From REPEAL & REPLACE to WRECK & REJOICE (from Obamacare to Trumpcare

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April 25, 2018 | Edit

On March 24th, 2017. “Speaker Paul Ryan (R-Wis.) on Friday said his party “came up short” in a news conference minutes after pulling the GOP healthcare bill off the House floor, acknowledging that ObamaCare will stay in place “for the foreseeable future.””

Yet on December 20th, 2017 the INDIVIDUAL MANDARE was repealed. ““When the individual mandate is being repealed that means ObamaCare is being repealed,” Trump said…“We have essentially repealed ObamaCare, and we will come up with something much better…”

“Andy Slavitt, who served as the acting administrator for the Center for Medicare and Medicaid Services under President Barack Obama, warned late Friday night that Republicans may try to repeal and replace Obamacare once again before the 2018 midterm elections. “Republicans have been meeting in secret to bring back ACA repeal,” he writes…

… Santorum and others may think that there will be a “blue wave” in 2018 no matter what, so this may be the last time the GOP has the opportunity to get rid of Obamacare. And that might make Republicans desperate enough to try again.” (R)

At the end of this post there are links to a series of over 60 posts tracking the activity between March 24th and December 20th. Laws are like sausages,” goes the famous quote often attributed to the Prussian Chancellor Otto von Bismarck, “it is better not to see them being made.”

In 2018, mostly under-the-radar, efforts are continuously underway to continue to undermine what’s left of ObamaCare.

“Republicans, having failed to repeal Obamacare, have stumbled, almost accidentally, into replacing it. For better and for worse, and with little coherent vision at work, they are making Obamacare their own. And over time, they are likely to embrace it…,

Congress has already repealed several unpopular parts of the law as part of last year’s tax legislation — most notably the individual mandate, which now expires at the end of this year, but also the Medicare cost-control board (known as the Independent Payment Advisor Board).

The executive branch has exerted its own influence on the law. In October of last year, President Trump signed an executive order calling for the expansion of association health plans and limited-duration insurance, in hopes of creating a secondary market for health plans that are cheaper and less regulated, and this year, the administration released extensive proposals for each. The administration also stopped paying the law’s cost-sharing reduction subsidies, which reimburse insurers for low-income beneficiaries. And the Department of Health and Human Services has begun allowing states to attach work requirements to Medicaid, making the program more bureaucratic, but possibly enticing red states that have so far declined to expand the program to do so…

Having failed in their repeal effort, Republicans are now in something of an arranged marriage with the health care law. These alterations are being made in a predictably haphazard fashion, with little in the way of guiding theory, but the cumulative effect is to turn Obamacare into a law that they can, if not love, at least learn to live with.”(A)

“Bigger changes are coming. The administration has proposed regulations that would allow so-called short-term health plans to be offered for nearly a year of coverage. Those plans aren’t subject to any Obamacare rules in most states, and are likely to be marketed aggressively. They are likely to cover fewer health services and be available only to the healthy — but at a lower price. Another pending rule would expand the availability of association health plans, a form of group insurance purchasing that may be attractive to small businesses looking for cheaper, less comprehensive options….

People buying those plans may face some unpleasant surprises. The plans are likely to require applicants to fill out detailed health histories, and to exclude those with prior illnesses. They also are likely to exclude or limit services — like addiction treatment, maternity care or prescription drugs — that all Obamacare plans require. Association plan buyers have tended to have problems with fraud. And some short-term plans have a history of declining to pay for serious illnesses after the fact.

But even if the new plans serve their customers well, their popularity could leave the remaining markets a bit shakier. Because the short-term plans will be open only to the healthy, the remaining customers will tend to be sicker, and more expensive to insure.” (B)

“It’s been well documented that the Trump White House has filled federal agencies with bureaucrats whose life work is destroying the very agencies they’ve been assigned to. But one is in a better position than her fellows to threaten the health of millions of Americans—and she’s been working at that assiduously.

We’re talking about Seema Verma, who as administrator of the Centers for Medicare and Medicaid Services also is effectively the administrator of the Affordable Care Act. In the Trump administration, that has made her the point person for the Trump campaign to dismantle the act, preferably behind the scenes…

Still, Verma had spent enough time in the healthcare field that observers thought she might not be totally egregious as CMS administrator. But then, during her confirmation hearing in February 2017, she let on that she didn’t see why maternity coverage really needed to be mandated for all health policies, since “some women might want maternity coverage, and some women might not want it…

It wasn’t an auspicious start. But since then she has lived down to our expectations. Verma never has concealed her hostility to Medicaid — especially Medicaid expansion, a provision of the ACA. Her animosity is fueled at least in part by ignorance (willful or otherwise) about the program. Back in November, on the very day that voters in Maine and Virginia were demonstrating full-throated support at the polls for expanding Medicaid in their states, Verma was unspooling a string of misleading statistics and suspect assertions about the program to support a policy of rolling back enrollment.” (C)

“Passing two measures aimed at stabilizing the Affordable Care Act marketplaces by infusing insurers with more funds would lower monthly premiums by 20 to 40 percent and prompt an additional 3.2 million people to get covered, says an attention-grabbing independent analysis released yesterday by the firm Oliver Wyman.

These measures – which would pay insurers for extra cost-sharing discounts for the low-income and reimburse them for their most expensive customers – are currently stuck in political limbo as leaders on Capitol Hill consider whether to include them in a massive, must-pass spending bill next week.

The bills have become emblematic of inter and intraparty disputes over how to approach a world with most of the ACA still in place. Democrats are bitter that Republicans are still chipping away at parts of the law by repealing its individual mandate and changing other provisions through the executive branch…

And Republicans can’t even agree among themselves how to handle the law now that they’ve failed to entirely wipe it from the books. (D)

“Republicans campaigned for roughly a decade, promising voters they would dismantle former President Barack Obama’s landmark health care legislation; but one of their own senators is trying to keep it alive through the 2018 election cycle…

Sen. Lamar Alexander, R-Tenn., along with Sen. Patty Murray, D-Wash., is using the deadline to sway leadership to include a proposal that would fund politically contentious Obamacare subsidies through 2019. The proposal would provide $10 billion a year for three years for these subsidies…

Additionally, the proposal would give states greater Obamacare waiver flexibility and would broaden consumer eligibility for “copper” plans. Abortion-covering health insurance plans would not receive subsidies under the proposal…

Republicans are either not thrilled about Alexander’s proposal, calling it a bad idea and one that could hurt the party going into 2018, or they think it could be one way to provide taxpayers some relief from the financial burdens Obamacare imposed.” (E)

“The House passed the $1.3-trillion omnibus spending package meant to keep the government running until Sept. 30 in a vote of 256-167, leaving the Senate barely 35 hours to get the same legislation approved by Friday at midnight to avert a shutdown.

The bill boosts funding for the National Institutes of Health, the CDC, and the Department of Veterans Affairs (VA) as well as other key agencies, but keeps funding flat for the Centers for Medicare and Medicaid Services…

The bill also does not include the health insurance stabilization bill from Sen. Lamar Alexander (R-Tenn.) and Sen. Susan Collins (R-Maine). They had wanted the omnibus package to include measures restoring for 3 years the cost-sharing reduction subsidies (monies that help insurers defray out-of-pocket costs for low-income enrollees), establishing 3 years of reinsurance (monies that help pay for the sickest of patients and keep premiums from spiking) at $10 billion per year, and streamlining the 1332 waiver process to allow states more flexibility in health plan design.” (F)

“The Trump administration hopes to move forward with a rule expanding alternatives to ObamaCare plans by this summer, Secretary of Labor Alex Acosta said Monday. The rule allows small businesses and self-employed individuals to band together to buy insurance as a group in what are known as association health plans. “We hope to have that by this summer,” Acosta said Monday during a tax reform event alongside President Trump in Florida.” (G)

“In 2012, the Supreme Court of the United States upheld Obamacare in a 5-4 ruling, with Chief Justice John Roberts writing the majority opinion. Many Obamacare opponents believe Roberts used contorted reasoning to save the law by labeling Obamacare’s individual mandate penalty a tax.

Now, six years later, 20 states have seized on the Roberts ruling to ask the courts again to undo Obamacare. These states filed a lawsuit indicating that because the December 2017 tax reform bill repealed the individual mandate penalty, there’s no longer any legal rationale for the mandate. They also argue that because there’s no “severability clause” in Obamacare, the entire law must be struck down.

If this sounds confusing, read on to unpack what’s going on with this latest attempt to undo Obamacare through the courts.

The Obamacare mandate was ruled a tax…

Opponents of the law argued Congress didn’t have the power to require individuals to purchase a product from private insurers, while the Obama administration argued authority for the mandate came from the Commerce Clause, which gives the federal government power to regulate commerce “among the several states.”” (H)

“Gov. Scott Walker has asked for a federal waiver to operate a state-based reinsurance plan designed to stabilize the state’s individual health insurance market and hold down premiums under the Affordable Care Act.

Following a 44 percent average spike in Obamacare premiums this year, Walker’s office estimates the $200 million program would lower premiums by 11 percent from what they otherwise would have been, amounting to a 5 percent decrease in premiums compared to 2018.

Under the plan, the state would pay $34 million for reinsurance in 2019, while $166 million would come from federal funds…

“We are taking action to address the challenges created by Obamacare and bring stability to the individual market,” Walker said. “Our Health Care Stability Plan provides a Wisconsin-based solution to help stabilize rising premiums in order to make health care more affordable for those purchasing in the individual market. With Washington D.C. failing to fix our nation’s health care system, Wisconsin must lead.” (I)

“The American Academy of Family Physicians and other doctor groups have unleashed detailed critiques of Trump’s effort to introduce cheaper health insurance with skimpier benefits….

“Insurers could reduce or eliminate certain essential health benefits to avoid vulnerable, expensive patients by excluding specific services,” AAFP board chair Dr. John Meigs, Jr., a family physician from Alabama wrote in a letter last week to U.S. Health and Human Services Secretary Alex Azar.

“In doing so, insurers could potentially make plans more expensive for people with long-term chronic conditions or with sudden medical emergencies,” Meigs said. “Inadequate benefits could leave this population with too little coverage to meet their health care needs.” (J)

“The Affordable Care Act (aka Obamacare) banned any hospital, doctor, or insurance company who receives federal funding from discriminating against or denying services based on sex; the Obama administration made it clear in 2016 that provision included transgender and gender-nonconforming patients…

These benefits and protections are heading for oblivion though, according to the Times. The Trump administration is pointing to a January 2017 ruling from a Texas federal judge who said the 2010 law did not cover gender identity or presentation.

“Congress did not understand ‘sex’ to include ‘gender identity,’” Judge Reed O’Connor ruled. In the Affordable Care Act, he said, Congress “adopted the binary definition of sex.” (K)

“As Republicans careen toward the midterms with tax reform under their belts and not much else, rumor has it that a small group of Republican senators are working with the White House and former Sen. Rick Santorum (R-Pa.) to revive the debate over ObamaCare repeal.

Their purpose is laudable. But, privately, conservatives across Capitol Hill are expressing concern that the proposal may not do enough to dismantle ObamaCare’s regulatory structure, reduce its colossal spending, or allow freedom to innovate outside the law’s stifling framework…

The bill’s premise — to devolve much of the health-care spending to the states — is a good starting point. But its implementing details are still unknown, leaving conservatives to wonder if the new bill will actually repeal ObamaCare and reform the health-care marketplace, or if it will simply recast much of the law’s worst elements with a few minor tweaks…

Voters are still waiting for a full repeal effort. Anything less will not suffice as a solution for candidates who will soon be elected on a message of repeal. Nor will it suffice for a party who has spent years making the same promise.” (L)

“Less than a year after the GOP gave up on its legislative effort to repeal the law, Democrats are going on offense on this issue, attacking Republicans for their votes as they hope to retake the House majority…

ObamaCare’s favorability in polls has improved since the repeal push last year, with more now favoring the law than not. A Kaiser Family Foundation poll in March found that 50 percent of the public favors the law, while 43 percent holds an unfavorable view.

GOP strategist Ford O’Connell said the political winds have shifted on the issue, turning ObamaCare into a subject Democrats want to tout and many Republicans want to duck.

“I don’t think it’s seen as a winning issue,” he said. “It’s also an issue that tends to fire up the Democratic base more so than the Republican base.”” (M)

“While Republican moves to overhaul Social Security, Medicare or Medicaid appear unlikely — at least for this year — Democrats are increasingly warning about the prospect because of the deficit concerns created by the tax plan. The GOP argues Democrats want to distract from the fact that they did not support the tax overhaul, the signature Republican achievement of Trump’s first year in office.

Democrats’ ability to sell voters on their vision for health care and warn about the possibility of cuts to Social Security and Medicare could prove crucial for candidates, such as Manchin, who are trying to win in red areas…

Polling suggests Trump and the GOP’s efforts to reshape the American health-care system have not resonated with voters. Thirty-six percent of respondents to the Economist/YouGov poll said they strongly disapprove of how the president has handled health care, compared with only 15 percent who said they strongly approve.” (N)

“People have voted with their enrollment decisions: A sizable number of Americans do not get insurance from their employers and value the coverage on Obamacare’s markets. That refutes the GOP myth that the program forces Americans to purchase junk insurance that they do not want. A recent Kaiser Family Foundation poll found that these consumers seek to guard against major medical costs, to gain the peace of mind that comes with insurance and to obtain coverage for chronic medical care, suggesting that the law serves important and durable needs.

Another fictional Republican claim is that Obamacare has been collapsing. A Kaiser study this year found that insurance markets stabilized in 2017, despite Mr. Trump’s best efforts to undermine the law. This comports with findings from the Congressional Budget Office and a range of other independent analysts…

Obamacare continues to serve an important need. What’s sad to see is how easy it would be to make it even more useful, if Republicans would focus on improvement instead of sabotage.” (O)

“What’s the secret of Obamacare’s stability? The answer, although nobody will believe it, is that the people who designed the program were extremely smart. Political reality forced them to build a Rube Goldberg device, a complex scheme to achieve basically simple goals; every progressive health expert I know would have been happy to extend Medicare to everyone, but that just wasn’t going to happen. But they did manage to create a system that’s pretty robust to shocks, including the shock of a White House that wants to destroy it…

What this says to me is that if Republicans manage to hold on to Congress, they will make another all-out push to destroy the act — because they’ll know that it’s probably their last chance. Indeed, if they don’t kill Obamacare soon, the next step will probably be an enhanced program that lets Americans of all ages buy into Medicare.” (P)

“At the outset, Obamacare had three central features:

• Insurers could not charge higher prices to people with pre-existing conditions.

• Those without coverage had to pay a penalty to the government (the “mandate”).

• Low-income people would be eligible for subsidies.

The first two provisions were necessary to prevent the death spiral, and government couldn’t mandate insurance purchases without adding subsidies for the poor.

Despite a bumpy rollout and some frustrations over shrinking choices and rising prices at health care exchanges, Obamacare was working remarkably well by most important metrics. Program costs were much lower than expected, and the uninsured rate among nonelderly Americans fell sharply — from 18.2 percent in 2010 to only 10.3 percent in 2018.

This progress is now imperiled.

The mandate — by far the program’s least popular provision — was repealed as part of tax legislation passed in December 2017. And because economists predict that its absence will slowly rekindle the insurance death spiral, we’re forced back to the policy drawing board… (Q)

SEE OBAMACARE/ TRUMPCARE CHRONOLOGY AFTER THE FOOTNOTES

(A) The G.O.P. Accidentally Replaced Obamacare Without Repealing It, by Peter Suderman https://www.nytimes.com/2018/03/12/opinion/republicans-obamacare-health-care.html

(B) Republicans Couldn’t Knock Down Obamacare. So They’re Finding Ways Around It., by Margot Sanger-Katz, https://www.nytimes.com/2018/04/11/upshot/republicans-couldnt-knock-down-obamacare-so-theyre-finding-ways-around-it.html

(C) How Trump’s Obamacare administrator is taking a hatchet to Obamacare, by Michael Hiltzik, http://www.latimes.com/business/hiltzik/la-fi-hiltzik-obamacare-verma-20180417-story.html

(D) The Health 202: Republicans could lower Obamacare premiums. But will they?, by Paige Winfield Cunningham, https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2018/03/13/the-health-202-republicans-could-lower-obamacare-premiums-but-will-they/5aa6a81330fb047655a06c0d/?utm_term=.923a4143e8d5

(E) Senate May Fund Obamacare Subsidies With This Sneaky Move, by Robert Donachie, https://www.dailysignal.com/2018/03/15/senate-is-going-to-fund-obamacare-subsidies-with-this-sneaky-move/

(F) House Passes Spending Bill Without Obamacare Fix, by Shannon Firth https://www.medpagetoday.com/publichealthpolicy/healthpolicy/71945

(G) Trump Official: Alternative to ObamaCare Plans Likely This Summer, by Peter Sullivan, http://galen.org/2018/obamacare-watch-newsletter-4-20-18/

(H) States Take Another Run at Undoing Obamacare Through the Courts, by Christy Bieber, https://www.fool.com/investing/2018/04/22/states-take-another-run-at-undoing-obamacare-throu.aspx

(I) Amid rising Obamacare premiums, Walker seeks federal waiver for reinsurance program, by op 5 percent, by Lauren Anderson, https://www.biztimes.com/2018/ideas/government-politics/amid-rising-obamacare-premiums-walker-seeks-federal-waiver-for-reinsurance-program/

(J) Doctors Attack Trump’s Short-Term Health Plans Ahead Of Comment Deadline, by Bruce Japsen, https://www.forbes.com/sites/brucejapsen/2018/04/22/doctors-attack-trumps-short-term-health-plans-ahead-of-comment-deadline/#9049bad3fb10

(K) Trump to Allow Anti-Trans Discrimination in Health Care, by BY NEAL BROVERMAN, https://www.advocate.com/transgender/2018/4/22/trump-allow-anti-trans-discrimination-health-care

(L) Republicans have a long way to go toward fully repealing ObamaCare, by Rachel Bovard, http://thehill.com/opinion/healthcare/383722-republicans-have-a-long-way-to-go-toward-fully-repealing-obamacare

(M) GOP in retreat on ObamaCare, by BY PETER SULLIVAN, http://thehill.com/policy/healthcare/384032-gop-in-retreat-on-obamacare

(N) It’s not all about Trump: Democrats’ midterm chances ride on health care and Social Security, too, by Jacob Pramuk, https://www.cnbc.com/2018/04/16/not-just-trump-health-care-social-security-could-define-2018-midterm-elections.html

(O) Americans are sticking by Obamacare. If only the GOP would stop trying to kill it., https://www.washingtonpost.com/opinions/americans-are-sticking-by-obamacare-if-only-the-gop-would-stop-trying-to-kill-it/2018/04/15/9b817832-3c2b-11e8-a7d1-e4efec6389f0_story.html?noredirect=on&utm_term=.e10e892994e9

(P) Obamacare’s Very Stable Genius, by Paul Krugman, https://www.nytimes.com/2018/04/09/opinion/obamacare-trump.html

(Q) Back to the Health Policy Drawing Board, by ROBERT H. FRANK, https://www.nytimes.com/2018/03/16/business/back-to-the-health-policy-drawing-board.html

(R) Health Policy Expert Says Republicans Have ‘Secret’ Plan to Repeal Obamacare, by Cody Fenwick, https://www.alternet.org/news-amp-politics/health-policy-expert-says-republicans-have-secret-plan-repeal-obamacare 000000000000000

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