2018 MIDTERM ELECTION

Time: D H M S

As I noted last week, the Republican-controlled Michigan state Senate rammed through a draconian work requirement bill for ACA Medicaid expansion enrollees in spite of the fact that it would serve no positive purpose and would only "save money" by kicking thousands of low-income Michiganders off their healthcare coverage while actually harming the economy.

I further noted that while I was pretty sure the bill would easily pass the state Senate (where the GOP holds a supermajority) and will likely pass the GOP-controlled state House as well, there is a decent chance that it could be vetoed by GOP Gov. Rick Snyder. Snyder is guilty of a long list of sins during his time as Governor, including being indirectly responsible for the water supply for the entire city of Flint being poisoned a few years back. At the same time, oddly, once in a blue moon he'll actually do something decent and good, and the one he deserves the most praise for on this front is pushing to get Medicaid expansion through in the first place.

So, about a week ago I tweeted this out:

Last December Congressional Republicans, having mostly failed in their quest to take healthcare coverage away from 24 million Americans, decided to settle for half a loaf and simply kill off the ACA's individual mandate by itself.

It's important to keep in mind that they knew damned well that killing the mandate penalty without replacing it with some other type of "negative inducement" to encourage people to enroll in a fully ACA-compliant policy was a really, really bad idea. Proof? Both the GOP House and Senate versions of their ACA "replacement" bill included an alternative to the mandate penalty:

The American Health Care Act ("AHCA"):

Under the AHCA, the individual mandate is wiped out...except it's replaced with a 30% premium surcharge for people who don't maintain continuous coverage for more than 2 months.

(sigh) OK, gather 'round children, and let me tell you the story of how Cost Sharing Reductions went from being a thorn in the side of the Obama Administration to becoming a massive tree branch jammed into the kidney of Congressional Republicans. The following is an updated version of a lengthy post of mine from about six months ago.

The Cost Sharing Reduction (CSR) payment controversy has only really been sucking up a huge amount of political and policy oxygen for the past year and a half, since Donald Trump took office, but actually started long before then. Why? Because the whole reason the CSR payments were discontinued in the first place is a federal lawsuit filed by John Boehner on behalf of the House Republican Caucus back in 2014.

(sigh) Dammit, sure enough, as I expected, the full Michigan state Senate has gone ahead and passed the state Senator Mike Shirkey's "God's Safety Net" bill which would impose 29-hour-plus work requirements on 680,000 low-income Medicaid enrollees even though the vast majority of them already work, go to school, are medically fragile, take care of other medical fragile family members, elderly relatives or children and so forth. It was, as you'd expect, a party-line vote:

Able-bodied Medicaid recipients in Michigan may soon have to choose between finding a job or losing health insurance.

...Democrats condemned the proposal as harmful to thousands of Medicaid recipients who would not meet the several exemptions spelled out in SB 897 and said such a move is also illegal. Majority Republicans brushed aside those objections, and the bill passed 26-11.

The bill now heads to the House.

I've repeatedly written about how Donald Trump is still deperately trying to sabotage the ACA by any means necessary. Last year it was all about a combination of regulatory and legislative attacks, but aside from repealing the ACA's individual mandate (which was, admittedly, a pretty ugly blow), the GOP-held Congress was unsuccessful at tearing it down legislatively.

Therefore, for 2018, Trump has decided to double down on the regulatory side...and one of the main ways he hopes to achieve this is by opening up the floodgates on so-called "Short-Term, Limited Duration" policies, which aren't subject to most ACA requirements and therefore are a) free to siphon off healthy ACA-compliant enrollees into b) substandard healthcare plans which can leave thousands of people in dire straits.

Jonathan Cohn of the Huffington Post has the skinny:

Two more Democratic senators are introducing a bill that would create a version of Medicare for some working-age Americans, offering yet another sign that government-run insurance will figure prominently into the Democratic Party’s health care agenda going forward.

By my count, there are now a total of 5 different Universal Coverage policies officially on the table from Congressional Democrats, in addition to the two "ACA 2.0" bills proposed (both of which are presumably meant as stopgap measures until one of the UC bills can also get passed and take hold and be implemented a few years later). These bills include ones from Bernie Sanders ("Medicare for All"); Tim Kaine/Michael Bennet ("Medicare X"); Brian Schatz ("Medicaid Option"); and my preferred option of those I've seen so far, the plan from the Center for American Progress ("Medicare Extra"). The newest entry from Sen. Merkley & Murphy is apparently called "Medicare Part E":

Over at the Kaiser Family Foundation, Karen Pollitz and Gary Claxton have published a handy explainer which goes over the basics of the various types of NON-ACA individual market policies...specifically, the "Short Term" and "Association" plans which Donald Trump is attempting to flood the market with by essentially removing any restrictions or regulations on them, but also the "Idaho Style" plans which were rejected by HHS for being flat-out illegal as well as the "Farm Bureau" junk plans which Iowa recently decided to open the floodgates on (Tennessee already had a similar setup, and sure enough, it has proven pretty devastating to Tennessee's ACA market since 2014 as a result). The whole thing is worth a read, but in the early part of their explainer, however, they also happened to neatly lend support to my estimates from last week regarding the unsubsidized market:

 

(sigh) This is so predictable...via Jonathan Oosting of the Detroit News:

...Maitre, 62, spends dozens of hours each week babysitting her grandchildren and providing their working parents with free child care. But none of that time or her community service would count as work under an advancing plan that would require Medicaid recipients to spend 29 hours a week at a job or risk losing their health care coverage.

...The Republican-led Senate Competitiveness Committee approved the legislation a short time later in a 4-1 vote. The lone committee Democrat voted against the plan to reform the government health care program for lower-income residents, which has grown significantly in recent years after the state expanded eligibility under former President Barack Obama’s signature health care law.

It now moves on to the full state Senate, as I expected.

NOTE: I'm well aware that the math below is of the "back of the envelope" variety and has a lot of caveats and assumptions.

Today is Tax Day, so I decided to do a fun little exercise (OK, it's not fun for those getting stuck with the bill).

Last week I crunched the numbers and determined that roughly 6.5 million middle-class Americans enrolled in individual market policies are being hit with an average health insurance premium hike of around $960 apiece this year specifically caused by the various sabotage efforts put forth by Donald Trump and Congressional Republicans last year. This primarily consisted of the CSR remimbursement payment cut-off, but also included smaller factors like threats (later made reality) to not enforce and/or repeal the individual mandate; slashing marketing/outreach budgets by 90% and 40% respectively; and so forth.

I have mixed feelings about private health insurance companies and, by extension, health insurance brokers.

On the one hand, as a universal coverage advocate who'd prefer that it be pretty much all publicly funded, I see private, profit-based insurance carriers as a middleman which shouldn't be necessary in the first place.

On the other hand, until the day comes where universal coverage via a single Medicare-for-All-like national healthcare system, insurance carriers are necessary, and since they offer a variety of different policies with different networks, coverage features, premiums, deductibles, co-pays and so forth, that means a lot of hand-holding is also necessary.

A couple of weeks ago I reported that the state legislature and governor of deep red Utah has agreed to partly expand Medicaid under the ACA...

Gov. Gary Herbert signed a measure Tuesday to give more than 70,000 needy Utahns access to government health coverage, ending years of failed attempts on Capitol Hill to expand Medicaid in the state.

But whether House Bill 472 ever takes effect still remains uncertain. Under President Obama’s signature Affordable Care Act (ACA), the Utah law needs approval by the federal Centers for Medicare and Medicaid Services (CMS), which has sent mixed signals on whether it will fully sign off.

Even if CMS does approve HB472, it will likely be about a year — even on an aggressive schedule — before the state can begin enrolling people for coverage.

...but with two major caveats:

This morning I was contacted on Twitter by a woman in Louisville, Kentucky who appears to be in pretty dire straits:

On 7/1/18, in Ky, my Medicaid/ ACA will be canceled. I may still need a brain shunt, LP #8, RXs, PT, etc. I was informed that my PCP could write a letter stating I was "Medically Fragile" but even then the provider has final say. Like fox guarding hen house. Please help me/DM

Here's her story according to her GoFundMe page (I've cleaned up the formatting a bit for easier readability):

I am a disabled attorney living with my 76-year-old mother who takes care of me. In 2011, I was bitten by a tick and was infected with Ehrlichiosis Chaffeensis and Rickettsia. A week later, I contracted Coxsackie B4 virus. Because I was kept on antibiotics for 19 years, I had no immune system to fight these illnesses.

I was originally just planning on comparing the various provisions of the House and Senate Democratic versions of their "ACA 2.0" bills against my own, year-old "If I Ran the Zoo" wish list.

Then I wrote a post about a whole bunch of stand-alone bills in California which Louise Norris alerted me to and decided to throw those into the comparison table as well.

And now, with quick state-level action in both Maryland and New Jersey in recent days, I decided to expand this project across every state. I've started color-coding the status of each bill and am even adding some recent/past bills and/or waivers which have failed as I go (i.e., the failed/delayed mandate penalty restoration efforts in Connecticut and Maryland).

This is a work in progress, so the table is probably pretty incomplete for now and will likely be changing constantly as various bills are introduced, moved to committee, voted on, pass/fail, signed/vetoed by governors and actually implemented (or legally challenged).

UPDATE 4/20/18: Whew! OK, I've incorporated a bunch of Louise Norris' links for several states and have moved it to a full Google Docs spreadsheet. Be warned, it's pretty big now...

A few days ago I noted that Maryland Governor Larry Hogan had signed a bipartisan bill into law which creates a $380 million reinsurance fund which should cancel out up to 21% of next year's looming individual market premium hikes.

However, I forgot to mention the other important thing that the same bill does: Evidently it would also head off Donald Trump's attempt to open the floodgates on the type of minimally-regulated "short-term" and "association" plans which would further damage the ACA-compliant individual market risk pool:

(C) THIS SUBTITLE APPLIES TO ANY HEALTH BENEFIT PLAN OFFERED BY AN ASSOCIATION, A PROFESSIONAL EMPLOYEE ORGANIZATION, OR ANY OTHER ENTITY, INCLUDING A PLAN ISSUED UNDER THE LAWS OF ANOTHER STATE, IF THE HEALTH BENEFIT PLAN COVERS ELIGIBLE EMPLOYEES OF ONE OR MORE SMALL EMPLOYERS AND MEETS THE REQUIREMENTS OF SUBSECTION (A) OF THIS SECTION.

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