A Study of Efforts to Repeal and Replace the ACA 1


A Comparison of the ACA and AHCA

The following pdf compares ACA with AHCA as it pertains to insurance subsidies; the individual mandate; the employer mandate; essential health benefits; wellness; popular ACA market reforms; and much more.

Rather than reading a digest of the article, click on this link to look at the specifics: https://www.ciab.com/wp-content/uploads/2017/05/ACA-and-AHCA-Comparison-Chart.pdf

The Republican repeal of and replacement for ACA will come at a high cost to Medicaid and the patients currently covered

The salient data points provided below are extracted from an article in Business Insider (3/15/2017) and focus on the proposed cuts to Medicaid under AHCA.

ACA AHCA
Medicaid was expanded under ACA to include any adult living under 138% of the federal poverty level ($27,800 for a family of 3 in 2016).

The District of Columbia and 32 states chose to participate, and more than 11M people gained Medicaid coverage under ACA.

CBO estimates roughly $880B would be cut from federal Medicaid spending through 2026.

With the Medicaid spending cuts, CBO estimates 14M people will be cut from Medicaid assistance by 2026 due to changes in eligibility.

Since it began in 1965, “Medicaid has been an open-ended entitlement program.”

“Open-ended” means that if someone meets the criteria and qualifies, they are free to enroll. If costs of care go up over time, with more expensive procedures, treatments and/or more extensive care required, the states receive more federal money to provide it to those enrolled.

States do indeed fund a big portion of their individual Medicaid programs, but the federal government matches up to a certain percent, and poorer states like West Virginia (1/3 of population is on Medicaid) get a bigger matching sum.

AHCA proposes to replace an open-ended program with a per capita spending cap.

This means that starting in 2020, the federal government would send a fixed amount of money per Medicaid enrollee to the states. This amount could go up yearly according to the medical-care component of the consumer price index, 2%-5% depending on the year.

This change to per-capita coverage “does not take into account changes to population or unexpected crises.”

A critical, overlooked but expected change is the increasing baby boomer population. There were 43.1M people over 65 in 2012 and there are expected to be 83.7M over 65 by 2050, not to mention big increases in people over 85 as well.

The cost to cover people in this category would be determined by their 2016 spending patterns increased by medical-care CPI. Problem: Healthcare costs for elderly people increase at a far higher rate than medical-care CPI.

In addition, AHCA’s per-capita system categorizes recipients (elderly people, people with disabilities, etc), to determine the size of payments. Problem: the “elderly”category includes people aged 65 and those aged 85, but level of care and costs go up as people age.
Cost estimates predict AHCA will lead to a 9% shortfall in coming years, or about $10B per year that states would have to make up for.

Source: http://www.businessinsider.com/gop-obamacare-repeal-ahca-300-billion-deficit-medicaid-cuts-2017-3

Foreign Affairs website calls the Republican Health Care a Debacle and explains how the process of writing and passing AHCA provides a lesson in how not to make public policy

This article dated 5/24/17 describes and explains at length “the traditional process for developing and passing major legislation.” It also explains that while it is open and deliberate, it can also be tedious and cumbersome. However, this approach to writing legislation is worthwhile when trying to enact laws to give voters confidence that their government is working to serve them well.

The steps in a traditional process include:

  1. Members of Congress and their staffs present ideas for changing public policy;
  2. They analyze the advantages and disadvantages of their ideas;
  3. They invite experts, analysts, interested parties, and the public to provide input;
  4. They revise their ideas in response to the feedback;
  5. After multiple loops through steps 1-4, MoCs begin to write the specific legislative language.

This is open, deliberate, and straightforward. It is also tedious, cumbersome and time-consuming. But when a law is passed and signed into law using this process, it has the greatest chance of not being overturned on a political or party line whim later on. Ignoring this process can result in a public policy that is ineffective and often harmful.

The Republican leadership voted to repeal ACA tens of times over seven years. In seven years there was no committee assigned to write an alternative proposal for health care. In the rush to write legislation, AHCA weakens coverage for pre-existing conditions; cuts the number of people on Medicaid by 14M by the mid-2020s, and at the same time cuts taxes on people with annual incomes over $1M (in 2022).

To read the full article, click on this link: https://www.foreignaffairs.com/articles/united-states/2017-05-24/republican-health-care-debacle?cid=nlc-fatoday-20170525&sp_mid=54141127&sp_rid=Z2VvcmdlNTA5QG1hYy5jb20S1&spMailingID=54141127&spUserID=MjY3MjMzNTQ0NzU4S0&spJobID=1164220740&spReportId=MTE2NDIyMDc0MAS2

Behind closed doors, the Senate writes health care legislation and will seek a vote on their proverbial black box

Without transparency, hearings for input from outsiders, and cost analysis, this legislation will be put to a partisan vote, very much like bidding on the contents of a wrapped gift at a white elephant party.

This Bloomberg article from 6/13/17 shows how the GOP method to write legislation denies industry experts and the general public the opportunity to offer feedback.

https://www.bloomberg.com/politics/articles/2017-06-13/senate-republicans-writing-obamacare-repeal-behind-closed-doors?utm_source=yahoo&utm_medium=bd&utm_campaign=hosted&cmpId=yhoo.hosted

The New York Times asks, “Where will all the medical misfits go?”

This article from 5/26/17 discusses the essential “safety net” hospitals that were built or evolved to take care of “the patients no one else wants.” The GOP budget and proposed changes in health care pivot our attention to insurance providers and plans, Medicaid cuts, etc.

Perhaps we should consider instead “patients who don’t fit neatly into our medical system for reasons of health or finances or their social situation — the “medical misfits” that any one of us can become under the wrong circumstances — need far more long-term support. This is often where safety-net hospitals step in.”

Read this patient’s emergent case history and subsequent treatment at Ben Taub Hospital in Houston, TX. The hospital is a safety net hospital for indigent patients, but it is also recognized as a premier trauma center. What will happen to these effective facilities and highly trained staff when GOP health care plans begin? Why is there no discussion of how affordable, available health care and high-paying professional jobs will be lost?

https://www.nytimes.com/2017/05/26/opinion/sunday/safety-net-hospitals-health-care.html?action=click&pgtype=Homepage&clickSource=story-heading&module=opinion-c-col-right-region&region=opinion-c-col-right-region&WT.nav=opinion-c-col-right-region&_r=0


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