Charles Gaba's blog

...things have been a little hectic around these parts...

I'll try to post an update later this afternoon but, power might not be restored until as late as Sunday, so I have to deal with a whole mess of stuff (including my official day job, of course).

UPDATE 3/13/17: Nope, still out.

UPDATE 3/14/17:

WOO-HOO!!!

Yup, as of 8:12pm Monday evening, we finally got our power back. Yeesh.

 

Statements rolling in from advocacy, patient groups. American Health Association, American Hospital Association both won’t support AHCA.

— Sarah Kliff (@sarahkliff) March 7, 2017

Hospitals, nursing homes, physicians, patient advocates all releasing statements that AHCA is unworkable.

AMA's letter is below. pic.twitter.com/lhnbVrc87g

— Andy Slavitt (@ASlavitt) March 8, 2017

Trumpnation day 48-Fallout continues over Trumpcare bill. AMA, AHA, AARP, FAH, AAP, APA, some republicans and all democrats are now opposed.

--Khepri (@khepricorn) March 8, 2017

Has the American Heart Association or American Homerbrewers Association chimed in yet? 

Back in January, being a spreadsheet guy but not being a particularly good graphic artist, I put together a crude table which attempted to give a general idea of which groups of people the Affordable Care Act is, in general, working out for fairly well vs. which groups the ACA isn't working for, by income threshold. A couple of days ago, with details about the GOP's "replacement plan" popping up all over, I posted a similar version of the table which tried to compare the winners/losers between the two plans, and the contrast was remarkable: Nearly a complete reversal.

Last night, with the GOP's plan finally, officially revealed, I made some minor adjustments so that the two tables were more of an apples-to-apples and came up with the following:

Well, the early reviews are in, and it ain't pretty.

Democrats, progressives and patient advocates hate TrumpubliCare, which obviously surprises no one.

The American Health Association and American Hospital Association both hate TrumpubliCare (hoping the American Heart Association chimes in as well so I can make it an "AHA, AHA & AHA hates AHCA" trifecta).

Conservatives hate TrumpubliCare (for very different reasons, of course), which is perhaps more surprising.

So, it's finally here. After seven years and over 100 entries, Huffington Post healthcare reporter Jeffrey Young can finally shut down (or at least archive) his famous "JUST IN TIME!" Storify collection, which has been chronicling the endless empty promises of the Republican Party insisting that their "replacement plan" for the Patient Protection and Affordable Care Act was going to be revealed at any moment.

Yes, after seven years, it's finally here (Part 1) and here (Part 2). It has a catchier title than the ACA ("The American Health Care Act"), which is typical of Republican bills. Remember George W. Bush's "Healthy Forests Initiative", which actually opened previously protected forest areas to logging, often unnecessarily or under false pretense? See, it has the word "American" right there in the title, so it must be good, right? I'll be abbreviating tthis as "AHCA", although they're already annoying me by spelling "healthcare" as two words (I strongly believe it should be one).

Here's the stuff which CAN'T be changed via the reconciliation process, and is therefore not touched...yet. That is, these are changes which would either require 60 votes in the Senate or would require the GOP to kill the filibuster entirely to push through:

  • Guaranteed issue (no pre-existing condition denials)
  • Community rating (can't charge different people more for the same policy outside of a tight set of parameters)
  • The ACA's preventative benefits (I'm not sure if this list changes, but I'd imagine not)
  • No lifetime or annual limits on coverage (a few people have stated otherwise, but this seems to be the consensus)
  • Required essential benefits for every plan on the private market (ie, group or individual)
  • Limits on out-of-pocket costs for enrollees
  • Young adults 19-25 being allowed to stay on their parents' plan (I've noted before that I always suspected this would survive any repeal effort)
  • "Removing the lines" to allow carriers to "sell insurance across state lines" (at least not any more so than the ACA already allows them to)
  • The "Grassley Amendment": Congressional staffers will still have to enroll via the DC exchange in order to receive tax credits.
  • The 80/20 Medical Loss Ratio (requires insurance carriers to refund the difference to enrollees if they spend more than 20% of premium costs on anything other than actual, legitimate medical care)

All of the above sounds great at first glance...but again, keep in mind that for the most part this is only because they can't touch them without 8 Democratic Senators agreeing to do so...or killing the filibuster, which they could still do. That's a hell of a Sword of Damocles to be hanging over everyone's head.

OK, so what would change via the AHCA, assuming they manage to pass it with simple majorities in the House and Senate, and Trump signs it (which I'm certain he would)?

One of the most controversial aspects of the GOP's "Basement Bill" (aka the #DeplorableCareAct) until now is that it was supposed to replace the current funding sources for the ACA (including a 3.8% tax on investment income and 0.9% Medicare payroll tax for the wealthy) with a tax on 10% of the premiums paid by those receiving employer sponsored insurance...namely, tens of millions of middle-class workers.

A couple of years ago, an ACA-related "case study" story went viral for a week or so about a man from Fort Mill, South Carolina by the name of Luis Lang.

Initially, the story seemed to be about a man who railed against Obamacare while both taking absolutely no responsibility for failing to take advantage of the benefits of the law which he was entitled to and simultaneously blaming President Obama for the failure of his own GOP-controlled state to expand Medicaid under the law. Several people wrote up articles ripping Mr. Lang to shreds over his seeming hypocrisy, myself included.

In addition to all of the other horrific details which are oozing out of the House Republican's "Basement Bill" to replace the ACA, something else has been nagging at me for a few days now, but I couldn't quite put my finger on it until today.

The issue was sort of coalescing in my brain all afternoon, but it was a couple of other folks who laid it out first:

If you widen the age rating bands for health insurance and then scale the tax credit based on age, haven't you kind of done nothing?

— Josh Barro (@jbarro) March 2, 2017

@jbarro Belated response: I've thought the same thing and asked this question. No persuasive answers.

— Margot Sanger-Katz (@sangerkatz) March 3, 2017

@sangerkatz Drat. You both beat me to the punch. If they want 5:1 bands, shouldn’t 60+ subsidies be $10,000?

— ☪️ Charles Gaba ✡️ (@charles_gaba) March 3, 2017

Obviously there's no way of being 100% certain about this because the GOP still hasn't actually presented their ACA replacement bill (and in fact, have been playing a rousing game of Where's Waldo with it all afternoon), but we do have a pretty good idea of what it's gonna look like, thanks to a recent draft version of the bill which was leaked a couple of weeks back.

The Kaiser Family Foundation has crunched the numbers and compared what things look like financial assistance-wise under the ACA, the HHS Secretary Tom Price's "Empowering Patients First" bill and the recent "House Discussion Draft" bill to see how the GOP versions size up...and it's not pretty.

This is sheer insanity.

Russia, if you're listening, I hope you can find the GOP health bill that is missing, you will probably be rewarded mightily by our press

— Dan Diamond (@ddiamond) March 2, 2017

@charles_gaba Geraldo Rivera is on the case #ACAReplacementIsInCaponesVault pic.twitter.com/6YOL0AI1uo

— Brett Krasnov (@brett5355) March 2, 2017

The bill was in our hearts the whole time

— Adam Cancryn (@adamcancryn) March 2, 2017

The plot of literally the most boring National Treasure sequel is playing out in the Capitol right now and I can't believe I'm missing out

— Adam Cancryn (@adamcancryn) March 2, 2017

 

Sometimes the joke just writes itself.

“But the plans were on display…”
“On display? I eventually had to go down to the cellar to find them.”
“That’s the display department.”
“With a flashlight.”
“Ah, well, the lights had probably gone.”
“So had the stairs.”
“But look, you found the notice, didn’t you?”
“Yes,” said Arthur, “yes I did. It was on display in the bottom of a locked filing cabinet stuck in a disused lavatory with a sign on the door saying ‘Beware of the Leopard.”

--― Douglas Adams, The Hitchhiker's Guide to the Galaxy

via Jonathan Chait of New York Magazine:

Over the past month or so, I've been tallying up the number of people who would lose their healthcare coverage if and when the GOP actually does proceed with repealing the Affordable Care Act, breaking the totals out by both County and Congressional District in every state.

While this project has received high praise as a useful resource, one problem with it is that the numbers aren't static--between the high churn rate of the individual market and Medicaid, as well as the fact there's no limited enrollment period for Medicaid (you can sign up year-round), the enrollment figures are constantly changing.

Case in point: As of January 20th,, roughly 706.000 Pennsylvanians were enrolled in ACA Medicaid expansion. As of February 17th that number had increased to over 716,000.

I don't have a county-level breakout of the updated number, but I'm assuming that each county/congressional district has increased roughly proportionately:

Over the past month or so, I've been tallying up the number of people who would lose their healthcare coverage if and when the GOP actually does proceed with repealing the Affordable Care Act, breaking the totals out by both County and Congressional District in every state.

While this project has received high praise as a useful resource, one problem with it is that the numbers aren't static--between the high churn rate of the individual market and Medicaid, as well as the fact there's no limited enrollment period for Medicaid (you can sign up year-round), the enrollment figures are constantly changing.

Case in point: Just two weeks ago, roughly 400.000 Louisianans were enrolled in ACA Medicaid expansion. As of yesterday that number had increased to nearly 406,000.

I'm updating the spreadsheet versions now, but in the meantime, here's the latest county-level breakout:

Over the past month or so, I've been tallying up the number of people who would lose their healthcare coverage if and when the GOP actually does proceed with repealing the Affordable Care Act, breaking the totals out by both County and Congressional District in every state.

While this project has received high praise as a useful resource, one problem with it is that the numbers aren't static--between the high churn rate of the individual market and Medicaid, as well as the fact there's no limited enrollment period for Medicaid (you can sign up year-round), the enrollment figures are constantly changing.

Case in point: As of the beginning of January, roughly 640,000 Michiganders were enrolled in "Healthy Michigan", our name for ACA Medicaid expansion. By the end of January, that number had increased to just over 646,000.

 

For the most part, Republican Michigan Governor Rick Snyder has taken a fairly hands-off approach when it comes to both the Affordable Care Act and Donald Trump. He pushed for both Medicaid expansion and a state-based ACA exchange, but while he managed to get the former through the GOP-controlled state legislature (albeit 3 months late and with a few conservative trimmings), he failed on the latter front, and pretty much shrugged it off after that. Since then, Michigan's implementation of ACA Medicaid expansion has quietly been pretty damned successful, with 646,000 Michiganders (strike that...it's now up to 666,000!) enrolled in the program...over 6.5% of the entire state's population. Beyond that, however, Snyder has been fairly quiet about the ACA overall to my knowledge.

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