“The proposal would allow insurance companies the freedom to sell any kinds of health plans they want as long as they also sell at least one plan that qualifies under the regulatory requirements of the Affordable Care Act (ACA)….”
““It sounds like a recipe for segmenting the market in a way that would destabilize it. You would end up back in the scary dysfunctional world we were in before the ACA where healthy people could get coverage although that coverage might not protect them if they got sick and sick people would have to pay an unaffordable amount for coverage,” …..“The coverage that sick people need would still have to be offered but offered at any price, so probably unaffordable,” …. (A)
Here’s why the problem exists. Imagine that two plans are available from an insurer, one in which you get charged the same rate regardless of your medical risks and one in which your rates depend on your medical risks. It does not take a genius to forecast the results: people who believe themselves high risk will flock to the plan that does not base rates on medical risks (the “community rated plan”) while people who believe themselves to be low risk will go for the plan in which healthier people pay lower rates. This tendency will be even stronger if the latter plan also offers lesser benefits. But … the insurer, realizing that this separation will occur, will set the premiums in the community rated plan quite high, precisely because it knows the applicant pool is going to come disproportionately from the sick… In the end, then, the community rated pools are likely to have very high gross premiums, perhaps akin to a high risk pool. (B)
“Under Cruz’s model, many healthy consumers would avoid shelling out for high-cost, comprehensive plans. This would then make the pool of people willing to pay for such coverage disproportionately sick, which would cause the price of such plans to rise, which would make the pool even sicker, which cause prices to premiums to rise further, which would make the pool sicker still, on and on, in a death spiral, until the sick were priced out of the market completely.” …..
Conservatives are being honest about one thing: A full repeal of Obamacare would send the health-care system back to the pre-ACA status quo ante. In those days people with preexisting conditions were mostly out of luck (aside from whatever succor they are offered via the health-insurance ghettos states create under the rubric of “high-risk pools”), while healthy people had a wide range of affordable options — including the option of going without insurance…..” (C)
(A) GOP tensions rise over Cruz proposal, byAlexander Bolton, http://thehill.com/policy/healthcare/340765-gop-tensions-rise-over-cruz-proposal
(B) Senator Cruz’s Healthcare Reform Proposal Creates A Monster “Income Cliff”, by Seth Chandler, https://www.forbes.com/sites/theapothecary/2017/07/03/senator-cruzs-healthcare-reform-proposal-creates-a-monster-income-cliff/#5dc929484615
(C) Cruz Amendment to Senate Health-Care Bill Now Dividing GOP, by Ed Kilgore, http://nymag.com/daily/intelligencer/2017/07/cruz-amendment-to-senate-health-care-bill-now-dividing-gop.html
…….The President’s tweet also could have the effect of further complicating health care negotiations. A GOP official close to leadership and supportive of the current repeal/replace effort told CNN.” (A)
President Trump tweeted: “If Republican Senators are unable to pass what they are working on now, they should immediately REPEAL, and then REPLACE at a later date!” (B)
Senate Majority Leader McConnell immediately rejected the idea and …”riffed on Trump’s winning campaign slogan, saying, “It’s not easy making America great again is it?”” (C)
“The logic makes some sense, in the abstract. If Democrats are confronted with Obamacare being ripped out, root and branch, would they really not work with Republicans to restore funding to things like Medicaid?
The problem is that legislating health care, as we’ve found out, is a hugely messy process. Any replacement of funding would be subject to debate and would face an uncertain future. Democrats might hold out for more Medicaid funding. Republicans might hold out for less Medicaid funding or hold the line on something like cutting off Planned Parenthood. The GOP would essentially be gambling that Congress would have to pass something, thereby absolving them of whatever harmful effects might come from cutting off the Affordable Care Act in one fell swoop.
But we’ve been down this road before, to some degree, and the lesson is clear: Never underestimate Congress’s ability to gridlock itself.” (D)
In January before leaving Office President Obama called Repeal Now/Replace Later “reckless” and “irresponsible.” “Given that Republicans have yet to craft a replacement plan, and that unforeseen events might overtake their planned agenda, there might never be a second vote on a plan to replace the ACA if it is repealed,” Obama wrote. “And if a second vote does not happen, tens of millions of Americans will be harmed.” “(E)
Repeal alone….”would probably leave 18 million more people without coverage in the first year after its enactment and 32 million more by 2026, according to a Congressional Budget Office report that looked at an earlier GOP bill to repeal Obamacare.
It would also cause premiums on individual market policies to increase by up to 25% the first year and to nearly double by 2026.
All this would happen mainly because the individual mandate — which requires nearly all Americans to get coverage or pay a penalty — would be repealed. But some insurers would also likely pull out of the market, the CBO said. The remaining carriers would likely raise rates dramatically because the remaining enrollees would tend to be older and sicker.” (F)
“Repeal of the ACA hurts employer-based insurance. With tens of millions of people no longer insured via Medicaid expansion and subsidies, hospitals and doctors would find themselves back in the bad-old-days of uncompensated care and inadequate pools to support their free care. There will be nowhere else to turn for resources than to higher premiums for people who do have insurance.”….” Bottom line: if you think your employer-based premiums went up too much under the ACA, just wait until it’s gone to see what the ACA was actually protecting you from.” (G)
“Senate Republican leaders trying to break a logjam on their proposed health-care legislation are working with congressional budget officials to examine the impact of various changes they’re considering, a process that could take about two weeks, according to a GOP aide….(H)
Here’s one columnist’s small ball proposal:
“First, the smaller bill would repeal the individual mandate requiring the purchase of health insurance. It would replace it, as the Senate bill does, with a continuous-coverage requirement — a waiting period to purchase insurance if you go without it for more than two months.
Second, the bill would repeal some of the taxes on health care spending, saving and services imposed by Obamacare — including the taxes on medical devices and prescription medications, the higher threshold for deducting spending on chronic care, and the limits on contributions to health spending accounts.
Third, the bill would maintain the stabilization funds that the Senate legislation pays to states and insurers to help cover the sickest Americans and keep exchange prices from spiraling upward. (I)
Congress has three weeks to get this right between its July 4th recess and its month-long August recess.
(A) Trump: If GOP health care bill fails, repeal Obamacare now, replace later, by Eugene Scott, http://www.cnn.com/2017/06/30/politics/trump-healthcare-bill-twitter/index.html
(B) Trump to Senate Republicans: kill Obamacare now, replace later, by Doina Chiacu and Susan Cornwell, http://www.reuters.com/article/us-usa-healthcare-idUSKBN19L1F6
(C) McConnell rejects Trump’s advice to repeal ObamaCare now, replace later, http://www.foxnews.com/politics/2017/07/01/mcconnell-rejects-trumps-advice-to-replace-obamacare-now-replace-later.html
(D) Trump’s new idea to repeal Obamacare now and replace it later would be a massive gamble, by Aaron Blake, https://www.washingtonpost.com/news/the-fix/wp/2017/06/30/trumps-new-idea-to-repeal-obamacare-now-and-replace-it-later-would-be-a-massive-massive-gamble/?utm_term=.e98b661aee4a
(E) President Barack Obama Slams ‘Repeal And Delay’ Approach To Affordable Care Act, by Anna Almendrala, http://www.huffingtonpost.com/entry/obama-slams-aca-repeal-delay_us_586fe91be4b099cdb0fd0b7f
(F) 32 million people would lose coverage if Obamacare was repealed, by Tami Luhby, http://money.cnn.com/2017/06/30/news/economy/obamacare-repeal-trump/index.html
(G) What Happens If Republicans Repeal Without A ‘Replace’?, by Donald M. Berwick, http://www.huffingtonpost.com/entry/what-happens-to-the-insurance-market_us_5878d878e4b0e58057fe4a14
(H) Senate GOP Leaders Said to Aim for New Health Plan in Two Weeks by Laura Litvan , Elizabeth Titus , and Steven T. Dennis, https://www.bloomberg.com/news/articles/2017-06-30/trump-floats-repealing-obamacare-now-replacing-it-later
(I) Going Small on Health Care by Ross Douthat, https://www.nytimes.com/2017/07/01/opinion/sunday/going-small-on-health-care.html?smprod=nytcore-ipad&smid=nytcore-ipad-share
Since the American people overwhelming disapprove of the Trump/ Senate health care bill, why do Republicans remained determined to Repeal and Replace?
The facts are…
“Just 17 percent of those surveyed say they approve of the Senate’s health care plan, the Better Care Reconciliation Act. Fifty-five percent say they disapprove, while about a quarter said they hadn’t heard enough about the proposal to have an opinion on it…..
While Democratic opposition to the bill, as expected, is high, GOP support for the Senate GOP’s plan is very soft. Twenty-one percent of Republicans oppose the bill and just 35 percent support it. Sixty-eight percent of independents also oppose the proposed legislation.
In fact, while many Americans want changes to the ACA, also known as Obamacare, they want it to be more far-reaching. A 46 percent plurality say they want to see the ACA do more, while just 7 percent want it to do less. Keeping the ACA and having it do less is essentially what GOP congressional plans are doing.” (A)
Maybe here’s why….
“The budget office said the measure would leave 22 million more Americans without insurance by 2026. Hit hardest would be lower-income people between the ages of 50 and 64 and people struggling with chronic illness or battling addiction — many of the same voters who believed President Trump’s promises to improve their health care. The bill would cut $772 billion over the next decade from Medicaid, which covers most of America’s poor children and nursing home patients, to help finance tax cuts for the wealthy.” (B)
Doesn’t Senator McConnell care about Kentuckians? (Senator Paul too)
“Perhaps nowhere has health care law had as powerful an impact as in Kentucky, where nearly one in three people now receive coverage through Medicaid, expanded under the legislation. Perhaps no region in Kentucky has benefited as much as Appalachia, the impoverished eastern part of the state, where in some counties more than 60 percent of people are covered by Medicaid.
And in few places are the political complexities of health care more glaring than in this poor state with crushing medical needs, substantially alleviated by the Affordable Care Act, but where Republican opposition to the law remains almost an article of faith. While some Senate moderates say the Republican bill is too harsh, Rand Paul, Kentucky’s other Republican senator, is among Senate Republicans who say they are opposed to the current bill for a different reason: They believe it does not go far enough to reduce costs.” (C)
It is important to remember…
“Historically, insurance has been deeply intertwined with employment for many Americans. Most employed, non-elderly people in the U.S. get their health insurance through their employer. This means people often lose health insurance when they lose their jobs, making it nearly impossible to access care. The Affordable Care Act (ACA) – commonly known as Obamacare – sought to address this by creating premium tax credits so people could purchase insurance based on their income and expanded Medicaid to cover all low income adults. This was meant to help provide access to the health care system during periods of unemployment. Now, despite their promises to help the unemployed, the White House and Congress have begun the process of repealing the ACA, restructuring Medicaid, and reducing benefits.” (D)
One Republican legislative solution..
“The first step for McConnell and other Republican leaders is to get everybody in a room and figure out what it would take to get various factions on board. Moderates like Sen. Dean Heller of Nevada have argued that the cuts to Medicaid are too severe; perhaps McConnell can add enough Medicaid money to get Heller on board. Conservatives like Sen. Mike Lee of Utah wanted to see more flexibility for states to waive coverage requirements; perhaps there is a way to write this flexibility into the bill.” (E)
A better way….
“A once-quiet effort by governors to block the full repeal of the Affordable Care Act reached its climax in Washington on Tuesday, as state executives from both parties — who have conspired privately for months — mounted an all-out attack on the Senate’s embattled health care legislation hours before Republicans postponed a vote.
At the center of the effort has been a pair of low-key moderates: Gov. John R. Kasich, Republican of Ohio, and Gov. John W. Hickenlooper, Democrat of Colorado, who on Tuesday morning called on the Senate to reject the Republican bill and to negotiate a bipartisan alternative.”…
“Now that Senate Republicans have balked, aides to several of the governors said they hoped lawmakers in both parties would craft a different measure focused principally on stabilizing insurance markets. It is unclear whether the Senate might consider that approach.” (F)
Maybe that’s a start! Then move on piece by piece until ObamaTrumpCare is stabilized and sustainable.
In 2015 candidate Trump said:
“Save Medicare, Medicaid and Social Security without cuts. Have to do it,” he said then. “Get rid of the fraud. Get rid of the waste and abuse, but save it. People have been paying it for years. And now many of these candidates want to cut it….”
(A) Just 17 Percent Of Americans Approve Of Republican Senate Health Care Bill, by Jessica Taylor, http://www.npr.org/2017/06/28/534612954/just-17-percent-of-americans-approve-of-republican-senate-health-care-bill
(B) The Health Care Hoax Has Been Exposed, Senator McConnell, https://www.nytimes.com/2017/06/27/opinion/health-care-mcconnell-trumpcare-cbo.html?smprod=nytcore-ipad&smid=nytcore-ipad-share
(C) In McConnell’s Own State, Fear and Confusion Over Health Care Bill, by Sheryl Gay Stolbergjune, https://www.nytimes.com/2017/06/28/us/mcconnell-kentucky-health-care-bill.html
(D) Unemployment and Addiction: How Health Insurance Could Increase the Number of Working People, by Lindsey Vuolo, https://www.centeronaddiction.org/the-buzz-blog/unemployment-and-addiction-how-health-insurance-could-increase-number-working-people?gclid=Cj0KEQjwp83KBRC2kev0tZzExLkBEiQAYxYXOnlspN_Ruz4KnTgKTc7T8WE9qAHxLZJE7NEJtdq2EAUaAq9_8P8HAQ
(E) What’s next on health care now that the Senate has punted?, by Paul Singer, https://www.usatoday.com/story/news/politics/2017/06/27/whats-next-health-care-now-senate-has-punted/433058001/
(F) How Governors From Both Parties Plotted to Derail the Senate Health Bill, by Alexander Burns, https://www.nytimes.com/2017/06/27/us/politics/affordable-care-act-governors.html
Let’s recall that President Trump called the House “Repeal and Replace” bill “mean” after having celebrated its passage by bussing House Republicans to the Rose Garden. And then we were promised a Senate bill “… that’s going to be a phenomenal bill to the people of our country: generous, kind, with heart. That’s what I’m saying.”” (A)
so here are some articles to help you decide–
“The Affordable Care Act gave health insurance to millions of Americans by shifting resources from the wealthy to the poor and by moving oversight from states to the federal government. The Senate bill introduced Thursday pushes back forcefully on both dimensions.
The bill is aligned with long-held Republican values, advancing states’ rights and paring back growing entitlement programs, while freeing individuals from requirements that they have insurance and emphasizing personal responsibility. Obamacare raised taxes on high earners and the health care industry, and essentially redistributed that income — in the form of health insurance or insurance subsidies — to many of the groups that have fared poorly over the last few decades.
The draft Senate bill, called the Better Care Reconciliation Act, would jettison those taxes while reducing federal funding for the care of low-income Americans. The bill’s largest benefits go to the wealthiest Americans, who have the most comfortable health care arrangements, and its biggest losses fall to poorer Americans who rely on government support. The bill preserves many of the structures of Obamacare, but rejects several of its central goals.” (B)
now, to dig deeper…
START WITH THIS CHART
CHART: Who Wins, Who Loses With Senate Health Care Bill
THEN LOOK AT THESE ANALYSES
Who gets hurt and who gets helped by the Senate health care bill
The Senate health care bill: What’s in it and what to watch for in the CBO report
The Congressional Budget Office has not yet issued its analysis of how this bill would affect the federal deficit and the number of Americans who have health coverage. That “score” is expected to be released next week. It’s also not clear yet whether the Senate parliamentarian will give all of the bill’s provisions her go-ahead.
It was 1952 and we lived in Haddonfield, New Jersey and the public swimming pool was closed for the duration. A town in full panic!
So today’s New York Times article on a polio outbreak in Syria is particularly disconcerting.
Polio Paralyzes 17 Children in Syria, W.H.O. Says (A)
“The polio virus, once thought to verge on eradication, is one of the most contagious diseases in inadequately protected areas. One confirmed case of paralysis is considered an outbreak, as doctors assume it means up to 200 other people may have been exposed to the virus.”…..
“Unlike Syria’s first polio outbreak in 2013, caused by a wild strain that paralyzed 36 children before it was brought under control, the new outbreak derived from the polio vaccine itself…..
The vaccine, a weakened form of the polio virus that triggers the immune system’s response, is secreted in the waste of vaccinated children, and over time can mutate into an infectious strain that may afflict the unvaccinated. The risks are especially high in areas where not all children have received the vaccine and where the mutated virus can spread from contaminated sewage or water.”
A 2012 article noted:
“In 1952 alone, nearly 60,000 children were infected with the virus; thousands were paralyzed, and more than 3,000 died. Hospitals set up special units with iron lung machines to keep polio victims alive. Rich kids as well as poor were left paralyzed.
Then in 1955, the U.S. began widespread vaccinations. By 1979, the virus had been completely eliminated across the country.
Now polio is on the verge of being eliminated from the world. The virus remains endemic in only two parts of the globe: northern Nigeria and the border between Afghanistan and Pakistan.” (B)
In a world full of conflict such Syria, Iraq and Yemen (C) are we likely to see a broad reemergence of polio?
Are we prepared for emerging viruses?
“Whatever the explanation, hepatitis C (1989), West Nile virus (1999), SARS (2003), Chikungunya (2005), swine flu (2009), MERS (2012), Ebola (2014) and Zika (2015) have all since had their time in the media spotlight. A further 33 diseases have featured in the World Health Organization’s Disease Outbreak News since its inception in 1996. Of the “big eight” listed above, six are known zoonotic diseases – and the remaining two (hepatitis C and Chikungunya) are assumed to be so, although the animal reservoir remains undiscovered.”
To learn more click on http://doctordidyouwashyourhands.com/2017/05/ebola-is-back-in-africa-is-zika-next-are-we-prepared/
ZIKA UPDATE #1. EBOLA is back in Africa. Is ZIKA next? Are we prepared?
Lesson Learned from recent EBOLA and ZIKA episodes. We need to designate REGIONAL EMERGING VIRUSES REFERRAL CENTERS (REVRCs).
(A) Polio Paralyzes 17 Children in Syria, W.H.O. Says by Rick Gladstone, https://www.nytimes.com/2017/06/20/world/middleeast/syria-polio-children-paralyzed.html
(B) Wiping Out Polio: How The U.S. Snuffed Out A Killer by Jason Beaubien, http://www.npr.org/sections/health-shots/2012/10/16/162670836/wiping-out-polio-how-the-u-s-snuffed-out-a-killer
(C) 10 Conflicts to Watch in 2017 by Jean-Marie Guéhenno, http://foreignpolicy.com/2017/01/05/10-conflicts-to-watch-in-2017/
Recently I visited a medical specialist I have known for twenty five years. Back then I was a new hospital President and he was a junior attending. About ten years later I became his patient. And hadn’t seen him in two years.
When he saw me he said “hello Dr. Metsch” and I responded “hello Dr. Green” then we switched to first names. Even though I retired ten years ago and he is now a senior attending our initial greeting reflected mutual respect.
Mid-career I worked in the President’s Office at Mount Sinai for ten years for four physician CEOs. I always called them Doctor even as my younger colleagues would call them by their first names; they bristled at this informality.
About that time (1988) this was written: “The paper discusses the moral difficulties physicians encounter when determining the level of formality they will use when addressing their patients. It is argued that physicians ought not to use a patient’s first name unless the patient also uses the physician’s first name. In short, physicians and patients should always address each other with the same level of formality. It is argued that this is so even when patients invite physicians to address them informally.” (A)
“Developing a good rapport with a patient is essential, and what transpires during a first meeting can set the stage for the ongoing relationship. But unfortunately, there are no definitive guidelines on how physicians and other providers should be addressed, how patients prefer to be addressed, or how staff should introduce themselves.” (B)
There are certainly various points of view on this.
“If I call a patient by their first name, it would seem only fair and equal that I offer up my first name. I have always addressed my patients by their last names and titles, particularly in San Antonio, Texas, where military titles are extremely important. Familiarity also seems inappropriate in an environment where the patient does not see the same provider at each visit and has to start from scratch. Long gone are the days of a family physician who cared for three generations of the same family. Since a sizeable portion of patients and physicians may be offended by the use of their first name, it seems best that, unless invited to do so, we stick to formal titles.” (C)
“I address my patients (over the age of 18) by their titles and last names unless they have given me permission to do otherwise. When I meet new patients, I address them by their first and last names and then ask them how they would like for me to address them. My expectation is that they will address me as I prefer to be professionally addressed: “Dr. Middleton.”” (D)
Maybe I’m old school but I think all successful patient-doctor relationships are based on mutual respect. If a physician calls a patient by his first name, she should allow the patient to do the same. If a physician wants to be called Doctor, then he should use Mr., Mrs., Ms. or Doctor, Professor, Reverend, Captain or any other appropriate title.
I think formality should prevail initially and over time informality might be mutually OK and here’s a good example:
“I have at least a hundred patients who call me James, Jimmy, Dr. James, Dr. Bowtie, Dr. S, Herr Doctor or Jim. I have no need of an ego-massaging label. The difference is that we have long-standing relationships, and those patients have usually asked permission. We are friends, colleagues, in battle against the dread disease. I gain satisfaction to have built relationships where mutual respect is expressed in this way. Even so, when the proverbial excrement hits the spinning blades, many of those patients revert to “doctor.” That makes emotional sense to me.” (E)
To this day I never call a doctor by his or her first name without asking first and being comfortable the answer will be “yes.”
“I speak to everyone in the same way, whether he is the garbage man or the president of the university.” Albert Einstein
(A) What doctors should call their patients, by Michael Lavin, http://jme.bmj.com/content/medethics/14/3/129.full.pdf
(B) Should Patients Call You by Your First Name?, by Roxanne Nelson, http://www.medscape.com/viewarticle/852371
(C) What’s In a Name: What Should Patients and Doctors Call Each Other?, by Richard C. Senelick, http://www.huffingtonpost.com/richard-c-senelick-md/patient-doctor-relationship_b_1357605.html
(D) Should doctors be addressed by their first name?, by Jennifer Middleton, http://www.kevinmd.com/blog/2011/05/doctors-addressed.html
(E) Calling a Doctor by His or Her First Name, by James C. Salwitz, http://www.medpagetoday.com/Blogs/KevinMD/56354
It is obvious that Repeal and Replace shouldn’t and won’t happen.
After bussing republican House members to the White House Rose Garden several weeks ago to celebrate House passage of the American Health Care Act, President Trump now “… bluntly derided a House attempt to repeal the Affordable Care Act as “mean,” “ and said “that he expected the Senate to come up with something more generous…” (A)
President Trump tweeted “”2 million more people just dropped out of ObamaCare,” “It is in a death spiral. Obstructionist Democrats gave up, have no answer = resist!” (B)
We know that the Obama administration planned to look at the following changes: Expand The Medicaid Expansion; Simplify Health Insurance Plans; Fix Surprise Medical Bills; Extend Coverage For Kids; Buff Up The Cadillac Tax; Improve Insurance Provider Networks; Rein In Prescription Drug Costs (C)
Any big new program like Obamacare has a “million” moving parts and some assumptions in the initial algorithms need to be recalibrated. Fortunately there has been plenty of evaluation and recommendations to do a mid-course correction to maintain access and address affordability.
Here is a list of approaches that must be considered:
Some initial corrections: (D)
1. Patch things up: Since affordability is a big issue, the federal government could spend more money to bring down the costs that individuals and families face. This could be done directly by raising the level of subsidies available for plans purchased on the exchanges, or raising the income thresholds at which the subsidies phase out—or both. Alternatively, the government could offer more generous subsidies to insurance companies, particularly those serving high-risk populations, in which case they wouldn’t have to raise prices as much, or impose such large deductibles.
2. Apply some force: One of the big problems that insurers are facing is that too few healthy people, and too many sick people, are signing up for the plans sold through the exchanges. For insurers, that changes everything. Faced with higher claims per enrollee than they expected, they seek to raise their prices, which makes healthy people, especially young healthy people, even less likely to sign up the following year. If unchecked, this process could lead to a spiral of rising prices and falling enrollment.
3. An obvious way to address this problem would be to drastically raise the fines that people face if they don’t purchase insurance. Under the terms of the Affordable Care Act, getting enrolled wasn’t meant to be a choice—it was a legal obligation. For political reasons, however, the penalty for flouting this “individual mandate” was set at a very low initial level, which is supposed to grow gradually. In 2015, the fines started at three hundred and twenty-five dollars per adult
4. Generally speaking, private insurance markets only work well when there is a large and diversified risk pool. If we are going to rely on them to provide universal, or near-universal coverage, the individual mandate will have to be enforced. That means raising the penalties for non-compliance and enforcing them effectively.
5. The Public Option: The rising cost of health care is an issue all over the world. The way most countries have dealt with it is by enrolling the entire population, or almost all of it, in a single-payer system, and using the bargaining leverage that creates (usually coupled with administrative fiat) to keep down costs. So far, the American political system, which is highly vulnerable to capture by powerful interest groups, such as doctors, hospitals, and pharmaceutical companies, has resisted going down this route. But this may be changing.
Stabilize the marketplace: (E)
6. “Marketplaces will only succeed if enough insurers participate, and many are running away from what they perceive as a high-risk, low-reward market opportunity,” …..All of this — insurer withdrawals and sharply escalating premiums — was avoidable and is fixable. We know how to draw insurers into markets, keep them there, and limit premium growth. We can do so by subsidizing plans more and by limiting their risk of loss. We’ve done both before.”
7. The Medicare Modernization Act also established Medicare’s prescription drug program, Part D, which offers another lesson. It’s also run entirely through private plans. They’re cushioned against large losses by a risk corridor program. This helps plans stay in the market if they miscalculated the mix of patients they’d attract, and it allows them to keep premiums lower than they might need to if they had to hedge against the full brunt of potential losses.
8. The Affordable Care Act included a risk corridor program for marketplace plans, too, but it expires at the end of this year. So does a reinsurance program that compensates insurers for unusually high-cost enrollees. Following the model of Part D and making the risk corridor program permanent, as well as the reinsurance program, could help stabilize the marketplaces.
Policy fixes that could plausibly improve Obamacare and attract bipartisan support. (F)
9. Defuse the Crisis. The leading enemy of stability is uncertainty, and for insurers who must decide what to do about the exchanges by June, the leading source of uncertainty before last Friday was the Republican repeal push itself. That threat has apparently subsided, but the House lawsuit over cost-sharing subsidies could still blow up the exchanges. The House put the suit on hold after Trump’s election, anticipating Obamacare’s repeal, but if the Republicans want to avoid a major mess, they need to make the suit go away and make sure the subsidies keep flowing.
10. Insure the Insurers: The Democratic push for health reform in 2010 relied on what The Washington Post described as “the near-daily demonization of the insurance industry.” Obama routinely attacked “insurance company bureaucrats who raise premiums and deny care.” Pelosi called them “villains.” And Obamacare included tough new rules that prohibited them from discriminating against customers with pre-existing conditions or capping how much they could spend on any customer.
11. Relax the Rules: The best evidence so far that the Trump administration hopes to prevent the kind of implosion the president keeps predicting is a new set of rules his Department of Health and Human Services recently proposed for the exchanges. The rules involve fairly modest adjustments for the 2018 enrollment, giving insurers more flexibility to offer slightly more generous plans while closing loopholes the insurers thought consumers were using to game the system. But they amount to an insurer wish list, which suggests a desire to keep insurers happy on the exchanges.
12. A Drug Deal: Obamacare has helped reduce the overall growth of health care costs to the lowest rate in half a century, but prescription drug prices have continued to soar. The cost of six brand-name diabetes medications rose more than 150 percent over the past six years. Multiple sclerosis drugs now cost more than $5,000 a month, increasing more than fivefold since 2001. Connolly says the nonprofit plans she represents now spend more on drugs than hospitalization. “That’s mind-boggling,” she says. “There’s no rhyme or reason to it, and it’s driving up premiums.”
Changes that would help bring down premiums on the exchanges. (G)
13. Require all insurers who want to sell in the individual insurance market to offer their plans through the exchange, so they couldn’t cherry-pick individuals outside the exchange (this is an idea championed by Henry Aaron of the Brookings Institution).
14. Reduce the waiting period for those on disability insurance to get Medicare coverage from two years to six months to move some of the very high-cost enrollees out of the individual-market pool.
15. Require any insurer that wants to offer a Medicare Advantage plan in an area also to offer a plan in the marketplace for under-65 enrollees.
16. Have the federal exchange adopt the procedures used by California in actively bargaining with plans instead of acting as a passive clearinghouses.
17. Create a public option for those aged 55-64 clearly identified as an early buy-in to Medicare.Create a second federally run public option for enrollees from 18 to 54.
18. Restore the risk corridor and reinsurance provisions that have expired that were intended to protect exchange plans against adverse selection.
A good summary – (H)
“First, despite some genuine problems, the Affordable Care Act is mostly working quite well.
Second, far from solving the problems of Obamacare, the Republicans’ AHCA would have made them worse.
Third, real leaders don’t run away from problems; they fix them. Fourth and most important, a compromise plan could have appealed to — and could still appeal to — enough members of both parties to pass.”
(A) Trump, in Zigzag, Calls House Republicans’ Health Bill ‘Mean’, by Thomas Kaplan, et al, https://www.nytimes.com/2017/06/13/us/politics/trump-in-zigzag-calls-house-republicans-health-bill-mean.html?smprod=nytcore-ipad&smid=nytcore-ipad-share&_r=0
(B) Trump: Dems ‘gave up’ on fixing ObamaCare, by Rebecca Savransky, https://www.nytimes.com/2016/11/15/upshot/politics-aside-we-know-how-to-fix-obamacare.html?_r=0
(C) How Obama Would Fix Obamacare If Congress Would Let Him, by Jeffrey Young http://www.huffingtonpost.com/entry/how-obama-would-fix-obamacare_us_56bcd8d6e4b0c3c550506e19
(D) Three Ways to Fix Obamacare, by John Cassidy, http://www.newyorker.com/news/john-cassidy/three-ways-to-fix-obamacare
(E) Politics Aside, We Know How to Fix Obamacare, Austin Frakt, https://www.nytimes.com/2016/11/15/upshot/politics-aside-we-know-how-to-fix-obamacare.html?_r=0
(F) Four Things Trump Could Do Right Now To Fix Obamacare, by Michael Grunwald, http://www.politico.com/magazine/story/2017/03/four-things-trump-could-do-right-now-to-fix-obamacare-214962
(G) Obamacare has some problems. Here’s how we can fix them, by Paul Waldman, https://www.washingtonpost.com/blogs/plum-line/wp/2016/10/25/obamacare-has-some-problems-heres-how-we-can-fix-them/?utm_term=.4f04717a4c90
(H) Want to fix Obamacare? Here’s how by Henry Aaron, http://www.nydailynews.com/opinion/fix-obamacare-article-1.3013226