Trump is trying to kill Obamacare

Donald Trump is trying to convince everybody that the ACA is in a death spiral. It isn’t according to the CBO:

Although premiums have been rising under current law, most subsidized enrollees purchasing health insurance coverage in the nongroup market are largely insulated from increases in premiums because their out-of-pocket payments for premiums are based on a percentage of their income; the government pays the difference between that percentage and the premiums for a reference plan. The subsidies to purchase coverage, combined with the effects of the individual mandate, which requires most individuals to obtain insurance or pay a penalty, are anticipated to cause sufficient demand for insurance by enough people, including people with low health care expenditures, for the market to be stable in most areas.

Nevertheless, some areas of the country have limited participation by insurers in the nongroup market under current law. Several factors could lead insurers to withdraw from the market—including lack of profitability and substantial uncertainty about enforcement of the individual mandate and about future payments of the cost-sharing subsidies to reduce out-of-pocket payments for people who enroll in nongroup coverage through the marketplaces established by the ACA.

Pay attention to that last bit because the Trump administration is trying very hard to kill the ACA:

As the fate of the Affordable Care Act dangled dramatically in the Senate last month, the Trump administration abruptly canceled contracts with two companies that have helped thousands of Americans in 18 cities find health plans under the law.

The suspension of the $22 million contracts, which ends enrollment fairs and insurance sign-ups in public libraries, is one of the few public signs of how an administration eager to kill the law will run the ACA’s approaching fifth enrollment season.

President Trump continues to stage photo ops at the White House and on travels with people he terms “Obamacare victims.” The Department of Health and Human Services is issuing weekly maps showing the few dozen counties that might lack an ACA health plan for next year.

Officials provided no assurances at that meeting, however, about whether the administration would continue the government’s other usual enrollment activities or promotion. (In January, it had halted most advertising aimed at encouraging consumers to sign up in the final crucial days before the deadline for 2017 coverage.)

For now, the largest mystery looming over the upcoming enrollment season is whether the president will carry out his stated resolve to end payments made to insurers on behalf of about 7 million lower-income customers to help them afford their ACA plans’ deductibles and copays.

There are other unknowns that also will shape — or upend — the enrollment period when it begins Nov. 1: Will the government contact the roughly 10 million people with ACA coverage to alert them that sign-ups will last just 45 days, about half as long as in the past three years? Will HHS run call centers for consumers who need help as they look for plans? Will the HealthCare.gov computer system be adjusted to accommodate a possible crush of shoppers given the shorter time frame?

And how will automatic enrollment be handled? In previous years, notices have been sent out in mid-December, informing customers with coverage about price changes for their current health plan and urging them to shop around. This year, Dec. 15 is when enrollment will end.

If the rates go way up ( or if insurance companies drop out of many more parts of the country) it will be largely because insurance companies won’t know how much the government will subsidize people and they don’t know if the mandate will be enforced; if the number of people who sign up for the ACA goes way down it will be for the same reasons and because the Trump administration won’t advertise and won’t help anyone if they want to sign up.

The only reason the ACA will fail is if the Trump administration kills it.

Let’s vote blindly

You might remember that old Republican talking point where Representative Pelosi says the other reps will have to vote on the ACA to see what’s in it. This is wrong (she was saying that there was so much disinformation around that the public wouldn’t really know what it did until it was passed into law), but now look what Republicans are doing:

Senate Majority Leader Mitch McConnell, R-Ky., scheduled the initial vote on beginning debate for Tuesday, though it remained unclear exactly which version of the legislation would be in play.

This would be funny if it wasn’t so tragic, McConnell expects Republicans to vote to open up debate on some bill even though they don’t know which bill. They will literally have to vote to see which bill they’re going to debate.

Update: And the Republicans voted to debate some bill, any bill, to give the rich huge tax cuts.

More about Medicaid cuts

The CBO has extended their estimate of what the Republican tax cut … errr healthcare plan will do to Medicaid:

In the Congressional Budget Office’s assessment, Medicaid spending under the Better Care Reconciliation Act of 2017 would be 26 percent lower in 2026 than it would be under the agency’s extended baseline, and the gap would widen to about 35 percent in 2036 (see Figure 1). under CBO’s extended baseline, overall Medicaid spending would grow 5.1 percent per year during the next two decades, in part because prices for medical services would increase. under this legislation, such spending would increase at a rate of 1.9 percent per year through 2026 and about 3.5 percent per year in the decade after that.

In CBO’s extended baseline, Medicaid spending is projected to be 2.0 percent of GDP in 2017 and 2.4 percent by 2036. The 35 percent reduction in that spending that CBO estimates for 2036 under this legislation would result in Medicaid spending of 1.6 percent of GDP.

That sure seems like a big cut.

Via here, Avalere Health looks at the impact for each state, for example my state of Massachusetts will see a decrease of 17% in funding for Medicaid by 2026 for a total cut of $9.7 billion. Thanks Republicans.

Senate version of Tax Cut bill cuts insurance for 22 million

So the CBO score for the Senate Republican’s tax-cut err healthcare bill is out and it’s about as bad as the House version:

CBO and JCT estimate that, in 2018, 15 million more people would be uninsured under this legislation than under current law—primarily because the penalty for not having insurance would be eliminated. The increase in the number of uninsured people relative to the number projected under current law would reach 19 million in 2020 and 22 million in 2026. In later years, other changes in the legislation—lower spending on Medicaid and substantially smaller average subsidies for coverage in the nongroup market—would also lead to increases in the number of people without health insurance. By 2026, among people under age 65, enrollment in Medicaid would fall by about 16 percent and an estimated 49 million people would be uninsured, compared with 28 million who would lack insurance that year under current law.

They also note that the ACA is not failing:

Although premiums have been rising under current law, most subsidized enrollees purchasing health insurance coverage in the nongroup market are largely insulated from increases in premiums because their out-of-pocket payments for premiums are based on a percentage of their income; the government pays the difference between that percentage and the premiums for a reference plan (which is the second-lowest-cost plan in their area providing specified benefits). The subsidies to purchase coverage, combined with the effects of the individual mandate, which requires most individuals to obtain insurance or pay a penalty, are anticipated to cause sufficient demand for insurance by enough people, including people with low health care expenditures, for the market to be stable in most areas.

Nevertheless, a small number of people live in areas of the country that have limited participation by insurers in the nongroup market under current law.

The rest of that second paragraph explains why there is a problem in small areas:

Several factors may lead insurers to withdraw from the market—including lack of profitability and substantial uncertainty about enforcement of the individual mandate and about future payments of the cost-sharing subsidies to reduce out-of-pocket payments for people who enroll in nongroup coverage through the marketplaces established by the ACA.’

Yup, they conclude it’s because of the actions of Donald Trump (who has told the IRS not to enforce the penalty for the individual mandate and has said he might cut the future payments for the cost-sharing subsidies) and Republicans in general.

So, the final analysis is we have to cut insurance for 22 million people so there can be large tax cuts for the rich, the ultra rich, and major corporations.

Republican tax-cut bill has no transparency

It seems Republicans don’t want anyone to know about their healthcare proposal:

This has become more evident each day, as the Senate plots out a secretive path toward Obamacare repeal — and top White House officials (including the president) consistently lie about what the House bill actually does.

There was even a brief moment Tuesday where Senate Republicans flirted with the idea of banning on-camera interviews in congressional hallways, a plan quickly reversed after outcry from the press.

Republicans decried the secrecy of the ACA but:

“There were hundreds of hearings and markups that lasted days — or in the case of the Senate Health, Education, Labor and Pensions Committee, months,” Rovner recalls in her piece.

Senators wanted to talk about the Affordable Care Act and why they believed they needed to pass it. They gave floor speech and after floor speech defending its provisions. Patients had months to lobby their legislators on particular issues that they thought were important. A few months ago I interviewed one woman, for example, who successfully lobbied former Sen. Kent Conrad (D-ND) to add a ban on lifetime limits in health insurance.

I remember Christmas Eve 2009 in particular, when I lived in New York and my roommate’s family came to visit for the holiday. They opened presents in our living room. I was holed up in my bedroom watching the Senate vote on the ACA, the culmination of a 25-day floor debate.

They really don’t want any time for the public to complain:

There are some factors that could slow down the Senate. In comparison to the House, the Senate is barred from voting on a bill before a cost and impact estimate is released from the nonpartisan CBO.

But if the Senate is to really vote before they leave town for a week on June 30th, a goal that many Republicans hope is still achievable, that leaves little time for the public to see legislation. A CBO score takes 10 to 14 days to produce. There are only 17 days left before the end of the month.

The approach is broadly similar to the process that produced the American Health Care Act in the House last month. At the time, leaders released a finished bill and voted on it within 24 hours — so fast that the Congressional Budget Office couldn’t estimate its cost and effects for another three weeks. The move was a jarring shift after years of promises from House GOP leaders to slow down major legislation and post all bills online several days before a vote.

That last bit is obviously ironic as Republicans never seem to have a problem breaking promises or norms.

Some Republicans are complaining about the secrecy:

“I’ve said from Day 1, and I’ll say it again,” said Senator Bob Corker, Republican of Tennessee. “The process is better if you do it in public, and that people get buy-in along the way and understand what’s going on. Obviously, that’s not the route that is being taken.”

Senator Ron Johnson, Republican of Wisconsin, offered a hint of the same frustration felt by Democrats seeking more information about the bill.

“I come from a manufacturing background,” Mr. Johnson said. “I’ve solved a lot of problems. It starts with information. Seems like around here, the last step is getting information, which doesn’t seem to be necessarily the most effective process.”

Mr. Paul said he had no plans to bring out the copy machine again, but he suggested that the Senate’s current course left something to be desired. “My preference would be a more open process in committees,” he said, “with hearings and people on both sides.”

but they obviously don’t really mean it. After all there are at least three Senate Republicans saying they would like the bill to be more open and yet it’s not open. Since there are 52 Republicans in the Senate and all Democrats are opposed to the bill, three Republicans could kill the bill. This gives them a lot of power and yet, somehow, they’re not using it to make the process more open. That tells you they don’t really care. Just like Republicans don’t care if millions of Americans lose their health insurance.

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