2018 MIDTERM ELECTION

Time: D H M S

Trumpcare

UPDATE: ALL 435 CONGRESSIONAL DISTRICTS NOW INCLUDED (broken out by state)

As regular readers know, earlier in the year I embarked on a project to break out the total number of people who would likely lose their healthcare coverage if & when the ACA were to be fully repealed without any replacement whatsoever (i.e., a "clean repeal"). When the dust settled, I estimated the grand total would come in at around 24 million people. I broke this out by state and even attempted to do so by both County and individual Congressional District. Since the GOP hadn't actually come up with any sort of a replacement plan for the ACA, I could only assume that they had a "clean repeal" in mind and work it from that angle.

 

So, like everyone else, yesterday I was poring over the BCRAP text, and one of the first things which caught my eye was the individual market tax credit structure table, to see how it compares with the ACA's formula. Here's how it stands under the ACA...again, these percentages are based on the benchmark Silver policy...

...and here's the BCRAP table, based on the benchmark Bronze policy:

After reviewing it for a few minutes late yesterday morning, I posted a tweet noting that under the ACA, a 60-year old earning about 300% of the Federal Poverty Line...roughly $37,000/year...only has to pay up to around $3,600/year in premiums for a Silver plan (9.69% of their income)...but under BCRAP, that same 60-year old would have to pay up to $6,000/year for a Bronze plan (16.2% of their income).

The tweet went viral...I think it was retweeted like 1,000 times or so over the next few hours.

The CBO score of the GOP Senate's #BCRAP bill is expected to be released early next week, just days (or, who knows, hours?) ahead of Mitch McConnell's rushed-through vote.

The biggest question from a process POV (that is, whether Senaterules will allow the bill to be crammed thorugh the reconciliation process) is financial; as David Anderson summarized the other day:

a) The Parliamentarian is most likely going to be stripping out significant non-germane to the budget items
b) $1 billion in savings must come from each of two committees (HELP and Finance)
c) Anything the Senate passes must meet or beat the $119 billion in budget window deficit reduction that the House AHCA was scored at.

However, from a political POV, the bigger question is how many people the CBO projects will lose coverage by 2026 if BCRAP becomes law.

Back in December, the CBO posted the following:

OK, this metaphor will take a bit, but bear with me.

On March 16, 1981, CBS aired the 17th episode of Season 9 of M*A*S*H. For those of you too young to remember, M*A*S*H, set at a U.S. Army medical camp in Korea during the Korean War, was one fo the most successful TV shows in history, running 11 seasons. I believe the series finale remains the most highly-viewed broadcasts in history. While M*A*S*H started out primarily as a sitcom, it evolved over the years into more of a drama with comedic moments.

Anyway, in S9 Ep17, "Bless You, Hawkeye", the main character, Dr. Benjamin Franklin "Hawkeye" Pierce (played by Alan Alda) finds himself stricken with a sudden, unexplained and violent allergic reaction to something. He spends much of the episode trying standard medical solutions, but his fits of sneezing and coughing become so bad that eventually a recurring character, psychiatrist Dr. Sydney Freedman, is brought in to see if there might be a psychological cause.

Freedman asks Hawkeye about his childhood, and Hawkeye, among other things, mentions his cousin Billy.

 

Back in 2011, when Paul Ryan and House Republicans first attempted to privatize Medicare, a progressive PAC ran the ad above. In it, "America the Beautiful" plays as we see a young, Paul Ryan-ish looking young man pushing an elderly, wheelchair-bound woman down a nature path...and eventually pushing her right off of a cliff. Needless to say, it caused quite a bit of controversy at the time.

Earlier today, as the GOP Senate's BCRAP bill was released, this happened:

HERE'S PART ONE.

I spent almost all of Part One discussing the butchering that the GOP Senate's BCRAP bill does to the individual market, because that's the primary focus of my work here at ACA Signups, but the truth is by far the worst fallout will be on the Medicaid side of things...and most of the damage doesn't even have a damned thing to do with the ACA itself, since it relates to pre-ACA Medicaid.

I'll get to the Medicaid side in depth in Part Three. However, there are still a few more things I need to discuss regarding the individual market: The sub-100% FPL population and how it relates to Medicaid expansion.

 

Yes, that's right: The official name of the Senate GOP's Trumpcare Plan is "The Better Care Reconciliation Act" Plan...otherwise known as "BCRAP".

There's a lot to absorb here, but this is the bottom line:

  • MEDICAID: It's MORE draconian and cruel to Medicaid enrollees than the House version...but delays the worst of it by a few more years.

Seriously, that's it in a nutshell. It phases out the ACA's Medicaid expansion more gradually...but as the years pass, would eventually squeeze even more people off their coverage...mainly via non-ACA Medicaid, which means that this bill really has little to do with "repealing Obamacare" and is mainly about giving massive tax cuts to the ultra-rich at the expense of the poor and low-income workers.

OK, so this is what the "Three-Legged Stool" of the ACA is supposed to look like for the individual market:

Of course, I say "supposed to" because two of the three legs are simply too short, causing it to lean over somewhat.

Back on November 15, 2016, one week after the election, I posted the following:

IMPORTANT: I cannot guarantee accurate federal data after 1/20/17.

...Most of the actual staff...the career employees at CMS/HHS, many of who've been there through more than one administration, will likely remain, and will do their jobs to the best of their ability, including trying to compile and publish data as accurately as possible.

HOWEVER, their bosses...the HHS Secretary and, I presume, the head of CMS...will be appointed by Donald J. Trump and confirmed by a 100% Republican-controlled Senate.

Given Trump's long, disturbing history of flat-out misstatements (aka "making sh*t up out of whole cloth"), and the type of sycophants he's likely to put into place, I can't guarantee with any certainty that the numbers spouted off by them are going to bear any connection with reality. Maybe they'll be accurate. Maybe they'll be off slightly. Maybe they'll be completely removed from any actual numbers. Who the hell knows?

An eternity ago (aka back in January/February), I attempted to compile and break out estimates of how many people would likely lose healthcare coverage in the event of a full, "clean" repeal of the Affordable Care Act (that is, a complete repeal of the ACA without any replacement healthcare policy whatsoever). I concluded that the total added up to roughly 24 million people nationally: Around 8.2 million highly-subsidized Individual Market enrollees, nearly 15 million Medicaid expansion enrollees and 750,000 Basic Health Plan enrollees (NY & MN only). I then attempted to break these out by both County and Congressional District​. I went with a "clean" repeal because there wasn't any actual replacement plan available to compare with.

Things are looking pretty precarious in Iowa for 2018, with Wellmark and Aetna bailing entirely on the state's individual market.

The good news, such as it is, is that Medica has stepped up to the plate as the sole insurance carrier filing to offer indy market policies (on the ACA exchange or off, I believe) across all 99 counties next year.

The bad news--although I can't really say that I blame them under the circumstances--is that they're insisting that they'll need a big rate hike to do so.

Here's the thing, though: First check out the headline in this story about it from The Hill:

Only ObamaCare insurer in most Iowa counties to hike premiums by 43.5 percent

One of the last insurers on Iowa's ObamaCare exchanges announced Monday it would sell plans in 2018 but proposed an average rate increase of 43.5 percent.

For heaven's sake. Here I sit, painstakingly digging up, downloading, compiling and analysing a mountain of 2018 SERFF rate filing forms for hours on end to find out what the weighted average requested rate hikes are in every state and to then go beyond that to figure out how much of the increases are due to normal factors vs. Trump/Price/GOP-specific sabotage efforts such as the threat to cut off CSR payments and/or not to enforce the individual mandate penalty...

...and then a big healthcare consulting firm like Oliver Wyman goes and steals my thunder by issuing hteir own analysis:

Two market influences, in particular, are complicating 2018 rate setting: the uncertainty surrounding continued funding of cost sharing reduction (CSR) payments and the question of how the relaxation of the individual mandate will impact enrollment and risk pools.

The Centers for Medicare & Medicaid Services is administered by Trump/Price pick Seema Verma, who is openly doing everything possible to trash the ACA and push the AHCA, to the point of allegedly committing borderline extortion in order to help push it through.

Therefore, this came as a bit of as surprise a few days ago (yeah, I'm late to the party on this one...busy week). The lead actuary for CMS, Paul Spitalnic, issued his own scoring of the impact of the AHCA on healthcare coverage, premiums and the federal budget.

It's important to note--as Mr. Spitalnic himself does right at the top of the analysis--that:

In case you needed more evidence that Donald Trump doesn't give a rat's ass about actual policy as long as it means people lavish praise on him at any given moment:

Washington (CNN)President Donald Trump told Republican senators lunching at the White House Tuesday the House-passed health care reform bill he celebrated earlier this year was "mean," a source told CNN.

Trump made clear multiple times that he was pleased that the Senate negotiations appeared to be moving away from where the House version of the repeal and replace effort ended up, according to three sources familiar with the meeting.

Trump told the lawmakers that the House bill didn't go far enough in protecting individuals in the marketplace -- and appeared to use that as his rationale for why he has ambiguously called twice for the Senate to "add more money" to the bill.

...But the comment belies the celebratory Rose Garden ceremony Trump hosted earlier this year when the House passed the bill and the President championed it as "incredibly well crafted."

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