Republicans’ Healthcare Word Choices Can’t Alter Facts

March 27, 2017

Maybe it’s because my formal education trained me to be sensitive — even hypersensitive — to words. Whatever the reason, I’m impressed and riled up when I read how House Republican leaders and some top officials in Trump administration are styling the features of their Obamacare repeal-replace bill.

Both responses because their word choices artfully appeal to widely-shared values, while obscuring basic truths that anyone who reads even a summary of their plan can see.

And just because neither the Republican House leadership nor Trump could herd enough of their cats to pass their final bill, doesn’t mean we’ve seen the end of this. Some notable examples then.

Access to Coverage. A favorite word. House Speaker Paul Ryan says it’s the Republicans’ “job to have a system where people can get access to affordable coverage.”

A Republican House staffer, speaking anonymously and thus perhaps less focused on the selling the work-in progress, said, “We would like to get to a point where we have what we call universal access, where everybody is able to access coverage to some degree or another.”

Now, access isn’t the same thing as ability to buy. For example, I have access to a full-length mink coat. The coat’s in a store I can get to. I can walk right up to it. And it’s great coverage, especially when in cold weather.

So a poor person can review a health insurance policy, with ample coverage, a minimal deductible and small co-pays. Doesn’t mean s/he can pay for it.

Now that we’ve got credible estimates of the many millions of Americans who’d no longer have health insurance, Ryan harps again on access, coupled with another favorite word — and not only in the healthcare context.

Choice. For families, Ryan says, access means, among other things, “more choices.” Well, who doesn’t like having choices? Do we like being told we must do or have some specific thing — or can’t?

But the bill, as I’ve just said, doesn’t mean more choices for lower-income families, except the choice of going without health insurance — or buying one of those low-cost, high deductible plans.

Ryan touts the larger maximum people can contribute to a health savings account, avoiding the corollaries, i.e., that only people with high-deductible plans can have them and that those who live paycheck to paycheck don’t have money to stash away.

Only 6% of families with incomes less than $30,000 a year contribute anything to an HSA now. More than half the families that contribute have incomes of at least $100,000 — a tax saver for them, rather than a needed savings account.

Freedom. When Ryan was asked how many Americans would lose coverage if the Republican’s bill became law, he said he couldn’t answer. “People are going to do what they want with their lives because we believe in individual freedom.”

And indeed we do, but only up to a point. We don’t believe everyone should be able to do whatever they want, especially when what they would cause harm to others, directly or otherwise.

In the immediate case, people would be freer to go without health insurance, since the bill would eliminate the annually-growing penalty for that.

But they’d drive up premiums because most would have reasons to believe they’d remain healthy — at least for awhile. But if they then had a medical emergency, a hospital would have to eat the costs of treating them.

An immigrant from Finland cites several other instances of the Republicans’ using “freedom” as a selling point and, as her op-ed’s headline says, explains why it’s “fake,” in contrast to the freedom she had before.

Care. The Director of the Office of Management and Budget asserts that the Republicans’ goal isn’t health insurance coverage nor a plan people can afford.

It’s care they can afford. He cites his family’s high deductible when he was in the House of Representatives, earning considerably more than would qualify them for a tax credit to subsidize it, let alone one for a family eligible for the highest.

We earlier heard something, though more extreme from the Secretary of Health and Human Services — a former orthopedic surgeon and then Republican House member who proposed his own version of repeal-replace.

While in the House, he said that he “knew oh so well how the intervention of the state and federal government into the practice of medicine destroys the ability to take care of people.”

Seems fair to gather what he means from the reported views of a radically right-wing professional organization he belonged to — minimal, if any health insurance regulations or medical quality standards, e.g., that physicians be licensed to practice, no vaccination requirements and no Medicare at all.

Well, save me from care so free of intervention. But these views hardly reflect what the majority of doctors believe — even those represented by the traditionally conservative American Medical Association, which has decided that the repeal-replace is far worse than the “imperfect” law we have.

Rebuttal Story. The Washington Post recently published a column by a doctor at primary care clinic that expressly rebuts the interference with care claim — and, by example, the other negatives that the Republicans’ word choices imply.

The doctor tells the story of one of his patients. Mr. R. first came to him when he got health insurance, having had none before because he couldn’t afford it.

The Affordable Care Act changed that, enabling him to purchase a plan that cost him less than $50 a month, thanks to the subsidies low-income people receive. But that’s not all.

Mr. R can neither read nor write. So he could hardly use the online system to choose and actually apply for a plan. He had the help of a navigator — a trained, unbiased helper — whose role the ACA established.

So he’d gotten help with logging on and entering some basic information. The the system then determined he had somewhat too much income qualify for Medicaid. So it kicked him over to the health insurance exchange.

The navigator explained terms like “premium” and “out-of-pocket maximum” and helped him fill out the forms. In short, as the physician says, “the federal policies … worked synergistically.”

Mr. R had — and still has — access to coverage, freedom, choice and care from a caring doctor. What “some politicians … seem not understand,“ the doctor says, “is that without the ACA, I wouldn’t have a relationship with patients like Mr. R at all.”

They actually do, I think, just as they understand the weasely way they’re using terms like “access,” “choice” and the rest. But what’s the alternative? To acknowledge that their bill would cause nearly as many people to have no health insurance than before the ACA?


House GOP Defunds Planned Parenthood, Endangers Low-Income Women

March 13, 2017

Nicholas Kristof wrote a presciently timely column for the next-to-the last Sunday New York Times. He recounts a visit to a women’s health clinic in small town in Maine, including what he observed during a consultation.

A teenager had come to the clinic because she felt itchy in her vaginal area. The nurse practitioner takes swab, diagnoses a yeast infection, but has also tested for sexually transmitted diseases.

She then talks to the teenager about birth control methods, including a long-acting reversible contraception. The young woman likes that, learns it’s fully covered by her insurance.

The nurse practitioner also gives her some condoms and tells her to always insist that her prospective sexual partner use one to protect her from STDs.

In short, as Kristof says, this is health care at its best, preventing both unwanted pregnancies and diseases.

Indirectly, poverty also, since the poverty rate for single-mother families is consistently the highest of any household type the Census Bureau reports — 36.5% last year and even higher for families with color, except Asian-Americans.

The Maine clinic apparently receives federal funds — either through the state’s Medicaid program, a Title X family planning grant or both. So it — —and the women who depend on it — are in big trouble because it provides abortions.

No federal funds used for these because laws already prohibit that. But the clinic probably can’t survive on donations and what it receives from health insurance companies for serving patients who’ve got the coverage the House Republicans’ Affordable Care Act repeal-replace bill would provide.

The bill won’t let people use the tax credits they’ll get to help pay their insurance premiums for a policy that covers abortions, except in the same limited cases the Medicaid prohibition carves out,

And, as you’ve probably read, it denies federal funding to Planned Parenthood, though initially for only one year. This perhaps to evade a stumbling block to swiftly passing the bill with only a simple majority in the Senate, rather than the usual 60 votes.

In the meantime, knowing the bill won’t pass swiftly anyway — if at all in its current form — the House passed and the Senate’s expected to pass a measure that overturns an Obama administration rule which effectively prohibits states from denying Title X funds to family planning projects because they provide abortions.

Well, none of this will make much difference to well-off women who live in cities or major suburban areas. They’ll have ob-gyns or other clinics they can go to. If they need an abortion, they can readily get one from their ob-gyn or another competent physician — and pay for it out of their own pockets.

But low-income women — and perhaps many not-so-low who live in small, rural towns — will no longer have a nearby clinic for tests that detect cancer as well as other diseases, counsel on how to prevent them and on safe, reliable birth control. Nor the procedure to insert a LARC — and replace it when necessary.

Planned Parenthood operates the largest network of women’s health clinics in the country — nearly 650, serving every state and the District of Columbia. They provide services to about 2.5 million women and men a year. Nearly 80% were poor or near-poor two years ago.

A tiny fraction of the funds it disburses go for abortions — 3%, as measured by services. Roughly a third help prevent untended pregnancies. Most of the remainder test, provide treatment and/or help prevent diseases.

Notwithstanding what some Republicans have said, other community clinics can’t readily meet these needs if the freed-up funds were available to them. Nor new clinics spring up all over the country.

Planned Parenthood is 100 years old now. You don’t get the resources to build or expand facilities, find and hire specialized health professionals to fully staff them, ensure stocks of testing equipment and supplies, etc. in a couple of years.

All these attacks on Planned Parenthood — and now apparently a broader attack on women’s health clinics — are a sop to the active pro-life movement.

What a cleverly chosen name, I’ve often thought, since it casts Americans who believe women should have the freedom to choose when and if to become mothers as against life.

Well, let’s consider the life of a low-income woman who can’t get regular Pap, other cervical cancer or breast cancer exams, plus instructions on how to monitor for breast lumps herself.

Or the life of a woman who doesn’t find out she has HIV/AIDS until she contracts some life-threatening infection — and perhaps by then has passed the disease on to a partner or a baby she’s borne.

How about a woman who’s decided that she’s unready — financially, emotionally or otherwise — to become a mother? She perhaps plans to enroll in a college-level program that will prepare her for a fulfilling, well-paying career — or is already in one.

She may, in fact, still be in high school and with no family member to care for a baby — or the money or the transportation to put him/her in an infant daycare program or even one nearby that’s not fully booked. She’s likely to drop out of high school, as 90% of pregnant teens do.

Her life may turn out okay, but the prospects are significantly dimmer. As I already said, she’s at high risk of poverty. What kind of life will that child have? Many studies tell us that children born and raised in poverty are at high risk for a host of problems and likely to remain poor long after.

None of this is to say that the self-labeled pro-lifers are wrong to publicly opposing abortions. If I believed that people were legally murdering others, I would speak out too, join with others to protest, call for an end to it.

But when human life begins, the value of preserving fetuses likely to die at birth or survive severely damaged, the countervailing weight of harms to the expectant mother and the like are matters of personal belief, often based on sectarian religious teachings.

The Supreme Court acknowledged women’s Constitutional Right to abortion more than 44 years ago. The federal government has nevertheless long curbed that right by prohibiting uses of federal funds for abortions.

Now, even if the House Republican leadership can’t push through its bill and the efforts to fashion a more acceptable substitute drag on, we can expect more proposals to defund Planned Parenthood — if not in Congress (though likely), then by states, 10 of which have already moved to do so.

And we can’t, I think, trust the new administration to intervene in defense of equitable funding for organizations that can provide the services Medicaid covers, given Trump’s bifurcated view on the Planned Parenthood issue.

A call to action then in defense of low-income women by the majority of voters who believe that abortion should remain legal in all or most cases. Because what’s a legal right if you’re too poor to exercise it?


House Republicans Unveil Reverse Robin Hood Healthcare Plan

February 27, 2017

House Speaker Paul Ryan and his lead colleagues have generated even more news about the Republicans’ plans to repeal the Affordable Care Act.

Still no legislation. Still spare details. And still, it seems, no genuine consensus, though a large majority now understand that simply repealing the ACA would be a disaster politically, as well as for the 20 million or so Americans who’ve gained health insurance coverage since the law kicked in.

Ryan, however, has released a policy brief that purports to set out the major elements of the House Republicans’ repeal-replace plan.

Needless to say, it aims to radically cut federal spending on health care. Beyond that, a New York Times headline captures the major thrust: “Republican Health Care Proposal Would Redirect Money From Poor to Rich.”

Here briefly are the major changes and how they’d make the shift. Long post, but on one of the biggest immediate threats to the well-being of low and moderate-income people in this country and our common — though obviously not universal — concept of equity.

End of Medicaid As We Know It

Many concerned parties, including yours truly, have animadverted before about Ryan’s plans to convert Medicaid to a block grant.

Basically, states would no longer receive partial reimbursements for the costs they incur in providing health care to the poor and near-poor people they’ve enrolled. They’d instead receive a fixed sum of money, coupled with even fewer requirements and restrictions on what they can do.

We can predict from the fate of other block grants that the fixed sum will either remain the same, regardless of increases in the number of very low-income people in need — or grow somewhat, but not enough to not enough to benefit everyone eligible or who would have been had the block grant not been created.

Ryan’s new plan includes this option, but leans toward a variation — per capita grants. These too use a formula to set states’ funding, but it’s based on the regular federal match that each received in a base year for people in specific categories, e.g., children, people with disabilities.

The grants would increase, based on the inflation rate. But the rate, as commonly measured, reflects the prices of goods and services consumers commonly pay for, e.g., food, fuel, housing, with medical expenses merely folded in.

As we all know, health care costs rise more. And they’re projected to rise considerably higher, boosted by aging baby boomers, new, high-priced drugs and other drivers.

In short, same basic result, achieved by something with less tarnished name — and with a further, predicable cost-shift to all the states and the District of Columbia that have expanded their Medicaid programs.

Specifically, the plan would fold in repeal of the higher federal government match for newly-eligible people enrolled in Medicaid programs. States would continue to have the it for some unspecified time so as “not to pull the rug out from” them or beneficiaries.

The rug would, however, be immediately pulled out from under adults deemed able to work, regardless of whether they do, but at a very low wage — or have any reasonable prospects of landing a non-poverty wage job.

Redirected Tax Credits

Under the current law, people who buy health insurance on an exchange get a tax credit that serves as a subsidy if their annual income is less than 400% of the federal poverty line — currently $97,400 for a four-person family. The subsidy goes directly to the company that provides the insurance the beneficiary chooses.

It’s greatest for those in the lowest income bracket and diminishes till it reaches the highest. So it ensures that very low-income people can afford comprehensive health insurance, while not spending federal money on people in upper-income brackets.

The Ryan plan would instead award tax credits directly to people who have no employer-sponsored health insurance or coverage under a government program.

They’d would be based only on age, with larger (unspecified) credits to older people. As the Times column suggests, this would seem to make some sense, since older people tend to need more medical care.

But it means is that some very wealthy people would get a larger benefit than many of the very poor, who not only need more help in affording health insurance, but often have more health care problems.

Expanded Health Savings Accounts

Our current system already offers people opportunities to sock money away tax-free for specific medical and dental needs by putting it into a Health Savings Account.

As with the better-known Individual Retirement Accounts, you can save only up to a maximum in any given year, but the cap is based on age, when you become eligible and the type of insurance you have (see below), rather than age and taxable earnings.

You’re not required to withdraw any money during a given year. So what you’ve invested continues to grow, assuming it’s invested well and that administrative costs don’t offset real-dollar gains.

And you don’t have to pay income taxes when you withdraw, if you spend the money for approved healthcare purposes — another difference from an IRA.

The biggest difference, however, is that you have to expose yourself and your family to budget and/or health risks because you can’t have an HSA unless your insurance plan is a high deductible, i.e., covers only what are sometimes referred to as catastrophic costs.

Current federal rules, for example, allow insurance companies to require high-deductible customers to pay as much as $7,850 for an individual or $15,700 for a family before they start covering costs.

HSAs are thus obviously beneficial to some people who can afford what they and any dependent family members need and still have money left over because they’ll owe less at tax time. But only those who can stash enough to cover thousands of dollars of healthcare costs.

The Ryan plan would allow people to contribute their maximum out-of-pockets to their HSAs. Another provision would allow spouses to contribute all or part of so-called catch-up contributions, i.e. those made in a given year to compensate for lower than maximum contributions previously.

Conservatives, including lead Congressional Republicans have long argued that healthcare costs would drop if people had “more skin in the game,” i.e., more to save or lose depending on whether they choose to seek health care and, if so, what sort and from whom.

This, as I think everybody knows, is profoundly unrealistic. We’ve neither the knowledge nor, in many cases, the time to choose healthcare services the way we choose, for example, large-screen TVs.

It’s nevertheless the theory underpinning the HSA expansion, with its inherent push toward high-deductible plans. And again, it’s effectively spending more on well-off people — in this case, by forfeiting tax revenues.

Undermining the ACA Before Full Repeal

Long as this post is, I haven’t covered all parts of the plan — most notably, the full repeal part.

Sufficeth it to say that it would roil the insurance market — by immediately eliminating the penalty for having no insurance, for example, and the penalty imposed on larger employers that don’t cover most of their full-time workers.

So if Obamacare isn’t failing now — as the policy brief misleadingly says it is — it surely would during the transition period the brief promises.

NOTE: Last Friday, two insider news sources posted a leaked draft of the House Republicans’ legislation. It generally tracks the measures I’ve summarized.


Let’s Not Forget Affordable Dental Care

January 23, 2017

A comment posted some time ago raised an issue about Medicaid that seems even more timely now because it opens to the door to larger current and prospective issues.

Seems the commenter had to have some teeth pulled. Her dentist told she would have to wait for dentures until her mouth heals instead of getting a temporary set. She felt that she and others covered by Medicaid were “treated differently from other people,” who aren’t doomed to toothlessness. Would I look into this?

And I did, learning more in the process about not only the source of her problem, bur dental care in our health insurance system — today and prospectively. Results, as follows.

The commenter is actually quite fortunate. States don’t have to include dental services in their Medicaid programs, except when they administer the Children’s Health Insurance Program by expanding them.

For adults, dental care is an optional benefit, both for those whom states covered before the Affordable Care Act and those who became newly eligible when states opted for expansion. Those states must provide “essential health benefits” for the latter, but dental care isn’t one of them.

Virtually all states and the District of Columbia do cover some dental services, but only fifteen cover a comprehensive mix, the Kaiser Family Foundation reports.

Many cap per person spending or the number of services covered. And thirteen cover only emergency treatment. Even coverage doesn’t ensure affordability because beneficiaries may face high out-of-pocket costs.

Not all states that cover dental services cover dentures. And even fewer cover dentures for all beneficiaries as often as they might need them. They’re responding here to limits the federal government sets on reimbursements.

But low-income adults aren’t treated all that differently from their better-off peers. Traditional Medicare provides no coverage for dental services, except in certain limited cases when the beneficiary is in a hospital.

We who’ve had employer-sponsored health insurance also know that incomplete—or no—coverage for dental services is more common than the commenter apparently assumed.

But better-off people can shell out for dental care or supplementary insurance. Not so for low-income working age adults. Only 19% of those who were officially poor went to a dentist in 2013. And 44% had had untreated cavities in the prior two-year period.

Nearly a third of those with incomes low enough to qualify for an expanded Medicaid program reported an unmet need for dental care last year.

Without it, they may not only lose teeth and have to live with gaps in their mouths. Untreated oral diseases, including cavities can cause or worsen a range of other health problems.

Lack of sufficient coverage is obviously a major barrier, but it’s not the only one. In some places, e.g. rural areas, inner cities, there simply aren’t enough dentists. That’s partly due to an unwillingness on their part to treat low-income patients, especially those covered by Medicaid.

Dentists object to the paperwork and lost income because Medicaid patients—at least, by reputation—often don’t show up for appointments. But dentists also cite low reimbursement rates—sometimes so low as to not even cover costs.

Now, we know that states often cut provider reimbursement rates when economic downturns drive up their Medicaid costs because that’s more politically palatable than tightening up on eligibility or coverage.

And we know they’d face budget crunches—and not only during recessions—if Republicans in Congress convert Medicaid to a block grant and the President agrees.

Not much of an “if” here. The Trump’s campaign’s policy positions included a block grant. And Congressman Tom Price, his choice for Secretary of Health and Human Services, folded a block grant into the House budget plan when he chaired the responsible committee.

Looking at how states now use their flexibility to limit dental care coverage, we could reasonably expect them to make further cuts there.

They might instead (or also) cut dentists’ reimbursement rates. More than half the states did that in the aftermath of the Great Recession. So Medicaid beneficiaries who still had dental coverage may have had more problems finding someone to treat them, as certainly seems the case in Washington and in Florida.

Some states might instead join those that provide no coverage whatever.

The block grant is only one of the clear and present dangers to the health of poor and near-poor people, including the health of their teeth, gums and everything else in and around their mouths.

The impending repeal of the Affordable Care Act would immediately deny higher federal reimbursement rates to the 31 states and the District of Columbia that have expanded their Medicaid programs.

The repeal, in and of itself, would free them to shrink or eliminate dental health benefits for the newly-eligible children they enrolled because they’d no longer have to provide the essential health benefits the ACA specified.

This would also be true for most other insurance plans, unless state regulations required them because the same EHB requirements apply. And if, as predicted, premiums soar, one could expect plans to drop dental care or, at least, radically cut back coverage.

Some of you may recall the boy who died from a brain infection because his mother couldn’t find a dentist to treat him in time—this for wont of Medicaid. We might have more such cases, with or without it.

We’d almost surely have more low-income adults toothless (and not only temporarily) and more dead too because they couldn’t afford dental care—or related medications.

I know this seems a worst case scenario and perhaps an unwarranted leap from a singular problem to a vast array. But when we think about what will happen in the aftermath of health care “reforms,” we need get beyond the numbers, as important as they are.

Price objects to our government programs because they get between doctors and their patients. But, in fact, people who should be patients won’t be.

And when we think of them, we shouldn’t forgot those who need dental care because, as one dentist said, “the mouth and the head are connected to the rest of the body.”


Another Stab at Defunding Planned Parenthood, Another Threat to Low-Income People’s Health

January 9, 2017

Last week, House Speaker Paul Ryan assured reporters that the forthcoming bill to repeal the Affordable Care Act would include a provision denying federal funds to Planned Parenthood. This is supposedly pro-life, but it’s a major threat to the lives and well-being of thousands of low-income women.

Republicans (and some Democrats) have put Planned Parenthood in the bull’s eye because it’s one of the country’s largest providers of abortion services — and in some areas, the only provider.

Yet abortions represent a small fraction of the services Planned Parenthood provides—about 3% in 2014-15.

And those abortions are rarely, if ever, funded by the federal sources Republicans would shut off — Medicaid and Title X of the Public Health Services Act. An amendment routinely attached to spending bills has seen to that.

So the loss of federal funds would deny both women and men other health services — notably, tests and treatment for sexually transmitted diseases, pap smears, breast exams and affordable, reliable contraception.

Shrinking Planned Parenthood’s resources would thus increase health risks — and the risks of unwanted pregnancies. The latter, among other things, would keep more women mired in poverty and increase the number of children born and likely to remain poor.

Defunding Planned Parenthood is hardly a novel notion. So we have some evidence of consequences. Texas shifted its family planning funds out of Planned Parenthood in 2013—this after cutting its family planning budget.

Researchers found a 35% drop in the number of women using long-acting, reversible contraceptives supplied by clinics the state funded. The pregnancy rate among women who’d previously used injectable contraceptives—an alternative long-acting form of birth control—rose 27%.

Another study looked at what happened in Texas and Wisconsin when clinics closed because they’d lost public funding. Researchers found that fewer women got Pap smears and breast exams — in both cases because they’d have had to drive much further to get to a clinic.

About 40% of Planned Parenthood’s funds come from Medicaid, through reimbursements, and Title X, through grants. These sources cover care for approximately 60% of its patients—roughly 1.5 million people.

Republicans have said that the funds they’ll deny Planned Parenthood will go to other organizations and thus sustain the services its clinics can no longer provide.

This might be true in the long-run. But it surely wouldn’t before many thousands of women suffered irreparable harms. Professor Sara Rosenbaum, who’s worked with community health services for years, cites three major reasons.

Rosenbaum was responding to a defunding bill introduced in the Senate about a year and a half ago. The House actually passed a one-year defunding bill shortly thereafter.

The Congressional Budget Office assessed that bill and concluded that it would have caused an estimated 400,000 Planned Parent clients to lose access to care while also increasing federal Medicaid costs due to more unintended births.

The fate of these vulnerable people—and thousands who’ll come after—hinges on the Republican leadership’s getting a simple majority of votes in favor of the vehicle chosen to repeal the ACA. Some have suggested they might not get there. A very iffy prediction.

Our incoming President has talked on both sides of his mouth on this, as on other issues. But he’s said he’ll sign a defunding bill so long as Planned Parenthood is involved in abortions.

What this means, of course, is that we’re looking at even worse prospects for comprehensive, affordable health care than what we glean from the ACA dismantling in the works.

NOTE: I’m indebted to posts by Judith Solomon at the Center on Budget and Policy Priorities for data and links to original sources on the impacts of the prospective defunding. You can find her latest here.


Devastating Effects of Affordable Care Act Repeal

January 5, 2017

The Urban Institute puts some hard numbers on what will happen if the Republicans in Congress dismantle the Affordable Care Act. They’re shocking.

An estimated 53.5 million people would have no health insurance in 2021. That’s more than double the number who’d have no coverage if the ACA were intact.

Coverage would shrink most for low-income people enrolled in Medicaid, presumably because states would no longer receive funds to cover most of the costs of people who became eligible when they expanded their programs.

They’d be hard put to make up the loss and so would probably set lower limits on income eligibility, cut back on services covered and/or further reduce their reimbursements to healthcare providers.

Looking only at the first of these cost-savers, the Institute estimates that 14.5 million fewer children and working-age adults would have coverage under Medicaid.

The Institute’s estimates do not include the results of converting Medicaid to a block grant, as lead Congressional Republicans—and our incoming President—favor.

His choice for Secretary of Health of Human Services included one in the budget plan he produced while Chairman of the House Budget Committee. It would have cut federal Medicaid spending by a whopping $1 trillion over the next 10 years.

No way that state and local governments could compensate for losses so great. The crunch, however, could well be larger.

An economic downturn (likely) would cause job losses and so make more people income-eligible, even with lower thresholds. The federal government would no longer pick up its share, as it does under the current system.

The Center on Budget and Policy Priorities used the Institute’s data to estimate state-level losses. Here’s what we learn about the District of Columbia.

In 2019, 32,000 fewer residents would have health insurance if Congress repeals the ACA. This, like the nationwide total, is more than double the number who’d otherwise no coverage.

Nearly 23,500 more residents have gained affordable health insurance through Medicaid since 2013. Many would lose this coverage unless the District used its own funds to make up for the federal funds that would no longer pay most of the costs for the newly eligible. That would require a total of $1.7 billion between 2019 and 2028.

The District would also lose $85 million in funding for its health insurance marketplace. And residents who now have insurance through the marketplace would immediately lose the tax credits that subsidize their costs.

The Center doesn’t estimate how much more they’d have to pay to retain the coverage they have now. It does, however, say that the credits cover 73% of monthly premiums nationwide. Faced with that much more out of pocket, many lower-income residents would presumably forgo insurance.

In short, repeal of the ACA will have devastating effects on low and moderate-income District residents, as it will on virtually everyone but the very well-off nationwide.

Millionaires would, in fact, get tax cuts bigger than the total average income of families in the bottom two-fifths of the income scale. The very wealthiest would get cuts averaging $260,630.

We’re given to understand that the Republican leadership has put repeal at the top of its agenda. It probably won’t, however, impose an immediate death sentence on every provision, what with not having the promised replace.

It does, however, have a bill that Republican majorities have already passed. It would eliminate the two provisions I’ve focused on here—the additional funding for states that have expanded Medicaid and the tax credits that low and moderate-income people get to subsidize the costs of plans they buy on exchanges.

Republicans also, as I’ve mentioned, have the basis for converting Medicaid into a block grant. So they could make a costly down payment on a major campaign promise.

Hard to find a hopeful note to end on. So I’ll borrow from Ron Pollack, the long-time Executive Director of Families USA, a leading advocacy organization for Americans’ healthcare needs.

“One should never underestimate the extraordinary backlash that occurs when people have something they value that’s taken away,” he says.

What remains to be seen is whether they’ll lash back forcefully enough before the affordable healthcare protections the ACA provides are taken away.


Broken Bone, But Not Broke, Thanks to Medicare

December 1, 2016

A week before Thanksgiving, I got up on the right side of bed, but from closer to the edge than I realized. Landed flat on my back and lay there in excruciating pain. But I managed to get dressed, make sure essentials were in my purse, call 911 and hobble downstairs to open the door.

Folks in the ER took X rays and a CAT scan. Determined I’d fractured a pelvic bone, but probably wouldn’t need surgery. So they sent me to a hospital, where the tests were repeated and the same diagnosis made.

Then on to a rehabilitation center, where I got both physical and occupational therapy to ready me for living at home alone and as much painkiller they’d allow. I’m still in pain, but otherwise in pretty good shape—and home again neither permanently disabled nor bankrupt..

I’m told that the transport, medical and therapy services and the rooms, food and the like in the hospital and rehab center will cost me nothing. The painkillers require copay, but it’s small. And my Medicare Advantage plan sets a low cap on all my out-of-pockets for the year.

I shudder to think of the bills I’d face if not enrolled in Medicare — or more precisely, the Advantage plan I chose. And I says to myself, what if I were twenty or so years younger now and I’d had the same accident when I was sixty-five?

You know, I’m sure, that this isn’t a hypothetical question. House Speaker Paul Ryan apparently plans to link his pet Medicare “reforms” to whatever the Republican majority does to dismantle the Affordable Care Act,

“Medicare has got some serious problems because of Obamacare,” he recently told Fox News, claiming, as he has in the past, that the program “is going broke.” This is wrong on both counts, as the Washington Post’s fact checker explains. And Ryan probably knows it.

But he also knows he’s got an opportunity he didn’t before. He’s produced multiple versions of his so-called Medicare reform plan. The latest, in his Better Way healthcare policy paper, is a dense, blame-heavy thing. This much, however, I think, we can gather in answer to my what-if question.

I wouldn’t have health insurance through any form of Medicare. Ryan would link the minimum eligibility age to the age former workers become eligible for full Social Security retirement benefits. That would be sixty-seven under current law. But Ryan, among others, has wanted to raise it further.

The rationale for withholding both sorts of benefits from people who’ve reached what we ordinarily think of as retirement age is that Americans are living longer. This, Ryan says, is because we’re healthier—thus, inferentially, not in need of Medicare until we’re significantly older.

Set aside the over-simple reading of the rising longevity figure, we’re not living longer because we’re healthier. It’s rather because medical science has gotten better at keeping sick people alive and because we’re spending more on healthcare—this according to the National Bureau of Economic Research.

The constantly evolving treatments of various sorts will mean nothing, of course, if people who need them don’t have insurance to cover most, if not all of the costs.

And what about a case like mine? My life expectancy had nothing whatever to do with my falling, though my age may have had something to do with the fact that a bone cracked.

Say, however, I’d reached the ripe old age for Medicare. It wouldn’t come close to covering my healthcare costs. I’d get a subsidy of some sort to help me pay premiums for either a non-government insurance plan, misleadingly termed an Advantage Plan, or traditional Medicare, also misleadingly termed.

Ryan misleads because neither of the choices we’d have would offer as much care for as relatively little. Our premium support would do more for the poor than the well-off. But it wouldn’t rise to keep pace with rising healthcare costs.

This is a main feature, not a bug. Ryan’s fundamental aim isn’t to save Medicare, as he claims, but to cut federal spending. So the subsidy—not, he protests, a voucher—would cover less and less over time.

But we’d get more bang for the buck, he says, because insurers would reduce costs and improve quality of care so we’d choose their program over competitors’. Medicare would then have a built-in cost containment mechanism, as it doesn’t now.

It already has various price controls, however, though Republicans would blow some away in repealing the ACA.

The bigger deal, however, is that private insurers can’t keep premium costs and out-of-pockets low enough for most of us to afford them. Nor can what’s now traditional Medicare, which would be in even worse shape than its alternatives.

And the bigger deal yet is that the soon-to-be Secretary of Health and Human Services has long objected to Medicare and enthusiastically supported Ryan’s privatization plan.

Shortly before his nomination, he said he expected Congress to move forward with a Medicare replacement plan in six to eight months—as soon as it’s dispatched with the ACA.

Republicans can tackle both without any Senate Democrats voting in favor, through a somewhat arcane process known as budget reconciliation. So unless more than two Republicans heed the vast majority of Americans, who oppose any spending cuts to Medicare, future seniors won’t have affordable health care.

This tally assumes that Trump will ignore his promise to leave Medicare alone. We still don’t have a clear read on that. But I’m even less confident now than I was a couple of weeks ago. One need only look at the healthcare reform page on his new website—and, of course, his choice for HHS.

The fact that I personally got—and will continue to get—the healthcare services I need at a price I can afford doesn’t make what seems to be coming down the pike irrelevant to me, though that’s clearly what the Medicare reform crew intends.

Nor do I rest easy, knowing that ending Medicare as we know it is only one piece of the attack on our affordable healthcare system.

We know, for example, that block granting Medicaid appeals to Trump—and that he’ll almost surely have a chance to sign a bill that denies low-income people, seniors among them, the affordable healthcare services they can count on now.

This wouldn’t directly affect me. But if I had less money, it would because Medicaid would help pay for my Medicare out-of-pockets—and, in at least some states, the costs of a home health aide. Anyone hobbling around the way I am needs someone to help with basic tasks.

But how many states would still provide it as healthcare costs rise and federal funding doesn’t?