government money, will Republicans actually pass it? Who knows–it’s not like they care about people.

The poor don’t need healthcare

Here’s the Trump administration’s idea of helping people out:

Underpinning that effort is Verma’s belief that the expansion of Medicaid under the Affordable Care Act was a disastrous move that extended coverage to millions of low-income people who shouldn’t be getting insurance from the government.
“We’ve put more than 10 million people, 12 million people into this program where the doctors won’t see them, and the policies that are in the Medicaid program are not designed for an able-bodied individual,” she said. Verma added that the administration’s goal is to keep those people in the private insurance market, where they would not be “dependent on public assistance.”

Umm, Verma, the whole reason they are on Medicaid is they don’t have and can’t afford private insurance so keeping them in the private insurance market means keeping them without insurance. I know that’s the Republican ideal but you would think she might want to circumspect when she says people don’t deserve insurance.

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