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What The Hell(th) is Gonna Happen to Obamacare?!

What The Hell(th) is Gonna Happen to Obamacare?! November 28, 20162 Comments

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What The Hell(th) is Gonna Happen to Obamacare???!?!?!

First, I want to mention, and argue, that people—Democrats AND Republicans—understand that Obamacare must be reformed in some form or fashion. Many who have it are not happy with it, and even many choose not to get it at all.

To prove that, here are some DEMOCRACTIC health policy experts talking about the issues with the ACA, and then some DEMOCRATIC American citizens talking about what they love and hate about the ACA. In short, it’s not just Republicans who want ACA reform. Everyone does. It’s just HOW we reform the ACA that’s not bipartisan.

In a Kaiser Health Foundation podcast, Richard Lane from The Lancet and renowned health policy analysts Julie Rovner and Margot Sanger-Katz discussed that both Democrats and Republicans want ACA reform:

RICHARD LANE (From The Lancet): We’re sort of getting the impression that what Trump might be saying now is what Hillary Clinton might have been saying if she’d become President, which is ‘Yeah, I know the Affordable Care Act is having problems, but my God, I’m going to fix it.’ I’m pretty sure Hillary Clinton was saying, ‘I’m going to fix the Affordable Care Act,’ wasn’t she? So it would seem that… there’s a bit of convergence going on.

JULIE ROVNER (from Kaiser): That’s an excellent point and I’ve been thinking of it myself.

MARGOT SANGER-KATZ (from Kaiser): “Republicans… say that the real problem is not that we haven’t forced people to buy insurance effectively enough. It’s that we haven’t made insurance affordable enough that everyone wants to come into the system. So I think that’s something that we can look forward to in their policies are ideas that are designed to make insurance cheaper. I don’t think that’s so easy…as it is just expensive to provide health insurance… but [REFORMING] the Affordable Care Act is probably the most unifying issue across the waterfront of policy issues.”

Here are excerpts from two articles about Democrats who choose not to use the ACA:

1) Some Panic, Others Shrug At Prospect Of Losing Obamacare (Story)

A recent Gallup poll found that 51 percent of respondents are in favor of repealing Obamacare, and 45% are opposed to repealing it.

Denise Martinez Gascoigne, 49, in Greenland, N.H., has been paying $1,130 in premiums each month for insurance for her family of four that she purchases through the state’s exchange. Their deductible is $5,000 per person. Gascoigne and her husband are both self-employed and earn too much money to qualify for a subsidy.

“It’s so ridiculous that we pay over $1,100 a month, and we’re still left footing the bill for whatever prescription or procedure we might need in addition to the health insurance,” she said. “We just don’t go to the doctor.” Her premium is set to increase to nearly $1,330 in 2017.

Gascoigne, who is a Democrat, is “very disappointed and distraught” over the results of the election and supports a single-payer health system. Nonetheless, she said, she’s “somewhat indifferent” to the impending changes to the Affordable Care Act.

Rebecca Geitz of Austin, Texas, said her subsidized premiums have been affordable, but her plan “is the most useless thing in the world. No one takes it!” When Geitz, 33, did get sick, her copays were so expensive that she said it was cheaper for her to just pay an urgent care clinic out of pocket. Nonetheless, she said, “I do know that if a serious emergency happened my coverage would help to some degree.” If the law is repealed, she worries she may not have that.

Richard Coppola, 48, believes the Affordable Care Act has been a failure. He pays $378 for a plan with a $2,000 deductible, and his premiums are going up to $480 next year. But still, he said, he’s “terrified” about going back to a world without it. He worries about a system where he could be denied coverage for once having a mole removed years ago. He’s also concerned about lifetime cost limits being restored and the loss of subsidies for people with low incomes.

“The ACA is a piece of garbage,” Coppola said, “but the Wild West before was a lonely place.”

2) Electing To ‘Opt Out’ Of Obamacare
(California Healthline Story)

Steven Lopez has gone without health insurance for 15 years, and the Affordable Care Act hasn’t changed his mind. Once again this year he will forgo coverage, he said, even though it means another tax penalty.

Last tax season, the 51-year-old information technology professional and his family paid a mandatory penalty of nearly $1,000, he said. That’s because they found it preferable to the $400 to $500 monthly cost of an Obamacare health plan.

“I’m paying $6,000 to have the privilege of then paying another $5,000 [in deductibles],” said Lopez, who lives in Downey, a suburb of Los Angeles. “It’s baloney — not worth it.”

While millions of people have gained coverage through the Affordable Care Act, an estimated 28 million Americans remain uninsured… And preliminary data shows that about 5.6 million paid a tax penalty rather than buy health insurance in 2015, according to The New York Times.

…Lopez said repeal is fine with him. Being penalized for not being insured is absurd, he said.

“We should not be forced to buy health insurance. The government should not be in the business of forcing us to buy anything,” he said.

Yet, even as a critic, Lopez does see some positive in the health law. He believes getting rid of the preexisting condition exclusion, for example, was a good thing.

So what happens if Lopez becomes ill? He must pay out of pocket.

In 2015, 46 percent of uninsured adults of varying ages, ethnicities and income levels said they didn’t have coverage because it was too expensive, according to a Kaiser Family Foundation survey.

Kathy Eller, 56, a janitor from Paducah, Ky., hasn’t had insurance for more than a decade, and she plans to opt out this year as well, she said. Sometimes she worries about her health, but not enough to pay a $250 monthly premium, which is what the most affordable Obamacare plan would cost her, she said.

“I smoke way too much and I’m overweight,” Eller said. “I go to the doctor once every six months for my high blood pressure medication and only pay $50 for it.”

Before she lost her employer-based coverage 10 years ago, Eller underwent several surgeries for a skin infection caused by a bacteria known as MRSA.

If she were to get severely ill again, she wouldn’t be able to pay for it, and she doesn’t think she’d seek treatment… Last tax season, Eller was fined close to $800 for not having health insurance. Eller said she is indifferent to the possible repeal of Obamacare. “It hasn’t helped me much, but I know it’s helped a lot of people,” she said.

Shannon Drees, 26, a student from Orlando, Fla., hopes possible reversal of the Affordable Care Act could lower premiums for young, healthy people. She has not had health insurance since she was 21, when she was dropped from her parents’ plan before the ACA provision allowing young adults to stay on those plans until age 26 took effect.

“I don’t have outstanding health issues, it’s much cheaper to pay a penalty,” she said.

Last tax season, she was fined $500. That’s still less expensive than the estimated yearly cost in premiums for plans she looked into, she said. Many of her friends, about the same age, are in the same boat. Unless they are covered by an employer, they are not insured, she said.

She said she does not visit the doctor much and uses Planned Parenthood for birth control.

“For me, it’s about the math,” Drees said of getting health insurance. “Hopefully one day I’ll be able to afford it again.”

So now that I’ve argued that the ACA needs to be reformed no matter what, let’s talk about WHEN it’s likely to be reformed, and HOW.


WHEN the ACA will be reformed:  


Basically every, every, every article on the matter say repealing the ACA is Republicans’ first initiative. They will try as hard as they can to pass ACA reform in the first 100 days.

But it’s important to point out that whether Obamacare will be repealed and replaced within the first 100 days is not a yes or no question. Repealing and replacing is a long, complicated process.

Julie Rovner from Kaiser Health News says she thinks it unlikely that even a partial repeal would be possible within the first 100 days, saying that even if Republicans used “budget reconciliation” (basically the budget version of having a filibuster-proof supermajority), Congress still wouldn’t have time to iron out their differences, because they would first have to pass this budget reconciliation under their budget resolution (this budget resolution would also take weeks to finalize).

She goes on to say that a lot of Obamacare exists because of Executive Orders, so Trump would first reverse these executive orders. She says that “one of the things they’re [Congress] thinking about doing” is partially repealing the ACA and letting the other parts stay in effect while they try and come to agreement on the replacement. That would be a way for Republicans to keep the 20 million potentially impacted by the repeal from losing their insurance entirely (Video). That’s crucial because people everywhere are watching how Republicans will safeguard those 20 million. In fact, the American Medical Association released a two-page document saying not to increase the number of people already uninsured.

Now let’s talk about how HOW the ACA will be reformed, both theoretically and then practically (implementation-wise).


HOW it will be reformed, theoretically:


 To talk about how the ACA will be reformed, we need to make sure we’re on the same page about the different aspects of the ACA that people want reformed.

Trump has said multiple times that he supports certain aspects of the ACA, mainly the part that ensures people with preexisting conditions can still access healthcare.

“So, you know, if you have asthma, if you have had cancer in the past, if you’ve had even allergies, before the Affordable Care Act, if you went to an insurance company and said, “Sell me insurance,” they could say, “No, we don’t want to give insurance to someone who had allergies, we’d rather give health insurance to someone who had a completely clean bill of health.” And so the [preexisting health conditions] law said, no, you have to offer insurance to everyone” (The Washington Post).

According to Kaiser, “The health law’s individual mandate doesn’t actually require people to have insurance. Instead, it imposes a tax penalty on most people if they don’t have coverage. In 2016, the penalty is the greater of $695 per person or 2.5 percent of household income.”

The issue with this is that if we require insurers to accept anyone, insurance companies need a way to convince people to buy insurance BEFORE they develop expensive conditions (Kaiser).

“The purpose of it [the individual mandate] was to round up the stragglers who wouldn’t be brought in by subsidies,” Mark Pauly, a University of Pennsylvania economist, said in a 2011 interview. He co-authored a Health Affairs study in 1991 that aimed to persuade then President George H.W. Bush to adopt a universal health care requirement. “The drafters of Obamacare incorporated the individual mandate concept because they hoped to get Republicans on board,” said Sara Rosenbaum, a professor of health law and policy at George Washington University in Washington, D.C. (Kaiser).

To do something about this dilemma, Paul Ryan suggested a one-time open-enrollment period where people could sign up insurance regardless of their current health conditions. As long as they are enrolled in some type of coverage, they wouldn’t be charged higher rates if they get sick. But if they don’t sign up during that open enrollment period, then they could be charged higher rates (Kaiser).

Some argue these one-time open enrollment limits ignore extenuating life circumstances that may cause people to drop their coverage for a period of time, like losing a job or getting into a car accident.

The pre-existing conditions is not the only aspect of the ACA that Republicans want to reform. They also want to do something about some of the other incentives. Julie Rover from Kaiser explains that the ACA includes “all these other provisions that were designed to make sure that the market wouldn’t just become a market for really sick people. It created a lot of incentives for healthier people to also buy health insurance because if you have a health insurance market where sick people can get coverage when they need it, those people have a really big incentive to sign up. And healthy people have a really big incentive to just wait until they get sick and then they can buy insurance. And so what you end up with is a very, very expensive insurance pool. Insurance is not affordable for anyone, and it’s especially not affordable for those sort of good Samaritan healthy people that are like trying to be responsible and get in early” (Kaiser).

Using the process I’ve mentioned before called budget reconciliation, Congress could repeal some of the financial incentives around Obamacare, since those fall under the budget. They can say, “we’re going to stop giving people money to help them pay for their insurance premiums and we’re going to stop fining people who fail to buy insurance.’ But it would be much harder for them to use this process to take away those rules that allow everyone to buy insurance who wants it,” Rover says (Kaiser).

A popular reform idea is to put sick people in a separate pool called a “high risk pool.” But Rover points out that high-risk pools often have problems, too. High risk pools can be expensive, and often not enough money is put into the pools to cover the sick people who end up in them. “There have been all kinds of problems with high-risk pools. They could end up being as expensive, if not more expensive, than the subsidies that are being given out now,” Rover explains (Kaiser).

How the ACA will be reformed PRACTICALLY…

So now we know the types of reform that Republicans want to make. Let’s look at SPECIFIC policies that address these reforms. I’ll start with the two most popular, Better Way by Speaker of the House Paul Ryan and the Patient CARE Act by Utah Senator Orrin Hatch. I’ll then talk about some of the lesser-known policy proposals. These may seem irrelevant, but are in fact being championed by politicians Trump is considering to be his Health and Human Services Secretary, so it is important to understand these proposals.  


Paul Ryan’s  Better Way for Health Care is not a very new plan. It was released in June of this year. Since it comes from the Speaker of the House, though, it’s gotten a lot of publicity.

The specifics of this plan:

1) Restricts, but does not entirely ban, the use of preexisting conditions for determining coverage. About $25 billion would be invested in a high-risk pool to cover those with preexisting conditions who are unable to afford coverage on the marketplace. Better Way does not give specifics on who would be eligible to take advantage of the money being poured into this pool, but they are definitely calling for people with preexisting conditions not to get screwed over (just like Obamacare! Yay!). At the same time, insurers could charge sick people more if they do not maintain “continuous coverage.” This basically works to rectify the issue that people hop on and off Obamacare, costing the federal government a TON of money, but more than that, it costs American citizens TONS of money!! When sick people get insurance, and then drop off of it when they are no longer sick, when they get sick again, their insurance premium will be through the roof. A lot of Americans who have never had insurance before the ACA did not understand this, so they were hopping on and off. And then getting really frustrated when their insurance would skyrocket. Ryan’s solution to this is to essentially penalize people who hop on and off to encourage them not to do this. It makes sense, for sure, but from a public health standpoint I wish we could just initiate a giant public awareness educational campaign about the dangers of hopping on and off, without having to penalize people. But that’s me being a softy.

2) Eliminates the mandated health benefits package. This package mandated that everyone

with coverage would have 10 benefits that included pediatric care and maternity care, as well as a host of other things. This makes the premiums really expensive, and almost pointless to people who are healthy and young. For example, I think of the student I tutor at my local GED tutoring center. He doesn’t have health care, so Obamacare would make a lot of sense for him. However, he is 21, does not have kids, and is healthy. He cannot possibly afford—in fact, he laughs out loud—at the idea of buying expensive health care to cover things like maternity care when he is perfectly healthy. Thus, he’s not interested in signing up. Data confirms this phenomenon: The Obama administration originally wanted at least 33% of the ACA marketplace to be people between 18 and 34 but, right now it’s only about 25%. Obamacare has also had a hard time attracting healthy people, since many feel that they don’t need all of these benefits. Better Way takes a lot of steps to re-regulate the individual market to make it more advantageous for healthier people, allowing insurers to cut whatever benefits they no longer want to cover so that insurance companies can offer cheaper benefits packages. Sounds awesome, right? It definitely is, for healthy people. The problem is that the really, really, really sick people who needed all of those 10 benefits are now getting slightly screwed. Unfortunately, there’s no data on how many people actually use all 10 benefits of Obamacare. If there was, this could be the perfect data for deciding whether Better Way is a good idea. If no one is utilizing all 10 benefits, and since they are extremely expensive, then Ryan’s plan is a no-brainer. But what if lots of people are utilizing all 10 benefits? Then a lot of people will get screwed for the benefit of young, healthy people who don’t want to have to pay for all the benefits. My GUESS is that not many use all 10 benefits, but of course I have no data to back this up. It’s also a moral and political dilemma of whether our tax dollars should cover the costliest of procedures for the sickest Americans, and disadvantage the rest, or whether we should provide basic coverage for everyone, and disadvantage the few (I would guess, but no concrete data) that are extremely sick. This could be debated for hours, and there’s really no right or wrong answer. I tend to think in numbers, so the idea that MANY could be covered at the expense of FEW not getting all the help they need seems like the best approach. So I like Ryan’s reform. But I of course understand the sentiment of “we are only as strong as our weakest link,” so we should help the people who need the most extreme of care. It’s messy.

3) Charge youth lower rates overall. This is, again, to encourage young people to get care, and to stay on it. Insurers would be able to charge their oldest enrollees five times as much as young enrollee, instead of what they can charge right now: three times as much.

4) Better Way, like Obamacare, calls for Americans to use tax credits to purchase individual health insurance. Obamacare’s tax credits are based on income, with those who earn less getting more help. Better Way’s tax credits would be based on age, giving more help to those who are older (with, what it seems, higher premiums). This would, again, encourage more young people to get the care and stay on it, would provide more help to the older population that likely needs the help. Again, it would be more expensive for the older population at first—so the current older population for, say, the next 4-8 years—but in 10 years, so the next generation of older people, it would be much cheaper because those people would choose to sign up NOW and then wouldn’t pay the higher premium LATER.

5) Reforms Medicaid: cuts back funding and changes its structure to a “block grant” program. This means handing control of the program, and its funding, to the states. You heard about this in my first post, as Trump lists this idea on his website. It’s probably the most popular GOP healthcare idea. One thing that confused me about this is that 19 states have already scaled up their own version of this, where they control the funding and the program of the ACA. What would happen to these states? This Vox article answered my question:

“Better Way does allow states that have already expanded Medicaid to continue to run the expansion program, although the federal government would provide significantly less funding for it. Low-income Americans would be eligible to forgo Medicaid and buy private coverage through the marketplace — but given that the tax credits aren’t larger for poorer people, they might struggle to afford the premiums.”

6) It would cap the tax exclusion for employer-sponsored coverage. The health insurance tax break is the biggest in the federal budget; the government loses out on $260 billion annually by not taxing health benefits. And economists across the political spectrum agree that we should eliminate or at least reduce this tax break, which currently gives those with jobs a huge discount on their coverage — and an incentive to buy more coverage than they actually need. Better Way doesn’t say where this cap would be, though, only saying, ““our plan proposes to cap the exclusion at a level that would ensure job-based coverage continues unchanged for the vast majority of health insurance plans.” Wonderfully, politically vague. Thus, I can’t really argue for or against this…

The effects of this plan:

1) The Center for Health and Economy  estimate it would lead to 4 million Americans losing coverage.

2) The nonpartisan RAND Corporation has modeled the effect of this switch. It found that premiums for a 24-year-old would decline from $2,800 to $2,100. But premiums for a 64-year-old would rise from $8,500 to $10,600. The typical argument here is that older people tend to be the sicker people, so it would be a shame for their costs to rise. However, I will make this bold claim. My guess is that in the back of Ryan’s mind, he’s wanting to sacrifice older people paying more right now, so that over time everyone would pay less. You see, the older people right would have to pay maybe $2,000 more, but because young people would be encouraged to enroll and stay on, once they become old they are not paying much at all. Now, you could of course counter this with the fact that these older people right now are people who are probably having significant health concerns, so why are we prioritizing the healthy young who might eventually get sick over the people who might already be extremely sick? Again, it’s a moral and political dilemma. Who do we care about more? The present few, or the future many. I can’t decide that for you.

3) Overall, though, it seems that over a span of time, premiums for older people would decrease, too: Stephen Parente, a health economist at the University of Minnesota, worked with Speaker Ryan’s office to model the economic effects of the plan and found that premiums could drop anywhere between 9 and 35 percent over the next decade, depending on the plan. (This is great, but remember they are paying less to get less.)

4) Some worry that focusing on the youth and potentially hurting the old would mean that we wouldn’t help more get covered but instead just shift the demographic that’s covered. Again, I’d argue that this would happen at first, but over time, much more would be insured.

5) The Bipartisan Policy Center analyzed his 2013 block grant plan and estimated it would reduce Medicaid spending by $160 billion by 2022 — about one-third of the program’s entire budget. Parente estimates that Better Way would reduce Medicaid enrollment by 18 million people by 2026, but that a significant number of those people would shift into the individual market. He projects that in a decade, Better Way will leave an additional 4 million Americans without coverage compared with the Affordable Care Act. That may seem like a lot, but other Republican proposals—to completely get rid of Medicaid or to get rid of the ACA altogether—have figures of 20 million at the low end.

Patient CARE Act (Sen. Hatch (R-UT), Sen. Burr (R-NC), Rep. Upton (R-MI))

The Patient CARE Act comes out from Sen. Orrin Hatch (R-UT) who chairs the Senate Finance Committee, which will be heavily involved in any health care legislation in the chamber.

The Medicaid and employee-sponsored coverage aspects are exactly the same as Ryan’s. The individual market provisions are what’s different.

Similarities to Ryan’s plan:

Patient CARE would attempt to help maintain “continuous coverage” by having the government enroll some people in fallback plans. Like Better Way, the CARE Act would let insurers charge sick people more if they did not maintain continuous coverage.

The Patient CARE Act makes many of the same changes to the individual market as Better Way does. It repeals the mandate that insurers cover an essential set of health benefits, and also moves to letting insurers charge the oldest patients five times as much as the youngest.

Still, CARE still ends up with some of the same outcomes as Better Way: namely, making insurance cheaper for young people and more expensive for old people.


Differences to Ryan’s plan:

But the CARE Act gets a bit more aggressive about making sure people actually enroll in plans. It envisions the government picking a “default” health plan that those who don’t pick anything would automatically be enrolled into. The default plans would have “premiums equal to the value of the tax credit,” so that enrollees wouldn’t be forced to spend additional money. This means the premiums would need to be quite low — for 18- to 34-year-olds, for example, they’d need to be $164 per month — and likely provide pretty narrow, catastrophic coverage.

The Patient CARE Act is different from Better Way because it gives poorer people higher subsidies. One significant difference between Patient CARE Act and Better Way is how they structure subsidies for the individual market. Patient CARE appears to be the one Republican replacement plan that offers more financial support to lower-income enrollees. The proposal envisions the highest tax credits — the amounts shown below — given to those who earn less than 200 percent of the federal poverty line. The amount of support would phase down between 200 and 300 percent of the poverty line, when it would phase out entirely.

But the CARE Act would still be better for young people than it would for the old

Effects of this policy:

1) There are two economic analyses of CARE Act available at this point. One, from the RAND Corporation, estimates that it would cause 9 million Americans to lose coverage by 2026. Another, from Parente’s Center for Health Economy, estimates that 4 million would lose insurance the same year.

2) Eibner has done economic modeling of the CARE Act (although not Better Way yet) and is able to show who benefits and who loses under the proposal. She finds that under the CARE Act, only 85 percent of 21-year-olds would see their premiums either stay the same or decline compared with Obamacare. But 100 percent of 50- and 60-year-old enrollees would see their premiums increase under CARE Act.

So those are the two big health policies everyone’s talking about. But here are two reforms. And then a third “idea” of the Trump’s senior health advisor for his Transition Team so that you can get an idea of the kind of ideology/thinking he’s going to come in having regarding all of these policies, which would help us be able to predict which policy he’s going to champion.

The two reform bills:


Empowering Patients First Act (Rep. Tom Price)

Rep. Tom Price (R-GA) has been working on this proposal to repeal Obamacare for a while. Since he is  running to become health and human services secretary, we need to be very aware of this policy.

It’s the same as Better Way, but less money for the high-risk pool. Remember, Ryan was calling for $25 billion for the high risk pool. Price is calling for just $3 billion. While Ryan’s plan does not specify the employer-sponsored tax exclusion, remember that The Patient CARE Act specifies this cap at $12,000. Price calls for this cap to be $8,000. Basically, he’s just slashing funding, trying to make healthcare less expensive for the government. But, personally, I don’t like it. Ryan already knows how to be “stingier” in order to keep the US out of so much debt, so the fact that Price is being EVEN stingier is alarming to me. And this dude could be our next Health and Human Services Secretary! Panic!!

 Health Care Choice Act (Sen. Ted Cruz)

Okay, this one is at first glance kinda funny. Cruz kept saying allllll throughout his campaign that he was going to repeal ALL of Obamacare.

“Every last word of Obamacare must be repealed,” he  said.

But his plan only calls for getting rid of one aspect of it!!! He wants to leave all the rest of it the same.

The one thing Cruz wants to change is for insurance to be sold across state lines, but Cruz talked about that almost every time he talked about healthcare reform. And that’s a common Republican idea.

Other theories/plans:

Improving Health and Health Care: An Agenda for Reform (American Enterprise Institute)

This plan would make a lot of the changes to the individual market that others propose — repealing the essential benefits, getting rid of the mandate.

It includes the “default” plan idea, of the government signing people up for a low-cost plan if they fail to sign up for anything themselves, that shows up in the Patient CARE Act.

But it would, somewhat surprisingly, allow states to maintain their Obamacare-era insurance marketplaces. These are the government-run websites that allow consumers to compare different insurance plans.

“It would be impractical to require states to roll back exchanges they have already created,” the paper argues. Instead, it envisions these marketplaces sticking around to “enhance choices for consumers rather than to limit them.”

Transcending Obamacare (The Foundation for Research on Equal Opportunity)

Avik Roy is a longtime health policy analyst, and has released multiple editions of this plan. Roy’s plan is notable in that it does continue to tether the insurance premiums to income, giving those who earn less more generous support — much like Obamacare.

Roy would increase the space between premiums for young and old enrollees even more than other Republican options, allowing insurers to charge the oldest patients six times as much as the youngest. He argues that this would drive down the cost of health insurance for both old and young people, as it would create a healthier insurance pool — so premiums for the oldest-insured people would fall by $100 and premiums for the youngest decline by $833.

Roy also has an interesting alternative to the individual mandate. He proposes only running open enrollment every two years.

“Under this system, individuals who choose to forgo coverage could do so without paying a fine,” Roy writes. “However, they could not simply enter and exit the system at will.”

In other words: If someone skipped open enrollment one time, they’d have to wait another two years to get back into the system.

So what happens next?

The space between the different Republican replacement plans is quite broad, and the decisions legislators make about which direction to go in will be hugely important for the people who rely on Obamacare for coverage.

Based on all of this, what is Congress going to have to debate during the first 100 days to pass reform?

Two big things:

1) whether tax credits should be more generous for lowest-income Americans, since the Patient CARE Act calls for subsidies based on income (like Obamacare), and Better Way is based on age.

2) whether to limit the tax exclusion for employer-sponsored insurance. A lot of people are saying that this will create political backlash also as strong as  Obamacare’s Cadillac tax, which, if you’re not familiar, caused a LOT of backlash.)

The question right now isn’t whether Republicans have plans to repeal Obamacare. They will repeal it. It’s which parts of which plans they’ll pick, and how quickly they can agree. We talked about this in my first post, so there’s no need for me to repeat myself. But just a reminder that in Trump’s Government for People Again: Health Care, Trump does not give any specifics on the individual market, and overall gives less specifics in every area than Better Way or The Patient CARE Act. This seems to me like he really wants Congress to take the lead on coming up with a plan. Which is why we need to be informed on these policy ideas.

But even if Congress agrees on a policy, how do we know Trump would like it?

As a parting section, I wanted to include this article written by Trump’s transition team senior health advisor, Thomas Philipson. It may provide clues as to which policies debated in Congress would actually have Trump’s seal of approval. (See bolded stuff if you want to skim.)

 The Best of Both Worlds: Uniting Universal Coverage and Personal Choice in Health Care

The US health care system suffers from three structural flaws. First, it artificially inflates health insurance premiums for the healthy in an attempt to lower premiums for the sick. This encourages healthy individuals to reduce their insurance coverage or even exit the market entirely, driving up costs for everyone… Second, by relying heavily on open-ended fee-for-service public insurance, the present system rewards costlier high-volume care rather than higher-quality care. Perhaps as a result of these incentives to do more, per capita health care spending in the United States is the highest in the world, while patient health outcomes rank much lower. Third, the poor are funneled into a Medicaid system with reimbursement levels well below those of private payers. This relegates the most vulnerable groups in America to a separate and unequal health care system with more limited access and worse outcomes… Our approach reorganizes US health insurance around four principles:

  •   First, we allow and encourage insurance companies to charge individualized premiums to consumers that reflect their true health care costs. This moves away from the current approach of offering coarse and relatively uniform premiums to the wide range of individuals seeking insurance (through the use of group insurance or state-level community-rating mandates).
  •   Second, to ensure that offers of insurance are affordable, we propose government-financed premium supports. The poor, especially the sick poor, gain access to a basic insurance plan at no cost and to more generous plans at significantly reduced costs.
  •   Third, we propose eliminating the practical and legal barriers to multiyear (long-term) health insurance contracts. Such contracts protect all Americans from increases in insurance rates that could accompany major illness.
  •   Fourth, we propose to abolish the tax preference for employer-sponsored health insurance plans. This subsidy encourages excess utilization of both insurance and low-value health care services. It also costs the federal government nearly $300 billion in lost revenue—revenue that could be used to fund insurance for the sick and the poor. Finally, it forces an awkward bundling of health care and employment with adverse consequences for workers and firms alike.

From this, we can see that Philipson is a huge proponent of getting as many people on healthcare as possible, but keeping those people from hopping on and off of coverage, just like Ryan’s plan. He’s also a proponent of abolishing “the tax preference for employer-sponsored health insurance plans,” as he says that “this subsidy encourages excess utilization of both insurance and low-value health care services.” He also wants to get rid of the benefits package, just like Better Way. He says nothing about high-risk pools (i.e. a safety net for those with preexisting conditions) or about exactly how Medicaid would be changed. This leads me to believe a few things:

1) Better Way is likely to gain a lot of headway since Philipson’s ideas and Ryan’s ideas are similar. However, Ryan and Trump don’t exactly get along, so it remains to be seen if Ryan and Trump can work together effectively.

2) Price’s idea to reduce the cost towards a high-risk pool, from $25 billion to $3 billion, might pass. Trump is a huge fan of Price, and since Philipson doesn’t seem to care much about preexisting conditions, reducing the amount of money towards that might be attractive to Trump. However, at the same time, Trump has said since the beginning that he would not change the preexisting conditions mandate, championing its importance. We all know he changes his mind as much as a five-year-old though, so he might all of a sudden decide to forget about people with preexisting conditions.


(Some of these sources are links to PDFs. That means that when you click them, they won’t open. But if you type the words from the link into google, you’ll be able to access the PDF that way.)





NOTE: I did not cover Trump’s current lawsuit in this post. There’s a House lawsuit over insurer bailout, where Trump is being sued millions. He’s going to have to deal with this before he can actually do anything about the ACA. If you want to know more about it, you can read this article or this one.

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