it appears to be accomplishing one of its important goals of “bending the health-care cost curve.” Paul Van de Water highlights a remarkable finding in this regard. He shows that the Congressional Budget Office projection of how much it expects the federal government to spend on health care has come down by about $600 billion since 2010.
.. After growing 2 and 7 percent in 2015 and 2016, insurers in the state-based exchanges raised the cost of the benchmark plan by an average of 25 percent.
.. about three-quarters of those in the exchanges could find a plan for $75/month or less.
.. if the ACA survives, time will tell whether this 2017 jump was the one-time correction many analysts believe it to be. Marketplace insurers appear to have initially underpriced premiums, in part because they may have initially overestimated the wellness of those buying coverage in the exchanges
.. In fact, even with the big 2017 increase, premiums are about where nonpartisan analysts thought they would be at this point.
.. Studies find that Medicaid is particularly helpful in stabilizing patients with chronic diseases such as heart disease, diabetes and asthma. Medicaid patients are more likely to use preventive care and far less likely to experience catastrophic out-of-pocket medical expenses.
.. Medicaid eligibility during early childhood was found to reduce mortality rates among African Americans in their later teenage years by 13 to 20 percent.
.. Longitudinal studies that track children into adulthood find that children on Medicaid for more of their childhood earn more as adults and are more likely to attend and complete college.
.. Other positive outcomes include the fact that hospitals have seen a significant reduction in uncompensated care, but that reduction has occurred almost exclusively in the 32 states that opted for Medicaid expansion (including D.C.), which makes sense as low-income, uninsured people are those most responsible for uncompensated hospital care and are most likely to be covered by the expansion.
.. What do I mean by “we’ve taken health care out of the market?” Simply put, you show up to the supermarket hungry, and they don’t have to feed you. You show up to the ER sick, and they have to treat you. Unless we’re willing to punt on that commitment, and all evidence shows we’re not, the government will be a significant player in health care
.. The logic of insurance thus dictates that you’ll need to pool risk so that the healthy can subsidize the sick. Since some of the healthy won’t go for that deal, there needs to be a mandate to avoid an unbalanced risk pool leading to adverse selection, or the death spiral that health wonks warn about (with too many sick people in the risk pool, premiums must rise, pushing out the least ill, exacerbating the problem). But if you have a mandate, there will be those whose income is insufficient to comply, and they’ll need subsidies to afford coverage.
.. If you want to cover everyone, you need to pool risk. To do that, you need a mandate, and the mandate implies a subsidy.
.. Republicans seem to have somehow convinced themselves that people want to pay more out-of-pocket for health care — that’s certainly the philosophy behind their high-deductible plans and getting rid of the Medicaid expansion. I think they’re misreading the public.
.. Since 2000, funding for block-granted programs that serve low-income people fell by almost 40 percent once accounting for inflation and population growth.
.. Edwin Park estimates that over the next decade, the health plan being considered by the Republicans would shift over $500 billion in Medicaid costs to states. Park’s estimate implies ending the ACA’s Medicaid expansion, a stated goal of the repealers, leaving 11 million people without coverage, while also risking the coverage of the kids, seniors and disabled people who have long depended on Medicaid.
.. In other words, in the interest of providing low premiums to healthy persons, high-risk pools avoid the cross-subsidization that is basic to insurance. The only way that can work, however, is either if some other entity makes up the difference between spending and premium revenue, or those with preexisting conditions get a lot less care.
.. this whole high-deductible, HSAs play is based on the skin-in-the-game theory of cost control, i.e., the view that the more costs are directly shared with patients, the less unnecessary care patients will seek. But the problem here is that since few of us are doctors, we don’t always know what’s important and what’s wasteful.
.. 70 percent of the total value of HSA contributions comes from households with incomes above $100,000.
.. people with preexisting conditions have a track record of coverage gaps.
.. “about 23 percent of Americans with a preexisting condition (31 million people) experienced at least a one-month gap in coverage in 2014, and nearly one third (44 million) had at least a one-month gap of coverage during the two-year 2013 to 2014 period.”
.. I think of this continuous-coverage provision as the “kick-’em-while-they’re down” approach.
.. This part sounds a little like replacing Obamacare with the Affordable Care Act.
.. One recent study predicts that in five years, credits under the replacement plans will probably be about 40 percent to 55 percent less than those under the ACA.
.. My impression is that Americans want health care that is less complex and calls for less skin in the game, and yet Republicans appear to be teeing up the opposite.
Trump Voters, Your Savior Is Betraying You
made more than 280 campaign promises as a candidate, and a few — such as infrastructure spending to create jobs — would be sensible if done right. But there still is no infrastructure plan, and The Washington Post Fact Checker is tracking 60 specific campaign promises and found only six cases so far of promises kept.
.. But while you voted for Trump because you put faith in his gauzy pledges, I bet he will do no better with campaign promises than with marriage vows.
.. Health care will be one of the greatest betrayals.
.. Trump seems poised to weaken the contraception mandate for insurance coverage and curb funding for women’s health clinics. The upshot will likely be more unintended pregnancies, more abortions, more unplanned births — and more women dying of cervical cancer.
.. The biggest Trump bait-and-switch was visible Friday when he talked about giving Americans “access” to health care. That’s a scam his administration is moving toward, with millions of Americans likely to lose health insurance: Instead of promising insurance coverage, Trump now promises “access” — and if you can’t afford it, tough luck.
This promise of “access” is an echo of Marie Antoinette. In Trump’s worldview, starving French peasants wouldn’t have needed bread because they had “access” to cake.
.. The greatest betrayal of all will come if, as some of his advisers recommend, he “reforms” and tears holes in some of the big safety net programs like Medicaid, Social Security or Medicare. Medicaid is particularly vulnerable.
.. Trump’s career has often been built on scamming people who put their faith in him, as Trump University shows. Now he’s moved the scam to a much bigger stage, and he boasts of targeting Muslims, refugees and unauthorized immigrants.
Republicans and Medicaid Expansion
For all of the thermonuclear reactions in the press, the just-barely-started Trump administration hasn’t really had an unfixable mistake yet. Yes, the rollout of the executive order on immigration and refugees was a mess from start to finish, but the administration has the option of a mulligan and they’re taking it. (In retrospect, don’t even bother trying to enact a controversial change without your own attorney general in place to defend it legally.)
.. Strategists at Goldman put the mood of the market this way: “We are approaching peak optimism.” They forecast the S&P 500 will hit a high in the next month or so but end the year lower than where it is now as investors push back expectations for the timing of the tax cuts.
.. Ironically, some states are buying into the Medicaid expansion just as Republicans start talking about replacing it. In Kansas, the state House just voted to expand eligibility, 81-44.
.. Some might grumble that this is taking away Obamacare-era subsidies for purchasing insurance and replacing them with Trumpcare (or whatever the replacement is called) tax credits for purchasing insurance. But Walker seems pretty convinced that this is better if it is part of an overall emphasis of getting people into the workforce:
.. When governors are given the ability to really reform Medicaid and our other assistance programs, when I say it’s the same or better, I mean we help somebody get into the workforce. Now they’ve got an employer-based plan, or they’re making enough to be able to afford the co-pays or the premiums on that. They’re better off than they were before. The government just giving them something, even in the form of a subsidy, isn’t necessarily good for them. We can find a better alterative. It doesn’t mean we’re giving you more money, but rather we’re giving you more ability to earn and live a better life.
.. we were suddenly informed that because of a security sweep by the Secret Service, we all had to leave – meaning, everyone on “Radio Row” – every host, guest, producer, and technician had to clear out, even if they were supposed to be on the air.
.. CPAC didn’t have this problem when Republicans didn’t run anything in Washington!
Obviously the Secret Service needs to able to ensure a secure environment, but this felt like a massive failure of logistics and foresight. Radio stations pay big bucks to set up a mobile studio at CPAC. It’s probably some of their busiest days of the year; CPAC brings together a small crowd of potential guests in one place. Panel discussions were effectively canceled because no one could get through the checkpoints in time. There’s a good chance one of those panels was on effective communication and the need for conservatives to get their message out… and no one could actually hear it because of the sudden, unannounced security protocols.
The Quiet War on Medicaid
Progressives have already homed in on Republican efforts to privatize Medicare as one of the major domestic political battles of 2017.
.. Of the two battles, the Republican effort to dismantle Medicaid is more certain.
.. If Mr. Trump chooses to oppose his party’s Medicare proposals while pushing unprecedented cuts to older people and working families in other vital safety-net programs, it would play into what seems to be an emerging strategy of his: to publicly fight a few select or symbolic populist battles in order to mask an overall economic and fiscal strategy that showers benefits on the most well-off at the expense of tens of millions of Americans.
.. it will be too easy for Mr. Trump to market the false notion that Medicaid is a bloated, wasteful program and that such financing caps are means simply to give states more flexibility while “slowing growth.” Medicaid’s actual spending per beneficiary has, on average, grown about 3 percentage points less each year than it has for those with private health insurance
..Together, full repeal and block granting would cut Medicaid and the Children’s Health Insurance Program funding by about $2.1 trillion over the next 10 years — a 40 percent cut.
.. a similar Medicaid block grant proposed by Mr. Ryan in 2012 would lead to 14 million to 21 million Americans’ losing their Medicaid coverage by the 10th year, and that is on top of the 13 million who would lose Medicaid or children’s insurance program
.. Current Republican plans to eliminate the marketplace subsidies and A.C.A. Medicaid expansion in 2019 would create a health care cliff where all of the Medicaid funds and subsidies for the A.C.A. expansion would simply disappear and 30 million people would lose their health care.
.. In the face of such a manufactured crisis
.. About 60 percent of the costs of traditional Medicaid come from providing nursing home care and other types of care for the elderly and those with disabilities.
.. It would take only three Republican senators thinking twice about the wisdom of block grants and per capita caps to put a halt to the coming war on Medicaid.