Trumpcare

The other day it looked like the GOP Senate's BCRAP bill was going to take a hatchet to all 3 legs of the ACA's "three-legged stool", by getting rid of some provisions outright (CSR assistance and the Individual Mandate), weakening and slashing others in half (premium tax credits) and, most cynically, allowing virtually open-ended waivers which would allow individual states to wipe out many others (essential health benefits, minimum AV ratings, annual/lifetime benefits and the ACA's cap on maximum out of pocket costs). Here's what I figured this would make the "stool" metaphor look like:

 

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 of 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."

via Caitlin Owens, Axios (limiting the quote to fair use levels is tricky since the article itself is so short anyway):

Senate GOP won't release draft health care bill

Senate Republicans are on track to finish writing their draft health care bill this evening, but have no plans to publicly release the bill, according to two senior Senate GOP aides.

"We aren't stupid," said one of the aides. One issue is that Senate Republicans plan to keep talking about it after the draft is done: "We are still in discussions about what will be in the final product so it is premature to release any draft absent further member conversations and consensus."

...Democratic senators are already slamming Republicans for the secrecy of their bill writing process, and this isn't going to help. Republicans are sure to release the bill at some point, but it's unclear when — and they want to vote on it in the next three weeks, before the July 4 recess.

"We aren't stupid."

Laura Packard is a friend of mine. We first met about 10 years ago at a state convention in Detroit. She's an all-around awesome person, and one of the most accomplished people I know. Here's just a sampling:

I'm a partner at PowerThru Consulting, a growing national progressive digital consulting shop. At PowerThru we help nonprofits and Democratic campaigns use technology to spread their message and organize and activate their supporters online, to create change offline. We have staff in several states, and work with non-profits of all kinds and on progressive state and federal issues, campaigns and elections of all kinds. We've won four Reed awards and three Pollies for our work to date (including Best Congressional Website in both, Best State/Local Organization Website, Best County/Local/Judicial Website).

I'm a regular contributor to Campaigns & Elections magazine, Huffington Post, and Epolitics.

This is rather amazing, really. With all the dramatic twists and turns that the Trumpcare/AHCA debacle has taken in the 3 months since it was slapped together by Paul Ryan & Co., you'd think that there would be some movement of the approval numbers, wouldn't you?

Well, technically there has been: It went from 17% approval in March to 21% approval in May...

...and as of last week, had dropped right back down again to the same 17% it started out with:

American voters disapprove 62 - 17 percent of the Republican health care plan, compared to a 57 - 20 percent disapproval in a May 25 Quinnipiac University poll. Today, Republicans approve of the health care plan 42 - 25 percent, as every other listed party, gender, education, age or racial group disapproves by wide margins. 

UPDATE: Some people are crediting me with creating the "3-legged stool" metaphor, which simply isn't the case; that credit goes to (I believe) MIT Economics Professor Jonathan Gruber, who came up with the metaphor back in 2006 while helping develop Mitt Romney's "RomneyCare" model for Massachusetts, which was the basis for the ACA's exchange model for the individual insurance market.

I'm simply expanding on the metaphor to explain some of the terms and concepts which are swirling around these days during the repeal/replace brouhaha.

So, I got back from my trip to the NIHCM awards dinner in DC late last night, and am groggily attempting to bone up on all the healthcare stuff which happened while I was gone (ironic, of course, given that I was attending a healthcare-related event filled with other healthcare wonks/reporters).

In the past 2 days...

I've been warning for months now that the Trump administration is doing everything possible to disrupt, undermine and otherwise sabotage the ACA exchanges as much as possible. Yes, the GOP in general has been doing so for 7 years now, but they've really shifted it into overdrive now that they hold all the cards.

In the past, some of those sabotage efforts were obvious and had a direct impact on the exchanges (the Risk Corridor Massacre, for instance) while others were smaller, less obvious and harder to pinpoint a precise cause/effect relationship (red states attempting to obstruct ACA navigators, for example). Donald Trump and his rogue's gallery of cretins are not exactly known for their subtlety, however, so his obstruction/sabotage efforts have been pretty blatant, including:

Last week Donald Trump's new Assistant Secretary for Planning & Evaluation, Stephen Parente (an avowed and open opponent of Obamacare) issued a hit piece on the ACA just one day ahead of the Congressional Budget Office's devastating report on the GOP's AHCA "replacement" healthcare plan.

The ASPE report made a simple claim: That average individual market premiums have more than doubled since ACA-compliant policies were launched in 2014. It plugged in the average individual market premiums for this year and compared them against the average indy market premiums for 2013 (the last year before all newly-enrolled policies had to be ACA compliant). It only included the 39 states maintained by the federal exchange, HealthCare.Gov, and concluded that on average, monthly premiums had increased from $224 in 2013 to $476 in 2017...a 105% increase over 4 years.

IMPORTANT: ALL ESTIMATES BELOW are based on the CBO score of the HOUSE GOP version of the Trumpcare bill (AHCA).

Here's the updated link to the state/district breakout of the SENATE GOP version of Trumpcare (BCRAP) as of 6/27/17.

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

(this is Part Two of my analysis of the CBO score of AHCA 2.0 (the version which actually passed the House 3 weeks ago). Part One is here.

OK, digging into the PDF itself, let's see what else there is of interest... (this is a blog post in progress...check back for frequent updates...)

Here's a list of what HASN'T changed from the "1.0" version of the AHCA:

In this cost estimate, as in the preceding estimates, the budgetary effects related to health insurance coverage would stem primarily from the following provisions:

  • Reducing the federal matching rate for adults made eligible for Medicaid by the ACA to equal the rate for other enrollees in the state, beginning in 2020.

Goodbye 90% Federal funding! States would have to pony up anywhere from 25-50% of the funding if they wanted to keep those folks covered.

 

UPDATE 4:30PM: SCROLL DOWN FOR THE ANALYSIS OF THE CBO SCORE.

Yes, this is it, kids...the Big Day all healthcare wonks have been waiting for: The Congressional Budget Office is releasing their score of the final version of the AHCA (that is to say, the version which was actually voted on and passed by a whisker 3 weeks ago) later on today.

Remember, Paul Ryan and the House GOP insisted on ramming the vote through before the CBO score came out, which means that due to the way Congressional budget rules work, depending on how much the CBO think the final changes to the bill impact the budget, they may have to go back and make more changes which would require another vote in the House...and that's all before it moves onto the Senate, where the GOP Senators have already said they plan on starting from scratch anyway. Fun times!

via Bob Herman of Axios:

Health Care Service Corp. — the parent company of the Blue Cross and Blue Shield affiliates in Illinois, Montana, New Mexico, Oklahoma and Texas — recorded an $869 million profit in the first quarter of 2017, according to the company's latest financial documents. That was a $1.3 billion turnaround after HCSC lost $442 million in the first quarter of 2016.

How to interpret this: The Affordable Care Act exchanges in some areas are hurting, but overall are not imploding. Many insurance companies continue to do well (like Florida Blue) or are turning things around (like HCSC). And HCSC carries a lot of weight, since it covers nearly 1.1 million people in ACA plans and is the largest Blue Cross and Blue Shield company after Anthem.

Something to consider:

Note: Given the time constraint--today is the deadline for submitting a letter--I've stolen some of the following from Andrew Sprung:

Topher Spiro of the Center for American Progress acquired a letter from Senate Finance Committee Chair Orrin Hatch to healthcare "stakeholders," inviting their input by May 23 on Republican senators' efforts to write an ACA repeal bill. Hatch asked that letters be sent to HealthReform@Finance.Senate.gov.

Since the Republican senators' bill-writing process is as secretive and rushed as the House's, Spiro seized the opportunity to encourage non-privileged "stakeholders" -- all of us -- to send their two cents to the email address provided. He has offered to tweet any letters tweeted at him, with a screenshot.

Here's mine:

Dear Members of the Senate Finance Committee:

via Kayla Tausche of CNBC:

The House of Representatives and Department of Justice plan to ask the DC federal appeals court to keep on hold for another 90 days a lawsuit that questions the legality of cost-sharing subsidies in the Affordable Care Act, according to four people familiar with the matter.

The White House, during that time, will continue to make payments to insurers, according to a senior administration official.

OK, assuming they do indeed ask for this, and assuming the court grants a third 90-day extension, this means that CSR reimbursement payments can continue for another 3 months. That's the good news.

Insurers planning to offer plans on the exchanges in 2018 must submit their pricing in the coming days and weeks.

This is the actual headline of an actual article posted on Breitbart.com right now:

I'm loathe to link to the article itself (I did include one somewhere on this page, feel free to look for it), but a Google search will bring it up. Even more remarkably for Breitbart, much of it is actually pretty darned accurate:

Obamacare will go into a death spiral on May 22 if the Trump administration chooses not to continue fighting in court to preserve cost-premium subsidies that were ruled illegal last year.

On May 12, 2016, U.S. District Court Judge Rosemary M. Collyer ruled House v. Burwell that the Obama Administration’s payment of cost-sharing subsidies without congressional approval was a violation of the Constitution’s Appropriations Clause.

Pages