Tag Archives: Repeal and Replace

Rest and Repair: Going Forward With The ACA

Breathe, regroup, and re-enlist in the movement to #Resist the egregious GOP agenda to dismantle the 20th century.  The health insurance bill was the first fight, but it won’t be the last.

First, expect the GOP to repeat ad nauseam all the old talking points about the Affordable Care Act, and to keep working in the background to eliminate key elements of health care assistance, and we need to be prepared to counter them.

“Premiums have skyrocketed”Counter: While there are some states in which premiums for health care insurance have increased dramatically, there are others like Indiana and Rhode Island in which premiums have actually decreased. Nevada’s increase was a modest 8% when compared to pre-ACA rate increases.  [See KFF chart for all 50 states.]  Counter: Premiums are only part of the consumer costs.  If an insurance policy offers low premiums, but includes higher co-payments and deductibles then it really isn’t “cheaper.”

“Democrats want to bail out the Health Insurance Corporations.”  The Republicans used this line when attacking the legislation to get ourselves out of the Great Recession, the product of unfettered financialism on the part of investment banks. This line has served them well, and Senator Dean Heller (R-NV) utilized it almost constantly to impress Nevada voters with his “independence” when bragging about how he voted against “bank bailouts” in the Dodd Frank Act, legislation which applied common sense regulation to investment bank practices.

A much better frame for this argument from the pro-ACA side would be that we want to stabilize the insurance markets.  Including a re-insurance element to the ACA would be helpful.  There is a way to introduce these topics without resorting to protracted arcane discussions about the nuances of the insurance market:  Explain the Three R’s.  Risk Adjustment. Reinsurance. Risk Corridors.

Government is forcing people to buy insurance they don’t want.”  I’m fond of hauling out my auto insurance — even though I’m fully aware of the fact that this is far from a good analogy.  I have one vehicle which works and one that doesn’t.  For the one that works I have a comprehensive policy, and for the one that doesn’t I have a basic policy.  What the ACA does is require a “basic policy.”  The old rig isn’t going to hit anyone or anything unless a tornado picks it up and moves it — but I still have some liability insurance for it. The policy pools all car owners, and basic is basic, so there’s liability insurance on a vehicle that isn’t moving and isn’t going to without a tow truck.  (Please don’t ask why I still have it…the answer is irrational.)

Individual mandates and employer mandates aren’t popular.  That’s fairly irrefutable. However, those mandates are an essential part of creating a widening POOL of policy holders, which in fact serves to help contain health care cost increases.

But everyone has access to health care…in the emergency room.”  No, all this means is that everyone has access to EMERGENCY health treatment, which, as we all know is the most expensive place to receive care.  Further, “having access” is not the same as being able to pay for it — thus the pre-ACA misery of personal bankruptcies and hospitals with disturbing amounts of uncompensated care on their books.

Secondly, have a plan.  A plan to address specific needs for specific problems.  If health care costs are rising faster than other consumer needs, then address this directly.  (1) Allow the government to negotiate prescription drug prices for Medicare the same way the VA negotiates prices for veterans’ medication. (2) Incentivize prescription drug research while limiting excessively high prices.  This sounds impossible, but really isn’t.  A paper from the Brookings Institution (pdf) explains how this might be accomplished.   If about $1 out of every $6 spent on health care is related to prescription drugs, holding the line in this realm would be helpful.  (3) Allow the importation, or re-importation, of medication.  This probably isn’t as efficacious as some of the other proposals, but it, too, could be helpful.

(4) Encourage practices which yield better health care outcomes.  Thus far we have a system which pays for services rendered — as it should — however, efforts to study and promote best practices.  This is a component of the ACA and one that should be publicized more effectively.  (5)  Emphasize preventive medicine.  This, too, is an element incorporated into the ACA, and deserves more attention.  It’s far better for all concerned to promote annual health check ups, healthy lifestyle and nutrition programs, and vaccinations than it is to cover the costs of heart attacks and preventable diseases.  The insurance corporation doesn’t have to pay out the claims for the heart attack, the hospital doesn’t risk providing uncompensated care, the physician doesn’t run that same risk, and the person who avoided the heart attack in the first place is working and continues being a productive member of society.

(6) The slippery slope message is already in the public domain.  “What the Democrats really want is ‘single payer.’” Yes, some do.  The Republican cognitive dissonance hits the surface when some conservatives decry socialized medicine while famously exhibiting their “Get Government Hands Off My Medicare” signs.  However, this argument is both accurate and speculative at the same time.  Some Democrats are, indeed, in favor of single payer. Some are more likely to support a public option where private corporations are reluctant to enter the private health insurance market.  Others would simply prefer to sustain the present health insurance exchange marketplace system under the current provisions of the ACA.  There’s no monolithic, lock step, Democratic position on this issue, which is both a political problem for massing support for a specific proposal, and a political opportunity to let local voters select the candidate who best represents their views.

Third, we need to recognize that “repeal and replace” was never a serious proposal in the first place.  Had it been serious, then surely in the seven years since the passage of the ACA the Republican party would have come up with something more substantial than cutting Medicaid, limiting jury awards for malpractice, defunding Planned Parenthood, and giving tax breaks to the ultra-wealthy among us.  They were perfectly happy to vote in favor of complete repeal of the ACA until the burden shifted to their own backs, then the GOP controlled Senate couldn’t come up with 50 votes for a sham bit of legislation no-one wanted.

Slogans are effective public relations, but they are woefully inadequate policy proposals.  No, the ACA isn’t “socialized medicine.”  If it were then the Heritage Foundation wouldn’t have provided the framework of the plan as a response to Hillary Clinton’s health care proposals back in the ’90s.’  Granted, the Heritage Foundation didn’t include increasing Medicaid coverage, and it did include ‘tort reform,’ but the other similarities are striking even if hard-line Republicans in 1993 opposed the bill based on the framework, and it never came to a floor vote.

The GOP Zombie Bills may be gone, but the fight isn’t over.  And the obese ladies who would do better to follow the advice given by their doctors (covered as part of the ACA mandated insurance) aren’t yet singing.

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Filed under Health Care, health insurance, Medicaid, Nevada politics, Politics

Heller at the President’s Right: Lunch Time At The White House

Nothing like watching Senator Dean Heller (R-NV) sitting next to POTUS, smiling and applauding as the remarks from the President replicate every standard talking point made by every Republican since the passage of the Affordable Care Act.  Including such wonderful clichés as:

You’ll pay lower premiums (Oh, such lower premiums you won’t believe) — Any fool can sell low premium policies, the ones with high deductibles and co-pays, limited benefits, and caps.  Worse still, these junk policies will be sold across state lines so that consumer standards and protections of the worst level of protection will be the standard.

The states will have control over Medicaid (smaller units will be better for individual needs)  Nothing like blowing a big wide ‘beautiful’ hole in the Nevada budget!  Cutting $770B from Medicaid will have effects far beyond Nevada’s capacity to support its elderly, its children, its rural health care facilities, its support for low income working families.  That was the point of Medicaid — expenses far beyond the capacity of individual states could be shared nationwide, allowing medical care and services for the greatest good for the greatest number.

Some counties only have one insurance corporation offering policies in the individual market.  Did the president recall that before the ACA there were some counties that had no insurance corporations offering policies in the individual market.  There’s a solution to this problem — one the president didn’t mention — establish a public option.

Then there flowed the usual barrel of platitudes and campaign rhetoric, freedom and flexibility, low cost with high coverage,  everyone can get better insurance, reduce burdensome taxation, burdensome regulation….

And there was Senator Dean Heller, smiling as though siding with the president isn’t going to be a major political problem for him in the 2018 campaign season.  It makes a person wonder.

Senator Heller can be reached at 202-224-6244, 775-686-5770; 702-388-6605

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Filed under Health Care, health insurance, Heller, Politics

Myths and Legends: The Medicaid Issue in Nevada

There was a Republican politician on my television screen this morning telling me, or trying to tell me, that Medicaid was “meant for mothers, children, and those who couldn’t work…” This is outdated. Then, he tried to convince me that Medicaid was being “abused” by those who work and ‘game the system,’ while spouting platitudes about the Free Market and the Joys of Competition.  Let’s start at the very beginning.

This is the explanation of Medicaid as reported by Nevada’s Division of Health Care Financing and Policy (pdf)

“Medicaid is the nation’s main public health insurance program for people with low incomes and the single largest source of health coverage in the U.S.”

The program is meant to help people with low incomes.

“The PPACA extended coverage to many of the non-elderly uninsured people nationwide. The June 2012 Supreme Court Ruling made Medicaid expansion optional for states, and Nevada elected to join the expansion and maximize federal dollars. Effective January 1, 2014, this move broadened Medicaid eligibility to nearly all adults under age 65 with income at or below 138% of the Federal Poverty Level (FPL). At the end of SFY 2014 that meant that there were an additional 125,989 new enrollees in Nevada Medicaid, and increased expenditures of $154,816,777.00. These new expenditures are 100% federally funded.” [NV med pdf]

Medicaid expansion added those working Americans who were earning 138% of the poverty line and below, (pdf) and more specifically: (1) Those between the ages of 19 and 64 who are earning less than 138% of the FPL. (2) Pregnant women in homes earning less than 165% of the FPL. (3) Children from birth to 19 years of age in homes wherein the earnings are at or below 205% of the FPL, with a small premium required in some cases. Translated into real people with real levels of low income earned, this means a family of four would be eligible for Medicaid in Nevada if the family earnings are less than $2795 per month; for pregnant women if the earnings are at or less than $3341 per month; and families are eligible for the kids’ Check Up program if family earnings are less than $4151 per month.

If we calculate annual earnings, then monthly earnings of $2795 mean an annual income  of $33,540. At $3341 annual earnings of $40,092, and at $4151 annual income of $41,630. Nevada’s median income is $52,431 (2015). To put these numbers in perspective, the average weekly wages of a person working in a private restaurant in this state are $382, or $1528 per month ($18,336 yearly). [DETR] The average rent for a 2 bedroom apartment in Las Vegas, the obvious site for most private restaurants, is $932 per month. [RJ] In short, not only are wages not all that generous in Nevada, the benefits available for Nevada families aren’t all that generous either.

Republicans, however, strenuously oppose benefits for adults capable of working. This would make infinitely more sense IF and ONLY IF they were willing to support a living wage for all employees. One really doesn’t get to have it both ways.  Either you want a reduction in benefits that most working people can afford to purchase on their own because they have the financial resources to do so, or you want lower wages which mean that individuals and families cannot afford those things, like health insurance, and the public benefits are required to make up the difference.  However, at this point we slam into another GOP myth.

Free market competition will make health insurance affordable for everyone, even those who are working in low wage jobs.  Good luck with that. Personally, I have yet to hear anyone explain with any specificity why health insurance corporations will be flocking to Clark, Washoe, or even Esmeralda counties because there is more “free market” applied to the situation. If the insurance companies weren’t wildly excited about selling individual and family health insurance before the enaction of the ACA, why would they do so now? Unless, of course…

They could sell policies that didn’t cover all that much? That cost more for those between the ages of 50 and 64?  That didn’t cover maternity expenses? That didn’t cover preventative care? That didn’t cover drug rehabilitation and mental health services in parity with physical treatments? That only covered the items required in those states with the least consumer protections? And, even then all we have to look to is the situation in Nevada when insurance corporations were free to offer what they were pleased to call comprehensive policies.  Again, if they weren’t interested in selling a plethora of individual and family policies then why believe they would be now?

And that Free Marketeering? It doesn’t work in the health care industry:

“In a free market, goods and services are allocated through transactions based on mutual consent. No one is forced to buy from a particular supplier. No one is forced to engage in any transaction at all. In a free market, no transactions occur if a price cannot be agreed.

The medical industry exists almost entirely to serve people who have been rendered incapable of representing their own interests in an adversarial transaction. When I need health services I often need them in a way that is quite different from my desire for a good quality television or a fine automobile. As I lie unconscious under a bus, I am in no position to shop for the best provider of ambulance services at the most reasonable price. All personal volition is lost. Whatever happens next, it will not be a market transaction.” [Forbes]

The only thing I can say with any certainty is that the Republicans have little idea exactly what constitutes a Free Market, and instead are waving it like a banner crovering their underlying desire to be free from the moral requirements compelling us to be our brother’s keepers.  The range of misanthropic explications are appalling, from “we need not do anything because the poor will always be with us anyway,” to “when Jesus told us to provide for one another he only meant fellow Christians.”

The Repeal and Replace campaign is as void of humanity as it is of understanding of the reality of most family economics, and of the comprehension of what the term ‘free market’ actually means.

 

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