Tuesday, January 17, 2017

"Repeal and Replace" Obamacare: How Will All of This Sort Itself Out?

Will the Republicans Follow Through on Their Promise to Repeal Obamacare?
Yes.

You have probably been reading press stories that bring into question whether or not Republicans will actually keep their campaign promise to "repeal" the Affordable Care Act (ACA). In fact, there is much discussion going on among Congressional Republicans about repealing key funding elements of the ACA as part of a budget process prior to having a replacement ready to pass the Congress.

But, they will defund the core elements of Obamacare sooner rather than later on their way to replacement. They have to. Repealing Obamacare as a first priority was a core campaign promise. If Congressional Republicans and President Trump fail to do this they will suffer a precipitous drop in credibility with their base.

Do Republicans Have a Replacement Plan?
Yes––at least a pretty specific outline for what they would do.

Speaker Paul Ryan's "Better Way" outline, last year's very similar Burr, Hatch, Upton bill (my analysis here), and a number of other similar Republican proposals lay out a clear path for a preferred Republican alternative. Donald Trump said this weekend that his plan, likely very similar to these, will be released once his new Secretary of HHS is confirmed.

These plans share the same key elements but have not yet been put in legislative form or been "scored." Just exactly what the new subsidy/tax credit scheme would look like and how it would impact consumers compared to what we now have in Obamacare is the biggest unknown.

The problem isn't that they don't have a plan. The problem is that Republicans don't have a plan that will garner the required 60 votes in the U.S. Senate to become law. With 52 Republicans, they will need at least eight Democrats to join them. There simply are not the eight Democrats, or a guarantee that all 52 Republicans can be counted on, to ensure something like the general Republican replacement outline can become law.

Does This Mean That Republicans Will Retreat on Repeal Until Such Time as They Can Secure the Needed Democratic Support?
No.

First, Republicans are now in so deep on the repeal promise they can't retreat and maintain credibility with their Republican/Trump base.

Second, the reality is that Washington, DC wouldn't be able to find a bipartisan route to get past gridlock on such a complex and politically charged issue as Obamacare without facing hard deadlines for replacement.

Those that argue that Republicans should first have the replacement plan in place before proceeding make the assumption that without the imperative repeal/defund would create the two sides would be able to come to a bipartisan solution. In this Washington, DC? I just don't see that happening.

But Hasn't the Republican "Repeal and Replace" Strategy Now Put Them on the Defensive?
Yes.

Republicans are clearly losing the messaging battle with Democrats now on the offensive. A lack of a clear message about replacement creates a huge information gap that is easy to fill with bleak assessments for how the health insurance market will quickly collapse in the wake of Republican defunding.

Right now, Democrats are effectively, but disingenuously, arguing that repeal without a replacement will lead to millions of people losing their insurance. Disingenuous because Republicans have never intended to repeal without a seamless transition to replacement. But the Democratic arguments just had gasoline poured on them by the Congressional Budget Office (CBO) which today estimated that repeal without replace would eventually add 32 million to the uninsured.

But Republicans have only themselves to blame for losing the messaging because they so far haven't been able to fill the information vacuum with the detail for what they will do.

Don't Republicans Now Need to Put a Detailed Bill on the Table In Order to Assure Voters?
No.

They need to detail a series of commitments complete with a timeline for how repeal, transition, and replace will look and how it will provide insurance security.

Vague Republican assurances that there will be an orderly transition and that people won't lose their coverage whither in the face of all kinds of bad scenarios the Democrats are and will be coming up with. Republicans have now let the Democrats take what had been their worst domestic issue over the past six years and turn the tables on the Republicans. Bad start for Republicans.

The final bill will be the result of complex negotiations first inside the Republican caucus and then with Democrats. But people need to know the Republican bottom line. What is the minimum that consumers can expect and over what timeline?

Republicans are now looking at a strategy to introduce a series of piecemeal Obamacare replacements to be voted on in the near term––some under budget rules as they complete the next 2018 budget and some requiring 60 Senate votes––thereby forcing Democrats to vote against what could be popular alternatives one at a time. But even this strategy will hit snags––for example repealing Obamacare's popular preexisting condition reform and replacing it with a lesser Republican "continuous coverage" provision that would require 60 Senate votes.

My follow-up post at CNBC.com deals with how the two sides could come to a bipartisan compromise.

Friday, January 13, 2017

Fixing Health Insurance Reform is a Zero Sum Game: The Only Way Republicans Can Lower Costs is to Provide Less Coverage––Wrong!

Don't Underestimate the Value of Rearranging the Deck Chairs

Anna Wilde Mathews and Louise Radnofsky have a well-done story in yesterday's Wall Street Journal. They point out that a relatively few sicker people account for most of the cost of care:
Congress has begun the work of replacing the Affordable Care Act, and that means lawmakers will soon face the thorny dilemma that confronts every effort to overhaul health insurance: Sick people are expensive to cover, and someone has to pay.
That is right.

But, this statement would seem to infer, as I have observed the general discussion about fixing Obamacare has often inferred, that there is a certain cost to health insurance and that Republicans can rearrange the deck chairs any way they want but the cost will be the same.

Wrong!

What I think this story, and the general discussion about how to cover people in the future is missing, is that Obamacare is so flawed that by itself it is manufacturing plan premium levels that are at least 30% to 40% higher than they need to be.

Thursday, December 1, 2016

"Republicans Are Being Awfullly Naive" About the Transition Period in "Repeal and Replace"

"To have an orderly ["Repeal and Replace"] transition, I think Republicans need to reimplement the risk corridors by February or March. That is the only chance they have. I don't think there is a single Republican member of Congress who has thought about this. I am reading all of these quotes and they're completely blind to the fiasco on the individual market that they're about to create."

Read my complete interview with Sarah Kliff at Vox.


Monday, November 28, 2016

Obamacare Repeal, Transition, and Replace: The Republicans Have a Tiger By the Tail

I wouldn't be surprised to see Obamacare more fixed than replaced before this is over. I'm not sure Republicans have really come to grips with the daunting task they face for both replacing Obamacare and managing through what will certainly be a problematic transition.

See my post at Forbes


Thursday, November 17, 2016

Will It Take a Crisis to Replace Obamacare?

My interview this morning with Steve Inskeep on NPR's Morning Edition

We discussed repeal and replace, Republican proposals for replacement, the fundamental differences between Democrats and Republicans on health insurance reform, and the outlook for what is likely to happen.

Saturday, November 12, 2016

It Isn't News That Trump Wants to Keep the Pre-Existing Condition Reforms----He Said So in February

Far from a news scoop, Donald Trump first said that he would preserve consumer protections against health insurance pre-existing conditions last February.

See my post at Forbes

Wednesday, November 9, 2016

"Now What Do We Do?" Trumpcare?

Of course, "Now what do we do," is the famous line from Robert Redford's character in The Candidate, stunned by his victory and confused about what to do next.

But it doesn't really apply here.

A few thoughts as all of this sinks in:

Obamacare: Dead Law Walking!

There is no doubt that Obamacare is dead.

The only question is just exactly how Republicans will get rid of it.

While Republicans have the votes they will need in the House, Republicans will not have the 60-vote Senate supermajority necessary to get rid of all of it. Therefore, they will use their slim Senate majority and Senate budget reconciliation rules. It takes just 51 Senators to make spending decisions.

There are two routes they will consider:

Thursday, October 27, 2016

The Good and the Bad of Obamacare

See my comments on CNBC today using this link.

In this interview, I mentioned the information a broker in Naples Florida sent me regarding some of their customers buying Obamacare compliant individual health insurance.

Here are the broker's 2017 examples:

Family of four, mom and dad age 40, two kids. Lowest Bronze annual premium $13,176. Deductible $7,150 single, $14,300 family. Income $130,000. Not eligible for subsidies. Exempt from the individual mandate because their premium exceeds 8.16% of their modified adjusted gross income (MAGI). The broker points out that their premium plus one deductible totals $20,236––16% of MAGI––the point at which they can begin to collect on claims (there may be some nominal first dollar benefits such as a wellness benefit).

Single woman age 45. Lowest Bronze premium $4,968. Deductible of $7,150. Income of $50,000. Not eligible for a subsidy. Exempt from the individual mandate because her premium exceeds 8.16% of her MAGI. Broker points out that her customer's premium plus the deductible totals $12,118––24% of the customer's MAGI––the point at which she can begin to collect on claims.

Couple ages 64 and 61. Lowest Bronze premium $20,004. Deductible of $7,150 single and $14,300 family. Income of $150,000. Not eligible for subsidies. Exempt from the individual mandate because premium exceeds 8.16% of MAGI. The broker points out that the total of their annual premium and one deductible is $27,154––18% of their MAGI––the point at which they can begin to collect on claims.

Premiums obviously vary by market. Rather than taking my word for it, I suggest you go to HealthCare.gov and check out a few markets. You do not need to log in to browse the plan offerings. You need only insert a zip code and age and family status, as well as to enter a big income like $100,000 to be assured of getting the unsubsidized price no matter their status. The unsubsidized price is the price that half of the people buying Obamacare compliant plans are paying.

Thursday, September 29, 2016

Will the Administration's Making Good on Billions of Dollars Due the Health Plans Solve Obamacare's Exchange Problems?

Amy Goldstein at the Washington Post is out with a story reporting that the Obama administration is looking to use an obscure federal law to pay billions of dollars in Obamacare risk corridor liabilities to participating insurance companies.

Tuesday, September 6, 2016

Detailed Obamacare Blue Cross Enrollment--About Half the Enrollment Doesn't Get a Subsidy!

About half of those buying Obamacare compliant individual health plans do not receive a subsidy.


I was struck by this comment coming from one of Obamacare's most vocal supporters, Vox's Sarah Kliff:
Obamacare's insurance expansion is on the path to looking like other safety net programs we know, offering limited services to a predominantly low-income population.
She might be right about Obamacare devolving into a low-income style safety net program. But she couldn't be more wrong about the people who have no choice but to buy Obamacare if they want health insurance.

In the September 2016 issue of the trade publication, The AIS Report on Blue Cross and Blue Shield Plans, reporter Steve Davis did something no other reporter I know of has done. He called a number of Blue Cross plans and asked how many of their Obamacare individual health insurance policyholders get a subsidy and how many do not. His report covers 26 state Blues plans.

Thursday, August 25, 2016

Big Obamacare Rate Increases Don't Reflect What People Actually Pay––Wrong!

How many people in the individual health insurance market don't get a subsidy to pay for their health insurance, or wouldn't be eligible for one it they did buy it?


Here is what an Obama administration spokesperson said yesterday about all of the big 2017 Obamacare rate increases: "Headline rate increases do not reflect what consumers actually pay," said Kathryn Martin, acting assistant secretary for planning and evaluation at the Department of Health and Human Services.

What she is once again referring to is that 85% of those getting subsidies could get their rate increases eliminated or blunted by the subsidies. It is worth pointing out that the consumer only avoids the big increase if they are in, or move to, the lowest or second lowest cost Silver Plan.

Staying with a higher priced plan they might now be in will not avoid the increases.

And, once again, the administration doesn't tell us that moving to a lower price plan may require higher deductibles and co-pays and more limited provider networks.

But more importantly, why does this administration, and so many Obamacare supporters that parrot this line, continue to ignore the many millions of people who do not get a subsidy and have no choice but to take the full whack from these rate increases if they want to stay covered?

Sunday, August 21, 2016

"The Blues Have Deep Reserves and They'll Be Here Long After We're Gone"--Here's How It Really Works

The denials about just how bad the Obmacare exchange situation is keep piling up.

Maybe the most uniformed and naive was this comment in the Dallas Morning News:
"The Blues have deep, deep reserves, and they'll be here long after we're gone,"[Sabrina] Collette [a research professor at Georgetown University], said. "They're probably calculating they can ride out this rocky time and emerge with a dominant position."
In the same article it was reported that local Dallas HMO Scott and While Health Plan is withdrawing from the exchanges. The article also pointed out that Texas Blue Cross has lost more than $1 billion on the exchanges over the last two years and is now seeking a rate increase of 60% for 2017.

These Blue Cross plans, particularly the community-based not-for-profits like Texas, do not have a bottomless bank account.

Thursday, August 18, 2016

Latest Proposals to Fix Obamacare Come Up Way Short--The Insurance Industry Trade Association Joins the List of Deniers

In my last couple of posts, I have lamented the degree to which prominent Obamacare supporters have been denial about the trouble The Affordable Care Act exchanges are in. Now we can add the insurance industry trade association, AHIP, to the list.

With the Obamacare exchange exits by the publicly traded health plans, the not-for-profit Blue Cross and regional HMOs now form the backbone of the Obamacare exchanges. I am not predicting any imminent exits on their part, but another year will be a different story if this isn't fixed. If you look at the size of their statutory surplus accounts and their staggering ongoing losses in the face of reports the risk pool continues to deteriorate, it's a simple exercise in math so see what's coming.

The clock is just plain ticking on the time left to fix Obamacare.

Wednesday, August 17, 2016

Obamacare on Life Support?

My comments on CNBC today.

"Those Whining Obamacare Insurers"

Affordable Care Act defenders need to understand that if we don't quickly move on to a robust conversation about how to fundamentally make the individual health insurance market viable many of the remaining often not-for-profit plans will have to walk away from the Obamacare exchanges.

See my post at Forbes

Thursday, August 4, 2016

According to Aetna We Have Two Kinds of Insurance Companies Under Obamacare: The "Less Worse Off" and the "Worse Worse Off"

Surviving Co-Ops Sue Feds Over Inadequate Obamacare Reinsurance Payments While Aetna Complains the Payments Aren't Enough For Their Only "Less Worse Off" Financial Results

I don't know if you noticed the recent juxtaposition between the surviving co-ops complaint that they shouldn't have to pay the big legacy carriers money under the Obamacare "3Rs" reinsurance scheme with Aetna's complaint this week that these same payments aren't enough for them to be confident they will continue in the exchanges.

Tuesday, July 19, 2016

Obamacare's 2017 California Rates to Increase an Average of 13% With the Biggest Players Going Up 17.2% and 19.9%

After last year's 4% rate increase, California's Obamacare insurance exchange rates appear to be catching up to the rest of the country.

The two biggest carriers are raising rates by much more than the average 13.2% increase. Blue Shield said its average increase was 19.9% and Anthem said it would increase rates an average of 17.2%

According to the LA Times, Covered California officials blamed the big increase on the "rising costs of medical care, including specialty drugs, and the end of the mechanism that held down rates for the first three years of Obamacare."

Well, once again when it comes to Covered California's explanations, not exactly.

On the argument blaming the rising cost of care, in late May Milliman published its Milliman Medical Index indicating that baseline medical cost trend was up 4.7% year-over-year––the lowest annual increase since Milliman first measured cost trend in 2001. And, of course, this 4.7% increase included the cost of specialty drug costs.

Wednesday, June 1, 2016

Everything Will Be Fine As Soon As The Obamacare Market "Stabilizes"––Not

North Carolina Family Plans Already Cost More Than $10,000 a Year With Rates Going Up By Double Digits for 2017

With one state after another announcing big 2017 Obamacare rate increases the latest refrain from Obamacare supporters is that with maybe one or two more years of rate increases everything will be fine.

Talk about missing the forest for the trees.

The latest example is in North Carolina where market leader Blue Cross, the biggest insurer with 330,000 people covered, is asking for an 18.8% 2017 rate increase. Aetna, with 130,000 customers is asking for 24.5%.
See My Post at Forbes
 
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