Obamacare Autopsy
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Maine’s Sen. Susan Collins co-develops plan to replace Affordable Care Act
It would let states keep the ACA insurance programs they have or try other options, she says,
hoping millions would avoid losing health coverage after a repeal of the law.
Susan Collins
Jan. 17th 2017
Republican Sens. Susan Collins of Maine and Bill Cassidy of Louisiana will introduce a replacement for the Affordable Care Act that would allow states to maintain what they have or choose other options to provide health insurance to their residents.
“If (states) like the Affordable Care Act, they can keep the Affordable Care Act,” Collins said on the Senate floor Tuesday afternoon, referring to the new plan as a more “comprehensive and creative” approach.
“Each state could opt to stay in Obamacare,” Cassidy said. “We think they should have the right to stay in Obamacare. If Obamacare is working for you, God bless you.”....................
https://www.pressherald.com/2017/01/17/sens-collins-cassidy-to-offer-obamacare-replacement/
I'm 'Bubba the Deplorable' and I need Obamacare
Russell McKee
By Russell McKee,
an independent voter and a CPA living in Mobile, Alabama
I'm your neighbor.
I sit behind you at church and next to you at Little League baseball games.
I joined you when we all screamed "Obamacare is bad."
Then my employer merged with another company and they didn't need me anymore.
I reassured Mrs. Bubba that all would be well.
Although outrageously expensive, my family and I used the COBRA health benefits from my former employer until they ran out.
Mrs. Bubba needed more assurance because she was not a big fan of going without health insurance.
I went to Blue Cross and they were happy to charge us $1,477 per month for insurance; but they said my blood sugar was too high, little Bubba had too many ear infections and Mrs. Bubba has that lower back pain so you have to pay for all that yourself - preexisting conditions.
Mrs. Bubba ended up on her knees every night praying for our family's continued health.
I sit behind you at church and next to you at Little League baseball games.
I joined you when we all screamed "Obamacare is bad."
Then my employer merged with another company and they didn't need me anymore.
I reassured Mrs. Bubba that all would be well.
Although outrageously expensive, my family and I used the COBRA health benefits from my former employer until they ran out.
Mrs. Bubba needed more assurance because she was not a big fan of going without health insurance.
I went to Blue Cross and they were happy to charge us $1,477 per month for insurance; but they said my blood sugar was too high, little Bubba had too many ear infections and Mrs. Bubba has that lower back pain so you have to pay for all that yourself - preexisting conditions.
Mrs. Bubba ended up on her knees every night praying for our family's continued health.
In 2013:
In 2013, Mrs. Bubba said we should check on Obamacare.
"But Obamacare is bad," I told her. She asked why. I couldn't answer. I thought I'd better find out for myself before Mrs. Bubba asked again.
I was shocked at what I found: Today, there are over 2.5 million people in Alabama that have health coverage through their employer. I was one of them back in the day. There are almost 1 million people covered by Medicaid or a Children's Health plan. There are almost 1 million people covered by Medicare. There are about 165,000 Alabamians covered by Obamacare.
What?
95 percent of my very vocal fellow citizens don't even have a dog in the fight? My friends told me it was wrong for the government to make anyone buy health insurance. Friends, I'm part of the five percent that wants to buy health insurance because most of us have a Mrs. Bubba.
Preexisting conditions - covered. Lifetime limits on coverage - gone. Little Bubba gets a "free" ride on my coverage until he turns 26 - yep (per Mrs. Bubba). Flu shots, cancer screenings, mammograms and other preventative care with no out of pocket cost - check.
There was even some good news for my parents because Obamacare tweaked Medicare to cover some preventative care and began to reduce the outrageous prescription drug cost they paid while in the Medicare donut hole.
Best of all, about 85 percent of Obamacare enrollees qualify for help in paying the premium but it turns out you have to be living pretty close to the poverty level to see any significant help. Or you can be a US Congressperson that makes $174,000 per year and gets a subsidy of 75 percent toward health insurance cost. I don't make anywhere near $174,000 but my family didn't qualify for a subsidy. It did not change our decision to buy Obamacare insurance.
Being a taxpaying, fiscally responsible citizen of Alabama, the final hurdle to cover in my support of Obamacare was where the Obamacare money came from. Clearly, my premium and the new 25 percent premium increase goes into the bucket along with everyone else who is covered by Obamacare.
It turns out that if you have taxable income over $250,000, congratulations! You are in the top five percent of earners in the US - you kick in a little if you have a lot of investment earnings. However, the average Alabama family earns around $43k.
The $1 trillion health insurance industry puts money in the bucket, the $1.1 trillion pharmaceutical industry puts money in the bucket and the $400 billion medical device industry kicks in some money.
Guess what?
I'm OK with those groups putting in a few dollars since, in my view, they can afford to support those that turn around and fork out princely sums for their services. In fact, so much money rolls through BC/BS of Alabama they had to have the Alabama legislature pass a law in 2015 to hide executive pay from the public. Nunya...
I want to keep Obamacare.
I was ignorant and just parroted the mantra that "Obamacare is bad."
Now I know better. Can it be improved? Sure.
First, call it anything other than Obamacare. That would help bigly.
Now I know better. Can it be improved? Sure.
First, call it anything other than Obamacare. That would help bigly.
Then get off your high horse and help regular people. Bradley Byrne and our Senators want to repeal and replace Obamacare. They convinced a large number of folks with little or no skin in the game based on nothing more than slogans. Just because you say it doesn't make it so.
But, Rep. Byrne, before you throw 165,000 of your neighbors in the ditch, I want to know more about the replacement you tout at every opportunity. I know what's best for my family, not the 95 percent with health coverage.
Tell me what you plan to do so I don't have to answer to Mrs. Bubba. She can read it and decide for herself.
SOURCE: http://www.al.com/opinion/index.ssf/2017/01/im_bubba_the_deplorable_and_i.html
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WATCH: Trump Voters In Coal Country Worried They’ve Voted Away Their Health Care (VIDEO)
December 30th, 2016
Elisabeth Parker Economy, elections, News, Politics, Poverty, Tea Party 72 Comments
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Contrary to what many of us liberals think, Trump voters in coal country aren’t dumb. They know they’re screwed without healthcare, they know they get it through Obamacare, and they know the GOP is champing at the bit to repeal it.
So why the hell did so many of them vote for Donald Trump? Because he said what Hillary Clinton won’t (and can’t without lying). He promised to bring their lost coal mining jobs back. And when push comes to shove, coal country voters don’t want Obamacare. They want well-paying jobs with healthcare, paid vacation, and all those other great benefits so many of us don’t get anymore.
On the campaign trail, Mein Trumpf vowed to fix those job-killing EPA standards and get those coal mines up and running again.
“We’re going to get those miners back to work … the miners of West Virginia and Pennsylvania, which was so great to me last week, Ohio and all over are going to start to work again, believe me. They are going to be proud again to be miners.”
After decades of decline, despair, and economic struggle in towns across coal country, this was music to their ears. Too bad Donald Trump can’t deliver on his promises. As the AP points out, clean air standards aren’t the only reason for coal’s decline. Other reasons for the coal mining slump are automation, dwindling reserves of coal, and the increased availability of cheaper, cleaner-burning natural gas.
Coal country voters also have another beef with Obamacare: While small business owners and other workers struggle to afford their ever-rising premiums on their bare bones, high-deductible plans, those lazy, undeserving, not-working poor get the good healthcare: Medicare and Medicaid.
Sarah Kliff from Vox reports “the uninsured rate declined 60 percent under Obamacare” in Whitley County, Ky. Yet, despite so many voters having access to healthcare for the first time in years, 82 percent of them cast their ballots for Donald Trump.
Many expressed frustration that Obamacare plans cost way too much, that premiums and deductibles had spiraled out of control. And part of their anger was wrapped up in the idea that other people were getting even better, even cheaper benefits — and those other people did not deserve the help.
After spending time there and talking with people, Kliff found the people of Whitley County fiercely believe Donald Trump can fix these issues and make Obamacare work better. Some even hope the Medicaid expansion “might become even more robust” so the working poor can receive the same healthcare the poor receive: In other words, a public option for healthcare.
This may sound naive, given that the GOP and Donald Trump himself have vowed to repeal Obamacare. But Greg Sargent from The Washington Post points out that the president-elect also promised to replace this botched healthcare program with “something terrific.”
In fact, he touted himself as being different than other Republicans. Trump sounded like he believes in a social safety net, but only for deserving people who work hard. And of course, we all see ourselves as “deserving”…Especially when we’re white. During the primary debates, he even told his fellow Republicans he won’t allow people to “die on the street.”
Trump also repeatedly vowed not to touch Medicare, explicitly holding this up as proof he is not ideologically aligned with Paul Ryan on the safety net.
Donald Trump likely won the White House more on these empty promises than on his bigotry. But now, he’s got a big problem.
If coal country voters lose their healthcare, there will be hell toupée.
Coal country voters went out on a limb for Donald Trump, but if he doesn’t deliver, a lot of them will be done with him. According to CNN report, there’s a little-known provision in the ACA that makes it easier for coal miners with black lung disease — or their widows — to get disability benefits, which include payments and healthcare. Now folks in coal country are deeply worried about losing these benefits.
One man who worked in the coal mines for over three decades fretted:
“When they eliminate the Obamacare, they may just eliminate all of the black lung program. It may all be gone. Don’t matter how many years you got.”
A miner’s widow who has applied for the benefits even told CNN’s Miguel Marquez that if the ACA gets repealed, she’ll see it as a rank betrayal.
“If he [Donald Trump] don’t come across like he promised, he’s not gonna be there next time. Not if I can help it.”
Alas, even if Donald Trump really wants to improve healthcare, he can’t do it without either more spending or a public option, both of which his party adamantly oppose.
December 30th, 2016
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Contrary to what many of us liberals think, Trump voters in coal country aren’t dumb. They know they’re screwed without healthcare, they know they get it through Obamacare, and they know the GOP is champing at the bit to repeal it.
So why the hell did so many of them vote for Donald Trump? Because he said what Hillary Clinton won’t (and can’t without lying). He promised to bring their lost coal mining jobs back. And when push comes to shove, coal country voters don’t want Obamacare. They want well-paying jobs with healthcare, paid vacation, and all those other great benefits so many of us don’t get anymore.
On the campaign trail, Mein Trumpf vowed to fix those job-killing EPA standards and get those coal mines up and running again.
“We’re going to get those miners back to work … the miners of West Virginia and Pennsylvania, which was so great to me last week, Ohio and all over are going to start to work again, believe me. They are going to be proud again to be miners.”
After decades of decline, despair, and economic struggle in towns across coal country, this was music to their ears. Too bad Donald Trump can’t deliver on his promises. As the AP points out, clean air standards aren’t the only reason for coal’s decline. Other reasons for the coal mining slump are automation, dwindling reserves of coal, and the increased availability of cheaper, cleaner-burning natural gas.
Coal country voters also have another beef with Obamacare: While small business owners and other workers struggle to afford their ever-rising premiums on their bare bones, high-deductible plans, those lazy, undeserving, not-working poor get the good healthcare: Medicare and Medicaid.
Sarah Kliff from Vox reports “the uninsured rate declined 60 percent under Obamacare” in Whitley County, Ky. Yet, despite so many voters having access to healthcare for the first time in years, 82 percent of them cast their ballots for Donald Trump.
Many expressed frustration that Obamacare plans cost way too much, that premiums and deductibles had spiraled out of control. And part of their anger was wrapped up in the idea that other people were getting even better, even cheaper benefits — and those other people did not deserve the help.
After spending time there and talking with people, Kliff found the people of Whitley County fiercely believe Donald Trump can fix these issues and make Obamacare work better. Some even hope the Medicaid expansion “might become even more robust” so the working poor can receive the same healthcare the poor receive: In other words, a public option for healthcare.
This may sound naive, given that the GOP and Donald Trump himself have vowed to repeal Obamacare. But Greg Sargent from The Washington Post points out that the president-elect also promised to replace this botched healthcare program with “something terrific.”
In fact, he touted himself as being different than other Republicans. Trump sounded like he believes in a social safety net, but only for deserving people who work hard. And of course, we all see ourselves as “deserving”…Especially when we’re white. During the primary debates, he even told his fellow Republicans he won’t allow people to “die on the street.”
Trump also repeatedly vowed not to touch Medicare, explicitly holding this up as proof he is not ideologically aligned with Paul Ryan on the safety net.
Donald Trump likely won the White House more on these empty promises than on his bigotry. But now, he’s got a big problem.
If coal country voters lose their healthcare, there will be hell toupée.
Coal country voters went out on a limb for Donald Trump, but if he doesn’t deliver, a lot of them will be done with him. According to CNN report, there’s a little-known provision in the ACA that makes it easier for coal miners with black lung disease — or their widows — to get disability benefits, which include payments and healthcare. Now folks in coal country are deeply worried about losing these benefits.
One man who worked in the coal mines for over three decades fretted:
“When they eliminate the Obamacare, they may just eliminate all of the black lung program. It may all be gone. Don’t matter how many years you got.”
A miner’s widow who has applied for the benefits even told CNN’s Miguel Marquez that if the ACA gets repealed, she’ll see it as a rank betrayal.
“If he [Donald Trump] don’t come across like he promised, he’s not gonna be there next time. Not if I can help it.”
Alas, even if Donald Trump really wants to improve healthcare, he can’t do it without either more spending or a public option, both of which his party adamantly oppose.
Boehner: Republicans won't repeal and replace Obamacare
'They’re basically going to fix the flaws and put a
more conservative box around it,' Boehner said.
more conservative box around it,' Boehner said.
Former House Speaker John Boehner’s comments come as Republican lawmakers across the country are facing angry constituents at
town halls worried that Obamacare will be yanked away without a suitable replacement. | AP Photo
ormer House Speaker John Boehner predicted on Thursday that a full repeal and replace of Obamacare is “not what’s going to happen” and that Republicans will instead just make some fixes to the health care law.
Boehner, who retired in 2015 amid unrest among conservatives, said at an Orlando healthcare conference that GOP lawmakers were too optimistic in their talk of quickly repealing and then replacing Obamacare.
“They’ll fix Obamacare, and I shouldn’t have
called it repeal and replace because that’s not
what’s going to happen. They’re basically going
to fix the flaws and put a more conservative box
around it,” Boehner said.
called it repeal and replace because that’s not
what’s going to happen. They’re basically going
to fix the flaws and put a more conservative box
around it,” Boehner said.
The former speaker’s frank comments capture the conundrum that many Republicans find themselves in as they try to deliver on pledges to axe Obamacare but struggle to coalesce around an alternative.
Republican lawmakers across the country this week are facing angry constituents at town halls worried that Obamacare will be yanked away without a suitable replacement.
President Donald Trump has said in recent days that he will release a plan by early to mid-March on how the administration plans to move forward on repeal-and-replace.
But so far, no clear path has emerged.
Earlier in the panel discussion, Boehner said he “started laughing” when Republicans started talking about moving lightning fast on repeal and then coming up with an alternative.
"In the 25 years that I served in the United States Congress,
Republicans never, ever, one time agreed on what a health
care proposal should look like. Not once,” Boehner said.
“And all this happy talk that went on in November and
December and January about repeal, repeal, repeal—yeah,
we'll do replace, replace—I started laughing, because if you
pass repeal without replace, first, anything that happens
is your fault. You broke it.”
Republicans never, ever, one time agreed on what a health
care proposal should look like. Not once,” Boehner said.
“And all this happy talk that went on in November and
December and January about repeal, repeal, repeal—yeah,
we'll do replace, replace—I started laughing, because if you
pass repeal without replace, first, anything that happens
is your fault. You broke it.”
Boehner added that he has told Republican leaders that unless a repeal is packaged with a replacement, GOP lawmakers would not likely reach a consensus about an alternative to Obamacare.
"And secondly, as I told some of the Republican leaders when they asked, I said, if you pass repeal without replace you'll never pass replace, because they will never ever agree on what the bill should be. Perfect always becomes the enemy of the good,” Boehner said.
Boehner said what Republicans ultimately come up with could share a lot of the same qualities with Obamacare.
"Most of the Affordable Care Act, in the framework, is going to stay there:
- coverage for kids up to age 26,
- covering those with preexisting conditions.
All of that's going to be there. Subsidies for those who can't afford it, who aren't on Medicaid, who I call the working poor, subsidies for them will be there," Boehner said.
"What will be different is that CMS will not dictate to every single state how the plan's going to run. And if the state wants to run an exchange, the state can run an exchange. The states will control the policies that are offered like they control every other insurance product offered in their states,” he added.
SOURCE: http://www.politico.com/story/2017/02/john-boehner-obamacare-republicans-235303
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What the bastards should have done all along, but didn't, leaving so many
to suffer through its flaws in the name of defeat the damn Black Guy.
.
What you lose in government benefits, you gain in tax cuts. I had mentioned how the insurance industry could have easily resolved the pre existing condition dilemma through the employer market without government mandates. They could have made money insuring people against this risk.
I am also seeing the same problem with workers comp, many people work in jobs that make them susceptible to cumulative trauma injuries that may not be covered. You work for FedEx delivering packages and you have back/knee problems that prevent you from working and supporting your family. Your employer could have gotten a policy to cover this type of injury instead of a bare bones plan. You could have been provided the option to pay to cover the difference.
I am also seeing the same problem with workers comp, many people work in jobs that make them susceptible to cumulative trauma injuries that may not be covered. You work for FedEx delivering packages and you have back/knee problems that prevent you from working and supporting your family. Your employer could have gotten a policy to cover this type of injury instead of a bare bones plan. You could have been provided the option to pay to cover the difference.
House Republicans release long-awaited
plan to repeal and replace Obamacare
http://wapo.st/2lPAw7APlay Video2:30
(Sarah Parnass/The Washington Post)
President Trump, Vice President Pence and House Speaker Paul Ryan (R-Wis.) keep saying a plan to repeal and replace Obamacare will be released soon, but few details have been released so far. Here's what they've said. Trump, Pence and Ryan keep saying a plan to repeal and replace Obamacare will be released soon, but few details have been released so far. (Video: Sarah Parnass/Photo: Jonathan Newton/The Washington Post)
By Amy Goldstein, Mike DeBonis and Kelsey Snell By Amy Goldstein, Mike DeBonis and Kelsey Snell March 6 at 6:40 PM
House Republicans on Monday released long-anticipated legislation to supplant the Affordable Care Act with a more conservative vision for the nation’s health care system, replacing federal insurance subsidies with a new form of individual tax credits and grants to help states shape their own policies.
Under two bills drafted by separate House committees, the government would no longer penalize Americans for failing to have health insurance but would try to encourage people to maintain coverage by allowing insurers to impose a surcharge of 30 percent for those who have a gap between health plans.
The legislation would preserve two of the most popular features of the 2010 health-care law, letting young adults stay on their parents’ health plans until age 26 and forbidding insurers to deny coverage or charge more to people with preexisting medical problems. It would also target Planned Parenthood, rendering the women’s health organization ineligible for Medicaid reimbursements or federal family planning grants — a key priority for antiabortion groups.
The debate, starting in House committees this week, is a remarkable moment in government health-care policymaking. The Affordable Care Act, former president Barack Obama’s signature domestic policy achievement passed in 2010 with only Democratic support, ushered in the most significant expansion of insurance coverage since the creation of Medicare and Medicaid as part of President Lyndon Johnson’s Great Society programs of the mid-1960s.
Taken together, the bills introduced Monday night represent the Republicans’ first attempt — and best shot to date, with an ally in the White House — to translate seven years of talking points about demolishing the ACA into action.
At the same time, major aspects of the plans, notably the strategy for tax credits and Medicaid, reflect the treacherous terrain that Republicans face to win enough votes within their own conferences in the GOP-controlled House and Senate.
The bills must address concerns of both conservatives worried about the cost of the overhaul and worries that it might in effect enshrine a new federal entitlement, as well as more moderate members who want to ensure that their constituents retain access to affordable health care, including those who received Medicaid coverage under the ACA.
Even so, signs emerged on Monday that Republicans in Congress’s upper chamber could balk either at the cost of the proposal or if it leaves swaths of the country without insurance coverage.
Sen. Rand Paul (R-Ky.) one of at least three conservative senators who opposes the plan to provide income-based tax credits, tweeted: “Still have not seen an official version of the House Obamacare replacement bill, but from media reports this sure looks like Obamacare Lite!”
And four key Republican senators, all from states that opted to expand Medicaid under the ACA, said they would oppose any new plan that would leave millions of Americans uninsured.
Democrats, meanwhile, have given no indication that they intend to work with Republicans, and top party leaders decried the GOP plan Monday as a betrayal of everyday Americans. “Trumpcare doesn’t replace the Affordable Care Act, it forces millions of Americans to pay more for less care,” said Senate Minority Leader Charles E. Schumer (D-N.Y.).
The tax credits outlined by the Ways and Means Committee’s portion of the legislation incorporate an approach that Republicans have long criticized: income-based aid to help Americans afford health coverage.
While the number of Americans who can afford health insurance has never been the priority for the GOP that it is for Democrats, President Trump has made clear that he is sensitive to any changes that would strand large numbers of people who gained coverage under the ACA.
[Conservative groups and lawmakers demanding ‘full repeal’ could derail Obamacare rollback]
Compared with the ACA’s subsidies, the tax credits would go to more people but provide less financial help to lower-income people, according to Larry Levitt, senior vice president of the Kaiser Family Foundation.
Meanwhile, the portion of the legislation drafted by the Energy and Commerce Committee would substantially redesign Medicaid in a way that attempts to balance the GOP’s antipathy toward the ACA’s expansion of the program against the concerns of a significant cadre of Republican governors — and the lawmakers from their states — who fear losing millions of dollars that the law has funneled to help insure low-income residents.
Medicaid would be converted from its current form of entitlement to anyone eligible into a per capita cap on funding to states, depending on how many people they had enrolled. In states that expanded Medicaid under the ACA, the government for now would continue paying for virtually the entire cost of the expansion.
Thirty-one states, plus the District of Columbia, have adopted that expansion. Starting in 2020, however, the GOP plan would restrict the government’s generous Medicaid payment — 90 percent of the cost of covering people in the expansion group — only to people who were in the program as of then. States would keep getting that amount of federal help for each of those people as long as they remained eligible, with the idea that most people on Medicaid drop off after a few years.
For the other 19 states that did not expand Medicaid, the legislation would provide $10 billion spread over five years. States could use that money to subsidize hospitals and other providers of care that treat many poor patients.
[A divided White House still offers little guidance on replacing Obamacare]
While members of the two committees working on the replacement drafts were determined to begin considering legislation this week, final work on them was still underway over the weekend and Monday, according to three individuals with knowledge of the process.
The change in thinking about tax credits emerged since Friday, when a White House meeting chaired by Budget Director Mick Mulvaney and attended by key GOP congressional figures was called to finalize key provisions.
At the same time, the shift to take income into account could create a potentially difficult ripple effect for Republicans, who regard a reduction in the federal government’s role in health care as a central reason to abandon the sprawling 2010 health care law. One motivation for the GOP thinking that credits could depend only on age was that the Internal Revenue Service would no longer have needed to verify the eligibility of people for financial help, as it has for ACA subsidies. If income is taken into account, the IRS would still need to be involved.
SOURCES: https://www.washingtonpost.com/powe...22680e18d10_story.html?utm_term=.480523b8b71a
.
plan to repeal and replace Obamacare
http://wapo.st/2lPAw7APlay Video2:30
(Sarah Parnass/The Washington Post)
President Trump, Vice President Pence and House Speaker Paul Ryan (R-Wis.) keep saying a plan to repeal and replace Obamacare will be released soon, but few details have been released so far. Here's what they've said. Trump, Pence and Ryan keep saying a plan to repeal and replace Obamacare will be released soon, but few details have been released so far. (Video: Sarah Parnass/Photo: Jonathan Newton/The Washington Post)
By Amy Goldstein, Mike DeBonis and Kelsey Snell By Amy Goldstein, Mike DeBonis and Kelsey Snell March 6 at 6:40 PM
House Republicans on Monday released long-anticipated legislation to supplant the Affordable Care Act with a more conservative vision for the nation’s health care system, replacing federal insurance subsidies with a new form of individual tax credits and grants to help states shape their own policies.
Under two bills drafted by separate House committees, the government would no longer penalize Americans for failing to have health insurance but would try to encourage people to maintain coverage by allowing insurers to impose a surcharge of 30 percent for those who have a gap between health plans.
The legislation would preserve two of the most popular features of the 2010 health-care law, letting young adults stay on their parents’ health plans until age 26 and forbidding insurers to deny coverage or charge more to people with preexisting medical problems. It would also target Planned Parenthood, rendering the women’s health organization ineligible for Medicaid reimbursements or federal family planning grants — a key priority for antiabortion groups.
The debate, starting in House committees this week, is a remarkable moment in government health-care policymaking. The Affordable Care Act, former president Barack Obama’s signature domestic policy achievement passed in 2010 with only Democratic support, ushered in the most significant expansion of insurance coverage since the creation of Medicare and Medicaid as part of President Lyndon Johnson’s Great Society programs of the mid-1960s.
Taken together, the bills introduced Monday night represent the Republicans’ first attempt — and best shot to date, with an ally in the White House — to translate seven years of talking points about demolishing the ACA into action.
At the same time, major aspects of the plans, notably the strategy for tax credits and Medicaid, reflect the treacherous terrain that Republicans face to win enough votes within their own conferences in the GOP-controlled House and Senate.
The bills must address concerns of both conservatives worried about the cost of the overhaul and worries that it might in effect enshrine a new federal entitlement, as well as more moderate members who want to ensure that their constituents retain access to affordable health care, including those who received Medicaid coverage under the ACA.
Even so, signs emerged on Monday that Republicans in Congress’s upper chamber could balk either at the cost of the proposal or if it leaves swaths of the country without insurance coverage.
Sen. Rand Paul (R-Ky.) one of at least three conservative senators who opposes the plan to provide income-based tax credits, tweeted: “Still have not seen an official version of the House Obamacare replacement bill, but from media reports this sure looks like Obamacare Lite!”
And four key Republican senators, all from states that opted to expand Medicaid under the ACA, said they would oppose any new plan that would leave millions of Americans uninsured.
“We will not support a plan that does not include stability for Medicaid expansion populations or flexibility for states,” Sens. Rob Portman (Ohio), Shelley Moore Capito (W.Va.), Cory Gardner (Colo.) and Lisa Murkowski (Alaska) wrote in a letter to Senate Majority Leader Mitch McConnell (R-Ky.).
The four senators were split on exactly what proposals would meet their standards, but with 52 Republicans, McConnell would not have enough votes to pass repeal without the support of at least two of them.
The four senators were split on exactly what proposals would meet their standards, but with 52 Republicans, McConnell would not have enough votes to pass repeal without the support of at least two of them.
Democrats, meanwhile, have given no indication that they intend to work with Republicans, and top party leaders decried the GOP plan Monday as a betrayal of everyday Americans. “Trumpcare doesn’t replace the Affordable Care Act, it forces millions of Americans to pay more for less care,” said Senate Minority Leader Charles E. Schumer (D-N.Y.).
In particular, the plan to target Planned Parenthood has already generated fierce pushback from Democrats and doubts from some Republicans who have noted that federal funds are already barred from funding abortions and that Planned Parenthood provides routine medical care to millions of American women.
There is no precedent for Congress to reverse a major program of social benefits once it has taken effect and reached millions of Americans.
There is no precedent for Congress to reverse a major program of social benefits once it has taken effect and reached millions of Americans.
Until now, the GOP had been intending to veer away from the ACA subsidies that help poor and middle-class people obtain insurance, insisting that the size of tax credits with which they planned to replace the subsidies should be based entirely on people’s ages and not their incomes. But the drafts issued Monday proposed refundable tax credits that would hinge on earnings as well as age — providing bigger credits for older and poorer Americans.
This big pivot, developed by the Ways and Means Committee under the guidance of House Speaker Paul D. Ryan (R-Wis.), stems from a combination of problems that were arising with the idea of age-only credits that would have been available to any individual or family buying insurance on their own, no matter how affluent.
The Republican plan would offer tax credits ranging from $2,000 per year for those under 30 to $4,000 per year for those over 60. The full credit would be available for individuals earning up to $75,000 a year and up to $150,000 for married couples filing jointly. The credits would phase out for individuals earning more — for each $1,000 in additional income, a person would be entitled to $100 less in credit, meaning a 61-year old could make up to $115,100 and still receive some credit.
This big pivot, developed by the Ways and Means Committee under the guidance of House Speaker Paul D. Ryan (R-Wis.), stems from a combination of problems that were arising with the idea of age-only credits that would have been available to any individual or family buying insurance on their own, no matter how affluent.
The Republican plan would offer tax credits ranging from $2,000 per year for those under 30 to $4,000 per year for those over 60. The full credit would be available for individuals earning up to $75,000 a year and up to $150,000 for married couples filing jointly. The credits would phase out for individuals earning more — for each $1,000 in additional income, a person would be entitled to $100 less in credit, meaning a 61-year old could make up to $115,100 and still receive some credit.
The income-based phaseout of the credit allows the GOP plan to be funded without taxes on employer-provided insurance that had been considered earlier in the drafting process. In addition, the latest proposal would delay the ACA’s “Cadillac” tax, a levy on the most generous employer-provided health plans, until 2025. It also retains the tax exclusion for premiums paid for employer-provided health plans.
Estimates from congressional budget analysts and the White House’s Office of Management and Budget kept showing that the credits would be both too small to provide enough help to lower-income people and too expensive overall for a GOP determined to slash federal spending that the ACA has required.
Those analysts have not had time to assess how this new configuration would affect federal spending or the number of people with insurance coverage.
Those analysts have not had time to assess how this new configuration would affect federal spending or the number of people with insurance coverage.
[Conservative groups and lawmakers demanding ‘full repeal’ could derail Obamacare rollback]
Compared with the ACA’s subsidies, the tax credits would go to more people but provide less financial help to lower-income people, according to Larry Levitt, senior vice president of the Kaiser Family Foundation.
Meanwhile, the portion of the legislation drafted by the Energy and Commerce Committee would substantially redesign Medicaid in a way that attempts to balance the GOP’s antipathy toward the ACA’s expansion of the program against the concerns of a significant cadre of Republican governors — and the lawmakers from their states — who fear losing millions of dollars that the law has funneled to help insure low-income residents.
Medicaid would be converted from its current form of entitlement to anyone eligible into a per capita cap on funding to states, depending on how many people they had enrolled. In states that expanded Medicaid under the ACA, the government for now would continue paying for virtually the entire cost of the expansion.
Thirty-one states, plus the District of Columbia, have adopted that expansion. Starting in 2020, however, the GOP plan would restrict the government’s generous Medicaid payment — 90 percent of the cost of covering people in the expansion group — only to people who were in the program as of then. States would keep getting that amount of federal help for each of those people as long as they remained eligible, with the idea that most people on Medicaid drop off after a few years.
For the other 19 states that did not expand Medicaid, the legislation would provide $10 billion spread over five years. States could use that money to subsidize hospitals and other providers of care that treat many poor patients.
[A divided White House still offers little guidance on replacing Obamacare]
While members of the two committees working on the replacement drafts were determined to begin considering legislation this week, final work on them was still underway over the weekend and Monday, according to three individuals with knowledge of the process.
The change in thinking about tax credits emerged since Friday, when a White House meeting chaired by Budget Director Mick Mulvaney and attended by key GOP congressional figures was called to finalize key provisions.
At the same time, the shift to take income into account could create a potentially difficult ripple effect for Republicans, who regard a reduction in the federal government’s role in health care as a central reason to abandon the sprawling 2010 health care law. One motivation for the GOP thinking that credits could depend only on age was that the Internal Revenue Service would no longer have needed to verify the eligibility of people for financial help, as it has for ACA subsidies. If income is taken into account, the IRS would still need to be involved.
SOURCES: https://www.washingtonpost.com/powe...22680e18d10_story.html?utm_term=.480523b8b71a
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From what I have heard it does not look too bad and they kept some elements. It actually fixes alot of the problems in the ACA where you end up having problems with the IRS.
Politically you can't mandate coverage and tie your fate to insurance companies. I liked to see more flexibility in being able to leave the health insurance market if prices get out of control and not get a surcharge.
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The next fix is Workers Comp, you can't have a disinterested party to whether a claim is paid paying premiums.
One of the things car insurance companies care about is treating you fairly if you have a claim because you decide to continue your business relationship with them. Rumors can spread affecting their revenue if they treat customers unfairly or if their coverage is perceived as being weak. This is why you see ads talking about how good their claims process is
Workers comp, the employer decides your coverage and has no interests in the claims process or may assist in denying your claim to keep their rate low! They will keep buying coverage with the same company regardless of how they treated your claim. The risk pools are predetermined by your employer which are minimal to keep their cost down. This needs to change.
One of the things car insurance companies care about is treating you fairly if you have a claim because you decide to continue your business relationship with them. Rumors can spread affecting their revenue if they treat customers unfairly or if their coverage is perceived as being weak. This is why you see ads talking about how good their claims process is
Workers comp, the employer decides your coverage and has no interests in the claims process or may assist in denying your claim to keep their rate low! They will keep buying coverage with the same company regardless of how they treated your claim. The risk pools are predetermined by your employer which are minimal to keep their cost down. This needs to change.
If they want to increase choice mandate that health insurance companies that offer employer plans compete in the individual market. The Republicans are trying to lure them back to the exchanges by picking up people that are costly and dumping them into high risk pools.
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In a place of need, an unhealthy contradiction
They are poor, sick and voted for Trump. What will happen to them without Obamacare?
By Jessica Contrera Photos by Bonnie Jo Mount
March 11, 2017
Nurse practitioner Keisha Saunders examines Clarence Workman at the Tug River health clinic in Northfork, W.Va.
Northfork, W.Va. — Another morning, another list of patients and problems in the hands of 35-year-old Keisha Saunders. Diabetes, depression, heart disease. Robert needs lower blood pressure. Buffy needs prescriptions filled. Mary needs to lose 50 pounds, so she can get what she really needs, a new hip.
Again, the list extends to the bottom of Keisha’s notepad, as it has so many days since the Affordable Care Act mandated that everyone have health insurance. Unlike in Washington, where health care is a contentious policy debate, health care where Keisha is a nurse practitioner is a daily need to be filled. The high rates of chronic diseases in McDowell County have made it the county with the shortest life expectancy in the nation.
It’s also a place that voted overwhelmingly for President Trump, whose promise to repeal the ACA will soon affect nearly every patient Keisha treats at the Tug River health clinic in Northfork, including the one waiting for her in exam room No. 2.
“How are you doing?” she asks Clyde Graham, who is 54 and has been out of work for four years.
“I ate a sandwich from Arby’s,” he says. “And it jumped me out for like, three days. I mean it just burnt.”
Clyde Graham, 54, is an unemployed Medicaid patient with a host of health issues.
Heartburn is just the latest problem for Clyde, a patient Keisha sees every three months. Like so many in this corner of Appalachia, he used to have a highly paid job at a coal mine. Company insurance covered all of his medical needs. Then he lost the job and ended up here, holding a cane and suffering not only from heartburn but diabetes, arthritis, diverticulitis, high blood pressure and high cholesterol.
Because of the ACA, Clyde’s visit is covered by Medicaid. Before the law, most West Virginians without children or disabilities could not qualify for Medicaid, no matter how poor they were. The ACA — better known here as Obamacare — expanded the program to cover more people, such as Clyde, who can depend on Keisha to fix his heartburn without having to worry about the cost.
As for the other problems in his life, he has put his hopes in Trump, who came to West Virginia saying he would bring back coal and put miners back to work. When Trump mentioned repealing Obamacare, Clyde wasn’t sure what that might mean for his Medicaid. But if he had a job that provided health insurance, he reasoned, he wouldn’t need Medicaid anyway, so he voted for Trump, along with 74 percent of McDowell County.
Tug River Health Association treats about 8,700 patients, resulting in some 20,000 visits a year to its five clinics. In 2016, 12,284 of those visits were from patients on Medicaid, up from 5,674 in 2013, before the ACA took effect here. Without the ACA, many of those patients wouldn’t be able to afford care. Will they soon lose their coverage? Will they stop coming to the clinic? Lately, Tug River’s chief executive has been telling his staff, “The key word going forward is uncertainty.”
To Keisha, all is uncertain beyond this moment, in which she prescribes Nexium for Clyde’s heartburn, examines him from head to toe and sends him to the lab across the hall for blood work.
“I’ll see you in three months,” she says, hoping that will be true, and heads to exam room No. 1, where another patient is waiting. “What’s going on today?” she asks, and walks in the room to find out.
An abandoned house and coal cars on tracks in nearby Capels, W.Va., an unincorporated part of McDowell County.
Meanwhile in the front of the clinic, more patients are coming in through the heavy doors and up to a glass window where a receptionist is waiting.
“Hi honey, how are you?” Tammy McNew says to each one. Over the past four decades, McDowell County has lost 60 percent of its population, so she rarely needs to ask their names. Instead, she asks what seems like the most important question in health care these days:
“Got your insurance card with you?”
If the answer is no, she will send them back to Keisha anyway, and the clinic will depend on federal grants to make up the cost. But more often in recent years, the answer is what a middle-aged woman with springy curls says as she passes her Medicaid insurance card through the window: “Yes, ma’am,” she tells Tammy, who slides it into a scanning machine.
In other parts of the country, the primary impact of the ACA has been requiring people to have private health insurance, but in poor and sick communities like McDowell County, the law’s dominant effect has been the Medicaid expansion, which has given more people access to the kind of health care that wasn’t widely available or affordable to them before. With an insurance card in her pocket, the patient at Tammy’s window can venture into the realms of medical care that are typically out of reach to those without one: blood work, immunizations, specialized doctors, surgery, physical therapy.
If she needs mental health counseling, the clinic no longer sends her to the next county over; last July, Tug River was able to hire a psychologist, who is now treating 180 people, many of whom are trying to overcome opioid addictions.
If she needs medication, the nurses won’t go digging in a closet of samples left by drug reps as they used to do for the uninsured. The medication will come from a pharmacy and cost no more than a few dollars.
“All right sweetie, I got you,” Tammy tells her, and the patient retreats to a chair to wait for her name to be called. The routine is repeated dozens of times a day as the phone rings behind the front desk. “For appointments, press one,” the callers hear. “Black lung, two.”
This clinic is in Northfork, a community of a few hundred people along the railroad that carries coal through the mountains. Keisha, who is black, was raised in this predominantly white county, in a home overlooking the cinder-block church where her father, a coal miner, serves as pastor. She attended the middle school beside the clinic parking lot, which now has busted windows and gaping holes in its brick facade. There weren’t enough children to fill it, as every year the closing of more mines drove job-seekers out of the county.
Eventually, Keisha was one of them. After graduating high school and becoming a mother at 18, she realized that if she wanted to become something more for her daughter, she would have to leave.
She moved 45 minutes away, to Princeton, W.Va., where she got a nursing assistant certification and a job in a nursing home. But every Sunday, she strapped her daughter Kiana in her car and drove back to McDowell County, checking in on her always-fading town. Bulldozed, shuttered or abandoned: the grocery store, beauty salon, florist and furniture store. Still open: the dollar store, medical equipment store, funeral home and her father’s church, where Keisha would usually sit with her brother Derrick.
A snapshot of Keisha’s brother Derrick, who was uninsured when he was diagnosed with kidney cancer. He died at 25.
It was 2003 when Derrick started to feel pains in his back and groin, and Keisha, then a 22-year-old licensed practical nurse, started to understand what insurance could mean. Derrick was 24 — too old to be covered by his father’s insurance but unable to afford his own. He thought his only option was to go to an emergency room. His parents remember him returning home, having been told there was nothing wrong with him. When the pain didn’t go away, Derrick tried a different ER. Keisha would later learn that doctors thought her brother was seeking pain pills. Months passed.
All the while, a tumor inside his kidney was growing. A few months after the cancer was finally discovered, Derrick died at 25.
Keisha didn’t allow herself to wonder what might have happened if he’d had insurance. She focused on remembering their last days together, when the doctors said the cancer was too advanced to be stopped by treatment, so she treated him with chocolate instead. M&Ms by his bedside.
She kept working at the nursing home and then in hospice care, raising Kiana and taking classes at night. When she was 30, she completed a graduate degree and became a nurse practitioner. She made the drive back to McDowell County again, this time to ask for a job.
At first, some patients at Tug River were wary of her loud laugh and big hoop earrings. Others had known her since she was a little girl. She cared for them all, and her schedule grew busier as the ACA came to McDowell County and made more people eligible for insurance.
In 2016, Trump yard signs and bumper stickers started appearing along her drive to work. In the clinic, one doctor and the janitor could regularly be heard rehashing the latest controversy and what they liked about Trump. Keisha had decided she would vote for Hillary Clinton, because of health care and because she wanted to see a woman become president. But it wasn’t in Keisha’s job description — or personality — to talk politics. She avoided the subject.
Come election night, she was too exhausted after another packed day at the clinic to stay awake. She didn’t learn who won until the morning.
In all of those Sundays at church, Keisha was taught that God has a plan. If God planned for Trump to win the election, she told herself that morning, it must be for a reason.
A recommended humidifier is cost-prohibitive for Andrea Easley, 50, who relies on Medicaid and disability payments.
Now Trump is in the White House and Keisha is pressing her fingers into the stomach of 24-year-old Ruby Thompson. Nearly every patient Keisha sees has been impacted in some way by the ACA, and in Ruby’s case, the ACA’s Medicaid expansion is the reason she has insurance.
According to the list on Keisha’s notepad, Ruby is just here to refill a prescription, but Keisha checks her as if they are meeting for the first time. She tries to feel for anything abnormal around Ruby’s stomach, which is a little too thin, but Keisha knows cigarettes can cut into a person’s appetite.
“Are you still smoking?”
“Yeah,” Ruby answers, tugging at a gold necklace that spells MOM.
“Do you want to stop?”
“I will eventually, I guess.”
Ruby is another patient who voted for Trump because of his promise to bring back jobs. She hasn’t yet lost hope that she can become a secretary, but for the past two years she’s been working at KFC. She has health insurance only because she was fined on her taxes for not having it, at which point she found out that because of the ACA, she qualified for Medicaid. It is insurance at its most tenuous, though, because if Medicaid reverts back to a program only for the neediest people, the working poor will be most at risk of losing their coverage.
“Go ahead and sit up,” Keisha says after checking Ruby’s ankles for swelling, a potential sign of diabetes. She writes a prescription and sends Ruby to the front desk to make an appointment for November, when she is due for a breast exam and cervical cancer screening.
Another patient comes in: Carolyn Hodges, 68, who tells Keisha that she’s been feeling dizzy. Carolyn has Medicare, the public health insurance for the elderly. Medicare doesn’t cover all health-care costs, which is why Carolyn is as worried about the price of her medications as the fact that she’s been bumping into walls.
The last time she went to pick up her husband Roger’s insulin, Carolyn tells Keisha, the pharmacist said it would be more than $600, instead of the $100 or so they usually pay. That was when she learned Roger was in the Medicare prescription “donut hole,” which means that the cost of his medications had exceeded his limit for the year, and he would be forced to pay far more for prescriptions until the year ended and the tab started over. One initiative of the ACA has been to close that hole incrementally, but Carolyn, unaware of that, sees the bills piling up and thinks she knows who must be to blame.
“Thank you, Obama!” Carolyn says, throwing her arms in the air.
Keisha nods, and keeps typing into her chart.
Around her neck, Keisha wears a cross on a necklace — and her stethoscope.
Another patient: Andrea Easley, 50, who has struggled for so long that there wasn’t much more the ACA could do to help her. She already had Medicaid, which she depends on for her health care, and disability payments, which she uses to pay her rent, support her 70-year-old mother and send checks to her son who is in prison in Charleston, W.Va.
“What’s going on, Miss Andrea?”
“My nose,” Andrea says, nearly shouting. “I had just come in. Sit down. Sneeze. My nose went to burning. I mean, it burned like someone gone and set fire to my nose.”
Despite taking more than a dozen medications a day, Andrea’s problems never seem to go away. Her life isn’t one where she thinks much about politics — she didn’t vote in the election — but of stomach issues, coughing, lack of sleep, fights with her mother, stress over her son.
“Have you tried a humidifier?” Keisha asks.
“What is that?” Andrea says.
“It keeps the moisture in the air,” Keisha explains. “Do you sleep with your mouth open?”
“I don’t know how I sleep. I’m not half sleeping. Now last night, it made me mad,” she says. “Them cats out there meowing, and I’m trying to go to sleep, and they’re out there doing all such things they have no business doing . . .”
Looking up at Andrea from her low swivel stool, Keisha listens. She knows other patients are waiting. But she also knows that sometimes her patients need to talk, so she gives no sign that she has anyplace else to be. Only when Andrea pauses does she say, “I do think you need a humidifier. I think that will help some.”
“Where can I get that from?”
“Well,” Keisha says, knowing her answer will upset Andrea, “you have to buy it.”
Another patient: Charles Collins, 39, who believes that the impact of the ACA was to make his own health-care costs rise. He is privately insured through his job at a coal mine one county over. The mine used to cover 100 percent of his medical expenses, but starting this year, only 90 percent is covered, and his dental insurance, he tells Keisha, “ain’t worth a nickel.”
“That’s a mess,” she says. Charles unclips his miner’s overalls so she can place the stethoscope on his chest, and tells her about getting his tooth pulled.
“I got a bill for $324 and they paid a dollar of it,” he says about his insurance. He is glad Trump is repealing the ACA, because in his opinion working people are being forced to pay for those who sit around and do nothing. But no matter what Trump does, Charles knows the bill for this visit is coming.
“Deep breaths for me,” Keisha tells him, and Charles exhales.
Another patient, here for the first time: a 33-year-old woman who voted for Hillary Clinton. She has no insurance, by choice. She didn’t feel she needed it. Now, because of a test result in Keisha’s hands, she will.
“Hi Miss Amanda, I’m Keisha, the nurse practitioner here.”
“Nice to meet you,” Amanda says, pushing back a lock of cherry-colored hair.
Keisha asks Amanda about her symptoms, then gets to the point. She turns to face her and says, “It looks like — you’re pregnant.”
“I’m pregnant?”
“Yes. Were you expecting . . .”
“That’s such good news!” Amanda says.
“I’m glad you’re happy,” Keisha says. “Good! Yay!”
Amanda lifts her palms in the air, and they double high-five. Then come the questions Keisha needs to ask for her chart.
Is the baby’s father involved? “I think he’s going to be a little apprehensive,” Amanda says.
Is she working? “Not currently,” Amanda says, explaining to Keisha that she just moved back to West Virginia after living in Ohio. So far she has put in applications at gas stations and restaurants.
Is she at all familiar with the area? With the doctors she’ll need to see? With what she needs to do now? Amanda wrings her hands between her knees. “I have no idea where to go next,” she says.
And here is another version of uncertainty in the clinic, this time a patient’s. If she signs up for Medicaid, which covers low-income, pregnant women, she’ll be covered through her pregnancy. But after that? Her access to insurance will depend on what happens over the next months in Washington, where so many plans for the ACA’s replacement are floating around. One, just unveiled in the House, would roll back the Medicaid expansion slowly, meaning Amanda could keep her public insurance after the baby is born. In a few years, however, someone like her might not be able to do the same, and instead might receive tax credits to help offset the cost of private insurance.
But that’s just one plan. There have been plans based on “block grants” and plans based on “per-capita caps.” Some plans give people tax credits based on their income. Some base the tax credits on their age; some on where a person lives. There’s the plan once proposed by Trump’s secretary of health and human services, which would get rid of the Medicaid expansion entirely. There’s the plan Vice President Pence implemented when he was governor of Indiana, which penalizes anyone who doesn’t pay for Medicaid coverage, even if all they can afford is a dollar a month. There’s even a plan that proposes keeping the Medicaid expansion just as it is.
With so much to be resolved, Keisha hands Amanda a form to sign up for Medicaid. They walk together to the front desk, where Keisha asks Tammy to schedule Amanda’s first prenatal appointment.
“Thank you,” Amanda tells her.
“You’re welcome,” Keisha says. “I hope everything goes well.”
Keisha confers with colleague Jennifer Fain in her Tug River office. Keisha grew up in the community.
Sometimes, between patients, Keisha retreats into her office, sits at the folding table she uses as a desk and takes a few steadying breaths. If she has enough time she also prays, and since January some of those prayers have been for President Trump.
“I just pray that he makes the right decisions,” she says. “I’m not sure what’s going to happen. All we can do is pray about it.”
She prays for others, too. Her daughter. Her parents. Her brother. She prays for her patients, that they stay healthy, that they lose weight, that they take their insulin shots the correct way, that the woman with the rotting tooth will follow up on her promise to go to the dentist, that the man whose wife died after saying to him, “Honey, do you think I’m getting better?” will find a way to ease his loneliness.
And what if, in a few months, those patients lose their insurance? She’ll pray about that, too, she says, but first she will explain the sliding fee program, the closet full of sample medications from drug reps, the forms she can submit asking pharmaceutical companies for discounts, the free clinic at the medical school four hours north — all the things she will do to try to get them the care they need, even if they can’t afford it.
One more deep breath and a last prayer for herself — “Okay, Lord, help me get myself together” — and then she picks up her stethoscope. It’s Friday afternoon, and seven patients need to be seen before she can go home to her teenage daughter.
“Hey there, how are you?” she starts with one.
“Oh goodness, you have been having a rough time,” she tells a man with kidney stones.
“I want to send you to a lung doctor to find out, because I just don’t know,” she explains to a patient whose cough won’t go away.
“You are not broken,” she says to a woman who the psychologist recently diagnosed as bipolar, and so it goes until she finishes caring for her last patient, nearly an hour after the clinic has closed.
She powers down her laptop and carries her notepad to the blood-work lab, where there is a paper shredder. Ripping off the top page with today’s list of patients and problems, she drops it into the machine and watches it disappear. Then she slides the notepad into her bag to take home. Another week of need is coming, and she wants to be prepared.
In West Virginia, in the county with the shortest life expectancy in the nation, night falls in Northfork.
They are poor, sick and voted for Trump. What will happen to them without Obamacare?
By Jessica Contrera Photos by Bonnie Jo Mount
March 11, 2017
Nurse practitioner Keisha Saunders examines Clarence Workman at the Tug River health clinic in Northfork, W.Va.
Northfork, W.Va. — Another morning, another list of patients and problems in the hands of 35-year-old Keisha Saunders. Diabetes, depression, heart disease. Robert needs lower blood pressure. Buffy needs prescriptions filled. Mary needs to lose 50 pounds, so she can get what she really needs, a new hip.
Again, the list extends to the bottom of Keisha’s notepad, as it has so many days since the Affordable Care Act mandated that everyone have health insurance. Unlike in Washington, where health care is a contentious policy debate, health care where Keisha is a nurse practitioner is a daily need to be filled. The high rates of chronic diseases in McDowell County have made it the county with the shortest life expectancy in the nation.
It’s also a place that voted overwhelmingly for President Trump, whose promise to repeal the ACA will soon affect nearly every patient Keisha treats at the Tug River health clinic in Northfork, including the one waiting for her in exam room No. 2.
“How are you doing?” she asks Clyde Graham, who is 54 and has been out of work for four years.
“I ate a sandwich from Arby’s,” he says. “And it jumped me out for like, three days. I mean it just burnt.”
Clyde Graham, 54, is an unemployed Medicaid patient with a host of health issues.
Heartburn is just the latest problem for Clyde, a patient Keisha sees every three months. Like so many in this corner of Appalachia, he used to have a highly paid job at a coal mine. Company insurance covered all of his medical needs. Then he lost the job and ended up here, holding a cane and suffering not only from heartburn but diabetes, arthritis, diverticulitis, high blood pressure and high cholesterol.
Because of the ACA, Clyde’s visit is covered by Medicaid. Before the law, most West Virginians without children or disabilities could not qualify for Medicaid, no matter how poor they were. The ACA — better known here as Obamacare — expanded the program to cover more people, such as Clyde, who can depend on Keisha to fix his heartburn without having to worry about the cost.
As for the other problems in his life, he has put his hopes in Trump, who came to West Virginia saying he would bring back coal and put miners back to work. When Trump mentioned repealing Obamacare, Clyde wasn’t sure what that might mean for his Medicaid. But if he had a job that provided health insurance, he reasoned, he wouldn’t need Medicaid anyway, so he voted for Trump, along with 74 percent of McDowell County.
Tug River Health Association treats about 8,700 patients, resulting in some 20,000 visits a year to its five clinics. In 2016, 12,284 of those visits were from patients on Medicaid, up from 5,674 in 2013, before the ACA took effect here. Without the ACA, many of those patients wouldn’t be able to afford care. Will they soon lose their coverage? Will they stop coming to the clinic? Lately, Tug River’s chief executive has been telling his staff, “The key word going forward is uncertainty.”
To Keisha, all is uncertain beyond this moment, in which she prescribes Nexium for Clyde’s heartburn, examines him from head to toe and sends him to the lab across the hall for blood work.
“I’ll see you in three months,” she says, hoping that will be true, and heads to exam room No. 1, where another patient is waiting. “What’s going on today?” she asks, and walks in the room to find out.
An abandoned house and coal cars on tracks in nearby Capels, W.Va., an unincorporated part of McDowell County.
Meanwhile in the front of the clinic, more patients are coming in through the heavy doors and up to a glass window where a receptionist is waiting.
“Hi honey, how are you?” Tammy McNew says to each one. Over the past four decades, McDowell County has lost 60 percent of its population, so she rarely needs to ask their names. Instead, she asks what seems like the most important question in health care these days:
“Got your insurance card with you?”
If the answer is no, she will send them back to Keisha anyway, and the clinic will depend on federal grants to make up the cost. But more often in recent years, the answer is what a middle-aged woman with springy curls says as she passes her Medicaid insurance card through the window: “Yes, ma’am,” she tells Tammy, who slides it into a scanning machine.
In other parts of the country, the primary impact of the ACA has been requiring people to have private health insurance, but in poor and sick communities like McDowell County, the law’s dominant effect has been the Medicaid expansion, which has given more people access to the kind of health care that wasn’t widely available or affordable to them before. With an insurance card in her pocket, the patient at Tammy’s window can venture into the realms of medical care that are typically out of reach to those without one: blood work, immunizations, specialized doctors, surgery, physical therapy.
If she needs mental health counseling, the clinic no longer sends her to the next county over; last July, Tug River was able to hire a psychologist, who is now treating 180 people, many of whom are trying to overcome opioid addictions.
If she needs medication, the nurses won’t go digging in a closet of samples left by drug reps as they used to do for the uninsured. The medication will come from a pharmacy and cost no more than a few dollars.
“All right sweetie, I got you,” Tammy tells her, and the patient retreats to a chair to wait for her name to be called. The routine is repeated dozens of times a day as the phone rings behind the front desk. “For appointments, press one,” the callers hear. “Black lung, two.”
This clinic is in Northfork, a community of a few hundred people along the railroad that carries coal through the mountains. Keisha, who is black, was raised in this predominantly white county, in a home overlooking the cinder-block church where her father, a coal miner, serves as pastor. She attended the middle school beside the clinic parking lot, which now has busted windows and gaping holes in its brick facade. There weren’t enough children to fill it, as every year the closing of more mines drove job-seekers out of the county.
Eventually, Keisha was one of them. After graduating high school and becoming a mother at 18, she realized that if she wanted to become something more for her daughter, she would have to leave.
She moved 45 minutes away, to Princeton, W.Va., where she got a nursing assistant certification and a job in a nursing home. But every Sunday, she strapped her daughter Kiana in her car and drove back to McDowell County, checking in on her always-fading town. Bulldozed, shuttered or abandoned: the grocery store, beauty salon, florist and furniture store. Still open: the dollar store, medical equipment store, funeral home and her father’s church, where Keisha would usually sit with her brother Derrick.
A snapshot of Keisha’s brother Derrick, who was uninsured when he was diagnosed with kidney cancer. He died at 25.
It was 2003 when Derrick started to feel pains in his back and groin, and Keisha, then a 22-year-old licensed practical nurse, started to understand what insurance could mean. Derrick was 24 — too old to be covered by his father’s insurance but unable to afford his own. He thought his only option was to go to an emergency room. His parents remember him returning home, having been told there was nothing wrong with him. When the pain didn’t go away, Derrick tried a different ER. Keisha would later learn that doctors thought her brother was seeking pain pills. Months passed.
All the while, a tumor inside his kidney was growing. A few months after the cancer was finally discovered, Derrick died at 25.
Keisha didn’t allow herself to wonder what might have happened if he’d had insurance. She focused on remembering their last days together, when the doctors said the cancer was too advanced to be stopped by treatment, so she treated him with chocolate instead. M&Ms by his bedside.
She kept working at the nursing home and then in hospice care, raising Kiana and taking classes at night. When she was 30, she completed a graduate degree and became a nurse practitioner. She made the drive back to McDowell County again, this time to ask for a job.
At first, some patients at Tug River were wary of her loud laugh and big hoop earrings. Others had known her since she was a little girl. She cared for them all, and her schedule grew busier as the ACA came to McDowell County and made more people eligible for insurance.
In 2016, Trump yard signs and bumper stickers started appearing along her drive to work. In the clinic, one doctor and the janitor could regularly be heard rehashing the latest controversy and what they liked about Trump. Keisha had decided she would vote for Hillary Clinton, because of health care and because she wanted to see a woman become president. But it wasn’t in Keisha’s job description — or personality — to talk politics. She avoided the subject.
Come election night, she was too exhausted after another packed day at the clinic to stay awake. She didn’t learn who won until the morning.
In all of those Sundays at church, Keisha was taught that God has a plan. If God planned for Trump to win the election, she told herself that morning, it must be for a reason.
A recommended humidifier is cost-prohibitive for Andrea Easley, 50, who relies on Medicaid and disability payments.
Now Trump is in the White House and Keisha is pressing her fingers into the stomach of 24-year-old Ruby Thompson. Nearly every patient Keisha sees has been impacted in some way by the ACA, and in Ruby’s case, the ACA’s Medicaid expansion is the reason she has insurance.
According to the list on Keisha’s notepad, Ruby is just here to refill a prescription, but Keisha checks her as if they are meeting for the first time. She tries to feel for anything abnormal around Ruby’s stomach, which is a little too thin, but Keisha knows cigarettes can cut into a person’s appetite.
“Are you still smoking?”
“Yeah,” Ruby answers, tugging at a gold necklace that spells MOM.
“Do you want to stop?”
“I will eventually, I guess.”
Ruby is another patient who voted for Trump because of his promise to bring back jobs. She hasn’t yet lost hope that she can become a secretary, but for the past two years she’s been working at KFC. She has health insurance only because she was fined on her taxes for not having it, at which point she found out that because of the ACA, she qualified for Medicaid. It is insurance at its most tenuous, though, because if Medicaid reverts back to a program only for the neediest people, the working poor will be most at risk of losing their coverage.
“Go ahead and sit up,” Keisha says after checking Ruby’s ankles for swelling, a potential sign of diabetes. She writes a prescription and sends Ruby to the front desk to make an appointment for November, when she is due for a breast exam and cervical cancer screening.
Another patient comes in: Carolyn Hodges, 68, who tells Keisha that she’s been feeling dizzy. Carolyn has Medicare, the public health insurance for the elderly. Medicare doesn’t cover all health-care costs, which is why Carolyn is as worried about the price of her medications as the fact that she’s been bumping into walls.
The last time she went to pick up her husband Roger’s insulin, Carolyn tells Keisha, the pharmacist said it would be more than $600, instead of the $100 or so they usually pay. That was when she learned Roger was in the Medicare prescription “donut hole,” which means that the cost of his medications had exceeded his limit for the year, and he would be forced to pay far more for prescriptions until the year ended and the tab started over. One initiative of the ACA has been to close that hole incrementally, but Carolyn, unaware of that, sees the bills piling up and thinks she knows who must be to blame.
“Thank you, Obama!” Carolyn says, throwing her arms in the air.
Keisha nods, and keeps typing into her chart.
Around her neck, Keisha wears a cross on a necklace — and her stethoscope.
Another patient: Andrea Easley, 50, who has struggled for so long that there wasn’t much more the ACA could do to help her. She already had Medicaid, which she depends on for her health care, and disability payments, which she uses to pay her rent, support her 70-year-old mother and send checks to her son who is in prison in Charleston, W.Va.
“What’s going on, Miss Andrea?”
“My nose,” Andrea says, nearly shouting. “I had just come in. Sit down. Sneeze. My nose went to burning. I mean, it burned like someone gone and set fire to my nose.”
Despite taking more than a dozen medications a day, Andrea’s problems never seem to go away. Her life isn’t one where she thinks much about politics — she didn’t vote in the election — but of stomach issues, coughing, lack of sleep, fights with her mother, stress over her son.
“Have you tried a humidifier?” Keisha asks.
“What is that?” Andrea says.
“It keeps the moisture in the air,” Keisha explains. “Do you sleep with your mouth open?”
“I don’t know how I sleep. I’m not half sleeping. Now last night, it made me mad,” she says. “Them cats out there meowing, and I’m trying to go to sleep, and they’re out there doing all such things they have no business doing . . .”
Looking up at Andrea from her low swivel stool, Keisha listens. She knows other patients are waiting. But she also knows that sometimes her patients need to talk, so she gives no sign that she has anyplace else to be. Only when Andrea pauses does she say, “I do think you need a humidifier. I think that will help some.”
“Where can I get that from?”
“Well,” Keisha says, knowing her answer will upset Andrea, “you have to buy it.”
Another patient: Charles Collins, 39, who believes that the impact of the ACA was to make his own health-care costs rise. He is privately insured through his job at a coal mine one county over. The mine used to cover 100 percent of his medical expenses, but starting this year, only 90 percent is covered, and his dental insurance, he tells Keisha, “ain’t worth a nickel.”
“That’s a mess,” she says. Charles unclips his miner’s overalls so she can place the stethoscope on his chest, and tells her about getting his tooth pulled.
“I got a bill for $324 and they paid a dollar of it,” he says about his insurance. He is glad Trump is repealing the ACA, because in his opinion working people are being forced to pay for those who sit around and do nothing. But no matter what Trump does, Charles knows the bill for this visit is coming.
“Deep breaths for me,” Keisha tells him, and Charles exhales.
Another patient, here for the first time: a 33-year-old woman who voted for Hillary Clinton. She has no insurance, by choice. She didn’t feel she needed it. Now, because of a test result in Keisha’s hands, she will.
“Hi Miss Amanda, I’m Keisha, the nurse practitioner here.”
“Nice to meet you,” Amanda says, pushing back a lock of cherry-colored hair.
Keisha asks Amanda about her symptoms, then gets to the point. She turns to face her and says, “It looks like — you’re pregnant.”
“I’m pregnant?”
“Yes. Were you expecting . . .”
“That’s such good news!” Amanda says.
“I’m glad you’re happy,” Keisha says. “Good! Yay!”
Amanda lifts her palms in the air, and they double high-five. Then come the questions Keisha needs to ask for her chart.
Is the baby’s father involved? “I think he’s going to be a little apprehensive,” Amanda says.
Is she working? “Not currently,” Amanda says, explaining to Keisha that she just moved back to West Virginia after living in Ohio. So far she has put in applications at gas stations and restaurants.
Is she at all familiar with the area? With the doctors she’ll need to see? With what she needs to do now? Amanda wrings her hands between her knees. “I have no idea where to go next,” she says.
And here is another version of uncertainty in the clinic, this time a patient’s. If she signs up for Medicaid, which covers low-income, pregnant women, she’ll be covered through her pregnancy. But after that? Her access to insurance will depend on what happens over the next months in Washington, where so many plans for the ACA’s replacement are floating around. One, just unveiled in the House, would roll back the Medicaid expansion slowly, meaning Amanda could keep her public insurance after the baby is born. In a few years, however, someone like her might not be able to do the same, and instead might receive tax credits to help offset the cost of private insurance.
But that’s just one plan. There have been plans based on “block grants” and plans based on “per-capita caps.” Some plans give people tax credits based on their income. Some base the tax credits on their age; some on where a person lives. There’s the plan once proposed by Trump’s secretary of health and human services, which would get rid of the Medicaid expansion entirely. There’s the plan Vice President Pence implemented when he was governor of Indiana, which penalizes anyone who doesn’t pay for Medicaid coverage, even if all they can afford is a dollar a month. There’s even a plan that proposes keeping the Medicaid expansion just as it is.
With so much to be resolved, Keisha hands Amanda a form to sign up for Medicaid. They walk together to the front desk, where Keisha asks Tammy to schedule Amanda’s first prenatal appointment.
“Thank you,” Amanda tells her.
“You’re welcome,” Keisha says. “I hope everything goes well.”
Keisha confers with colleague Jennifer Fain in her Tug River office. Keisha grew up in the community.
Sometimes, between patients, Keisha retreats into her office, sits at the folding table she uses as a desk and takes a few steadying breaths. If she has enough time she also prays, and since January some of those prayers have been for President Trump.
“I just pray that he makes the right decisions,” she says. “I’m not sure what’s going to happen. All we can do is pray about it.”
She prays for others, too. Her daughter. Her parents. Her brother. She prays for her patients, that they stay healthy, that they lose weight, that they take their insulin shots the correct way, that the woman with the rotting tooth will follow up on her promise to go to the dentist, that the man whose wife died after saying to him, “Honey, do you think I’m getting better?” will find a way to ease his loneliness.
And what if, in a few months, those patients lose their insurance? She’ll pray about that, too, she says, but first she will explain the sliding fee program, the closet full of sample medications from drug reps, the forms she can submit asking pharmaceutical companies for discounts, the free clinic at the medical school four hours north — all the things she will do to try to get them the care they need, even if they can’t afford it.
One more deep breath and a last prayer for herself — “Okay, Lord, help me get myself together” — and then she picks up her stethoscope. It’s Friday afternoon, and seven patients need to be seen before she can go home to her teenage daughter.
“Hey there, how are you?” she starts with one.
“Oh goodness, you have been having a rough time,” she tells a man with kidney stones.
“I want to send you to a lung doctor to find out, because I just don’t know,” she explains to a patient whose cough won’t go away.
“You are not broken,” she says to a woman who the psychologist recently diagnosed as bipolar, and so it goes until she finishes caring for her last patient, nearly an hour after the clinic has closed.
She powers down her laptop and carries her notepad to the blood-work lab, where there is a paper shredder. Ripping off the top page with today’s list of patients and problems, she drops it into the machine and watches it disappear. Then she slides the notepad into her bag to take home. Another week of need is coming, and she wants to be prepared.
In West Virginia, in the county with the shortest life expectancy in the nation, night falls in Northfork.
THE WIRE
GOP’s Obamacare Obituary: Premature
Republicans repeatedly claim that Obamacare is in a “death spiral,” collapsing of its own weight. This is wishful thinking on their part, with little evidence to support it.
Examples of the GOP line:
Federal officials announced a few days ago that 12.2 million people were signed up to be covered by Obamacare health insurance policies sold through the federal and state ACA marketplaces, or exchanges, this year — down less than 4 percent from the 12.7 million who signed up during the same period a year earlier. That’s a pretty lively corpse.
Furthermore, this year’s sign-up figure is expected to rise; it doesn’t include “waiting in line” sign-ups that California and three other states allowed for people who had started the enrollment process before the Jan. 31 cut-off. Also, part of the difference is due to Louisiana’s recent expansion of Medicaid, which now covers some who had obtained coverage in 2016 through the Obamacare exchanges.
Indeed, independent experts predict that the Obamacare exchanges — should the GOP Congress fail to repeal the law as promised — likely will remain stable for many years.
“If nothing else changed they would probably stabilize at a lower level of enrollment,” says Mark V. Pauly, a professor of health care management at the University of Pennsylvania’s Wharton School.
That’s also the judgment of the nonpartisan Congressional Budget Office, which said in its analysis of the House bill to replace Obamacare that the market for individuals to purchase policies “would probably be stable in most areas under either current law or the [GOP replacement] legislation.”
Problems, But No ‘Implosion’
It’s true that Obamacare — more formally known as the Affordable Care Act — has serious problems. These were summed up by the health insurance lobby itself in a Jan. 24 statement to the House Ways and Means Committee. America’s Health Insurance Plans said, “The challenges facing the individual exchange marketplace – which have been well-documented – include significant increases in average premiums in 2017, fewer health plan choices, and lower-than-expected exchange enrollment and risk pool stability challenges in some states.”
On average those signing up for ACA policies have been older, sicker and more expensive to care for than many insurance companies had expected. That has forced companies to raise premiums, and caused some to stop writing ACA marketplace policies altogether.
Problems have been particularly acute in Tennessee, for example, where the state’s insurance commissioner, Julie Mix McPeak, said last August that the state’s ACA market was “very near collapse.” Matters have grown worse since, when Humana announced it would cease offering ACA policies in 2018. That would leave people in 16 of the state’s 95 counties without any ACA option next year, unless some other insurer steps in.
But Tennessee is not typical. In a letter to Congress, the National Association of Insurance Commissioners said in January that markets are near collapse in “a few” states, but “in some other states the individual market is robust with increased enrollment and premiums have stabilized.”
That letter was signed by Commissioner McPeak — who is the national association’s president-elect — and by three other NAIC officers, the top insurance regulators for Texas, Maine and Wisconsin.
An example of a healthy market is New York, which has what’s been called one of the most robust ACA marketplaces in the country, with 17 insurance carriers offering plans. The state just announced a 28 percent increase in total enrollments for 2017, with 1.2 million covered by private and other non-Medicaid policies and 2.4 million signing up for Medicaid.
Besides Tennessee, other states with problems include Arizona, where virtually all enrollees have only one carrier option, according to Louise Norris, who tracks insurance markets for healthinsurance.org, an independent health insurance guide for consumers founded in 1994. Oklahoma is one of five states with only one insurance company participating, according to the Kaiser Family Foundation’s report on insurer participation, and where the average premium for a benchmark plan increased 69 percentthis year. And in North Carolina, most of the state is served only by Blue Cross Blue Shield, which says it has lost $405 million on ACA plans over a two-year period.
But there are several states besides New York where ACA markets are flourishing. In Wisconsin, Idaho, Massachusetts, New Mexico, Arkansas and California, there is still vigorous participation by insurance companies. Wisconsin alone had 14 insurance companies offering ACA policies.
Industry Opinion
Opinion is divided within the insurance industry itself. Aetna chief executive Mark Bertolini said last month that the ACA exchanges are in a “death spiral.”
“My anticipation would be that in ’18, we’ll see a lot of markets without any coverage at all,” he said. Aetna says it racked up $450 million in losses on ACA policies last year, and it has pulled out of writing ACA policies in 11 states.
But where Aetna has struggled, other companies have profited. “The marketplaces are generally performing well,” Mario Molina, CEO of insurer Molina Healthcare, said on his company’s last conference call following release of earnings, according to USA Today. “They only require modification and adjustment, not wholesale change.”
And while Aetna, Humana and others have pulled out, some new companies have gotten in for 2017. For example, Bright Health in Colorado, Cigna in North Carolina and Virginia, and Wellmark in Iowa.
USA Today reported that even Aetna managed to make nearly $12 million on individual ACA plans in Texas and more than $8 million in Pennsylvania before it pulled out of those states, according to financial filings with state regulators. And the newspaper also reported that Blue Cross Blue Shield of North Carolina — after its big losses on ACA policies in 2014 and 2015 — was taking in hundreds of millions more than it was paying out to beneficiaries in 2016.
Premium Subsidies
What’s often lost in the GOP’s recitations of Obamacare’s problems is that the large majority of those covered by private ACA policies don’t feel the effect of the rising premiums that are supposedly threatening the stability of the system. Most of them get subsidies, and what they pay for the premiums is capped at a percentage of their income.
For 2017, federal officials say 83 percent of those signing up qualifyfor subsidies — a total of 10.1 million people. That’s still a very large number of potential customers for insurance companies.
(A note of caution: Not everyone who enrolls for coverage ends up paying premiums and getting coverage. For 2016, when 12.7 million signed up, an average of 10.4 million ended up making their coverage effective during the first half of the year. The “effectuated” figure for 2017 isn’t yet known, so we can only compare initial sign-ups to get an apples-to-apples comparison.)
In theory, a health insurance market goes into a “death spiral” when too many sick people take out insurance, driving up premiums that in turn cause healthier people to drop out. But under Obamacare, CBO said, the subsidies, coupled with the law’s tax penalties for those who don’t obtain coverage, “are anticipated to cause sufficient demand for insurance by people with low health care expenditures for the market to be stable.”
Wharton’s Pauly says rising premiums could drive out everyone who isn’t heavily subsidized, but that wouldn’t cause a spiral. “The taxpayers will have to pay more so they could object but that is not what we usually mean by instability,” he says.
A still-living Mark Twain wrote in 1897 that “the report of my death was an exaggeration.” The same can be said of GOP claims that Obamacare is fatally ill. If they want it dead, they’ll probably have to kill it themselves.
SOURCE:
.
GOP’s Obamacare Obituary: Premature
- Posted on March 23, 2017
Republicans repeatedly claim that Obamacare is in a “death spiral,” collapsing of its own weight. This is wishful thinking on their part, with little evidence to support it.
Examples of the GOP line:
- “[T]he law is collapsing,” House Speaker Paul Ryan said over the weekend on “Fox News Sunday.” He cited limited choices in some states and insurance companies pulling out of some markets, and he predicted “massive” premium increases in the future.
- President Donald Trump said the law is “just about ready to implode,” during a March 17 photo-op with the Republican Study Committee members who support the GOP plan. “Obamacare is dead; it’s a dead health care plan.”
Federal officials announced a few days ago that 12.2 million people were signed up to be covered by Obamacare health insurance policies sold through the federal and state ACA marketplaces, or exchanges, this year — down less than 4 percent from the 12.7 million who signed up during the same period a year earlier. That’s a pretty lively corpse.
Furthermore, this year’s sign-up figure is expected to rise; it doesn’t include “waiting in line” sign-ups that California and three other states allowed for people who had started the enrollment process before the Jan. 31 cut-off. Also, part of the difference is due to Louisiana’s recent expansion of Medicaid, which now covers some who had obtained coverage in 2016 through the Obamacare exchanges.
Indeed, independent experts predict that the Obamacare exchanges — should the GOP Congress fail to repeal the law as promised — likely will remain stable for many years.
“If nothing else changed they would probably stabilize at a lower level of enrollment,” says Mark V. Pauly, a professor of health care management at the University of Pennsylvania’s Wharton School.
That’s also the judgment of the nonpartisan Congressional Budget Office, which said in its analysis of the House bill to replace Obamacare that the market for individuals to purchase policies “would probably be stable in most areas under either current law or the [GOP replacement] legislation.”
Problems, But No ‘Implosion’
It’s true that Obamacare — more formally known as the Affordable Care Act — has serious problems. These were summed up by the health insurance lobby itself in a Jan. 24 statement to the House Ways and Means Committee. America’s Health Insurance Plans said, “The challenges facing the individual exchange marketplace – which have been well-documented – include significant increases in average premiums in 2017, fewer health plan choices, and lower-than-expected exchange enrollment and risk pool stability challenges in some states.”
On average those signing up for ACA policies have been older, sicker and more expensive to care for than many insurance companies had expected. That has forced companies to raise premiums, and caused some to stop writing ACA marketplace policies altogether.
Problems have been particularly acute in Tennessee, for example, where the state’s insurance commissioner, Julie Mix McPeak, said last August that the state’s ACA market was “very near collapse.” Matters have grown worse since, when Humana announced it would cease offering ACA policies in 2018. That would leave people in 16 of the state’s 95 counties without any ACA option next year, unless some other insurer steps in.
But Tennessee is not typical. In a letter to Congress, the National Association of Insurance Commissioners said in January that markets are near collapse in “a few” states, but “in some other states the individual market is robust with increased enrollment and premiums have stabilized.”
That letter was signed by Commissioner McPeak — who is the national association’s president-elect — and by three other NAIC officers, the top insurance regulators for Texas, Maine and Wisconsin.
An example of a healthy market is New York, which has what’s been called one of the most robust ACA marketplaces in the country, with 17 insurance carriers offering plans. The state just announced a 28 percent increase in total enrollments for 2017, with 1.2 million covered by private and other non-Medicaid policies and 2.4 million signing up for Medicaid.
Besides Tennessee, other states with problems include Arizona, where virtually all enrollees have only one carrier option, according to Louise Norris, who tracks insurance markets for healthinsurance.org, an independent health insurance guide for consumers founded in 1994. Oklahoma is one of five states with only one insurance company participating, according to the Kaiser Family Foundation’s report on insurer participation, and where the average premium for a benchmark plan increased 69 percentthis year. And in North Carolina, most of the state is served only by Blue Cross Blue Shield, which says it has lost $405 million on ACA plans over a two-year period.
But there are several states besides New York where ACA markets are flourishing. In Wisconsin, Idaho, Massachusetts, New Mexico, Arkansas and California, there is still vigorous participation by insurance companies. Wisconsin alone had 14 insurance companies offering ACA policies.
Industry Opinion
Opinion is divided within the insurance industry itself. Aetna chief executive Mark Bertolini said last month that the ACA exchanges are in a “death spiral.”
“My anticipation would be that in ’18, we’ll see a lot of markets without any coverage at all,” he said. Aetna says it racked up $450 million in losses on ACA policies last year, and it has pulled out of writing ACA policies in 11 states.
But where Aetna has struggled, other companies have profited. “The marketplaces are generally performing well,” Mario Molina, CEO of insurer Molina Healthcare, said on his company’s last conference call following release of earnings, according to USA Today. “They only require modification and adjustment, not wholesale change.”
And while Aetna, Humana and others have pulled out, some new companies have gotten in for 2017. For example, Bright Health in Colorado, Cigna in North Carolina and Virginia, and Wellmark in Iowa.
USA Today reported that even Aetna managed to make nearly $12 million on individual ACA plans in Texas and more than $8 million in Pennsylvania before it pulled out of those states, according to financial filings with state regulators. And the newspaper also reported that Blue Cross Blue Shield of North Carolina — after its big losses on ACA policies in 2014 and 2015 — was taking in hundreds of millions more than it was paying out to beneficiaries in 2016.
Premium Subsidies
What’s often lost in the GOP’s recitations of Obamacare’s problems is that the large majority of those covered by private ACA policies don’t feel the effect of the rising premiums that are supposedly threatening the stability of the system. Most of them get subsidies, and what they pay for the premiums is capped at a percentage of their income.
For 2017, federal officials say 83 percent of those signing up qualifyfor subsidies — a total of 10.1 million people. That’s still a very large number of potential customers for insurance companies.
(A note of caution: Not everyone who enrolls for coverage ends up paying premiums and getting coverage. For 2016, when 12.7 million signed up, an average of 10.4 million ended up making their coverage effective during the first half of the year. The “effectuated” figure for 2017 isn’t yet known, so we can only compare initial sign-ups to get an apples-to-apples comparison.)
In theory, a health insurance market goes into a “death spiral” when too many sick people take out insurance, driving up premiums that in turn cause healthier people to drop out. But under Obamacare, CBO said, the subsidies, coupled with the law’s tax penalties for those who don’t obtain coverage, “are anticipated to cause sufficient demand for insurance by people with low health care expenditures for the market to be stable.”
Wharton’s Pauly says rising premiums could drive out everyone who isn’t heavily subsidized, but that wouldn’t cause a spiral. “The taxpayers will have to pay more so they could object but that is not what we usually mean by instability,” he says.
A still-living Mark Twain wrote in 1897 that “the report of my death was an exaggeration.” The same can be said of GOP claims that Obamacare is fatally ill. If they want it dead, they’ll probably have to kill it themselves.
SOURCE:
.
Obamacare can't be repealed until the free market comes up with mechanism to deal with pre existing conditions, getting healthy people to buy coverage. Currently, based on my assessment they don't have a clue on what to do, and will go back to their flawed methods and practices. It reminds me of the financial crisis where the free market failed and the government had to step in with trillion dollar bailouts and impose regulations.
If Republicans want to repeal Obamacare, these companies need to provide their non-governmental alternatives
If Republicans want to repeal Obamacare, these companies need to provide their non-governmental alternatives
The quote above applies to just about everything else Trump says or does.
In almost every case, its about trying to measure himself, against Obama.
And, we've seen how that's worked out . . .
