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.

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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.


House Budget Plan Endangers Health of Low-Income People

March 31, 2016

When I drafted my post on the House Budget Committee’s plan, I discovered that its impacts on affordable health care had too many interlocking parts to fit. So here, as promised, is a followup.

I’ve already mentioned the not-new plan to convert Medicaid to a block grant. But there is something new — a work requirement. State flexibility notwithstanding, able-bodied adults couldn’t qualify unless they were gainfully employed, actively seeking work or participating in a job training program.

Now, this may sound reasonable. But it isn’t — for three reasons. Two we’re already familiar with from the plight of able-bodied adults without dependents who will soon lose their SNAP (food stamp) benefits.

There aren’t enough jobs they can qualify for. There aren’t enough slots in training programs for all the jobless either. And states have no obligation to provide them. No evidence they’d have to for Medicaid — or get any funds for training, as they can with SNAP.

The third reason calls for a look beyond the block grant. The House budget plan would (surprise!) repeal the Affordable Care Act.

This would, among many things, deny a growing number of states and the District of Columbia the federal funds they counted on to cover a large share of the costs they incur because they expanded their Medicaid programs.

They’d lose a total of about $2.1 trillion over the upcoming 10 years. So it’s reasonable to expect they’d revert to their pre-ACA eligibility standards — or something much like. Basically, this would mean that the work requirement would apply to only very poor pregnant women and parents.

Studies of families in the Temporary Assistance for Needy Families program tell us that many of those parents face formidably high barriers to work — some that are also barriers to regular participation in a job training program. Seems they’d go hungry.

Many Medicaid recipients do work, however. Those with incomes at or above 100% of the federal poverty line could buy health insurance on an exchange — if the ACA were still intact. But without it, they’d have no subsidy to help pay the costs.

Other House committees have already passed bills within the framework of the Budget Committee’s attack on the ACA. So yet one more post to come on how key House Republicans would save money at the expense of their constituents’ health, the states they represent or both.

 


House Republicans Set to Promote Single Motherhood

August 3, 2015

Seems the House will vote next month on budgets for the agencies lumped together as Labor, Health and Human Services and Education. Some increases, many cuts. Two of the latter would deny low-income women safe, reliable, affordable contraception.

There’s something extremely perverse about limiting women’s opportunities to postpone childbearing until they feel ready to fulfill — alone or with a spouse or partner — the heavy-duty responsibilities of motherhood.

Especially perverse, given all the expressed concern about single mothers, their dependency on welfare, how they’re breeding criminals, etc.

Labor-HHS-Education Overview

The House bill would cut total spending for the programs it includes by $3.7 billion. On top of cuts made since 2010, they’d have $29 billion (16%) less in real dollars, the Center on Budget and Policy Priorities reports.

Republicans claim they’ve got no choice because the Budget Control Act caps spending on domestic programs subject to annual appropriations.

They could, of course, have adjusted the cap — or done away with it altogether — by adopting a more balanced approach to deficit reduction, as the President’s proposed budget would and Senate Democrats seem ready to insist on.

Cap aside, it’s still the case that the Appropriations Committee foisted the largest dollar cut — and the second largest percent cut — on Labor-HHS-Education.

Predictable Defunding of Health Care Reform

HHS would take a $216 million hit, as compared to its current budget. By far and away the largest part reflects a near-total block on spending related to the Affordable Care Act — a significant source of expanded health insurance coverage for birth control, as well as other preventive services.

Were the budget to become law, which it won’t, HHS could no longer operate health insurance exchanges in the 34 states that haven’t created their own — or in three others that use its infrastructure.

Hard to see how this wouldn’t mean loss of the subsidies that make health insurance affordable for low and moderate-income people — or the related measures that limit out-of-pocket costs for health care.

Low-income individuals and families could also wind up without affordable health care, including no-cost family planning services, because the Republicans’ bill effectively bars HHS from covering most of the costs of newly-eligible people in states that have expanded their Medicaid programs.

Hammering another nail into the coffin, the House bill would prohibit HHS from enforcing certain consumer protections.

These are intended to prevent insurance companies from denying coverage or charging higher premiums, based on health conditions or gender. They also require most companies to cover birth control, as well as numerous other preventive services at no extra charge.

Renewed Direct Attack on Family Planning Services

The Labor-HHS-Education bill would zero out funding for Title X of the Public Health Service Act — the source of grants to nonprofits and public agencies that provide free or low-cost family planning and certain other preventive services, e.g., screenings for sexually-transmitted diseases and for cervical and breast cancer.

They can’t use the funds for abortions. But earlier zero-funding efforts leave no doubt that House Republicans intend to cripple Planned Parenthood, which, as we all know, does perform abortions, using privately-donated funds and, in some limited cases, funds it can claim from Medicaid.

Now, I’m hardly the first to observe that if you object to abortions, then you should want women to have the option of effective, affordable birth control.

For women (and men) with incomes below the poverty line, Title X-funded services, including contraception, must, in most cases, be free. Somewhat over 70% of Title X family planning clients qualified in 2013, the latest year we’ve got official figures for.

Folding in the near-poor, we see that defunding Title X would jeopardize family planning and other reproductive health services for more than 4 million people, mostly women.

Roughly 3.5 million of them either began or continued using some form of contraception as a result of their last visit to a Title X center. Some who didn’t were pregnant or wanted to be.

Anti-Anti-Poverty Choice

Brookings Institution economist Isabel Sawhill has persuasively argued that encouraging and enabling women to deliberately choose motherhood, rather than just “drifting” into it is a more realistic poverty prevention strategy than the patently unsuccessful efforts to promote marriage.

The end result would be fewer poor single mothers — thus fewer children growing up in poverty, with all the disadvantages that entails. Fewer women forced to compromise education and career goals too. Fewer at risk of depression and perhaps abuse.

Yet LARCs (long-acting, reversible contraceptives) — the surest protections against unplanned pregnancies — can reportedly cost as much as $1,000, counting only one followup visit after the initial insertion procedure.

That’s a formidable barrier for low-income women — or rather, would be without effectively enforced ACA requirements, expanded Medicaid coverage and family planning services covered by Title X.

What Next?

It’s doubtful that the final budget for the upcoming year will deny all funds to Title X. The Senate’s Labor-HHS-Education bill — still in an earlier stage than the House bill — would allocate $257.8 million to the program.

This, however, would represent a cut of roughly $27.8 million. Even level funding would almost surely mean less available for services because program costs rise, much as our own living costs do.

What next year’s budget will look like is anybody’s guess, especially because the President has said he’ll veto any spending bill that reflects the caps.

Meanwhile, Senate Republicans — not quite all, however — have decided to make a cheap political gesture, before the pseudo-scandal stales, by denying federal funds of any sort to Planned Parenthood — the largest of our nonprofit family planning providers.

“[H]ard to see other clinics stepping in to fill the gap,” Vox health care blogger Sarah Kliff remarks. Indeed. We probably won’t see that sort of gap, however — at least, not right away.

But we won’t see enough funding for affordable family planning and other preventive healthcare services either.

UPDATE: I’ve learned that the Senate Labor-HHS-Education bill has cleared the full Appropriations Committee. So it is as far along as the House bill.