Saturday, July 29, 2017

Sabotaging the Affordable Care Act (Obamacare) – Revisited

“From the beginning, I have believed that Obamacare should be repealed and replaced with a solution that increases competition, lowers costs, and improves care for the American people… The so-called 'skinny repeal' amendment the Senate voted on today would not accomplish those goals.”  
Senator John McCain (R- AZ) after casting the deciding vote defeating the ACA “Skinny Repeal” on July 28th.

“3 Republicans and 48 Democrats let the American people down. As I said from the beginning, let ObamaCare implode, then deal. Watch!”  
Donald Trump’s July 28th continuing tweet/pledge to sabotage the ACA after Senate defeat ACA “Skinny Repeal.”
The early morning Senate vote on July 28th had three brave Republicans refuse to follow a highly pressurized effort from the GOP leadership to force a bill they absolutely acknowledged was a “bad bill.” 49 other Republican Senators believed that had the “Skinny Repeal” passed, it would simply return to the House without a genuine chance of passage until there were a conference committee review to implement a significant rewriting of an obvious inadequate and “bad bill.”
Of course, there were no guarantees that the House might not have passed the “bad bill” intact or that the conference committee might just fail to do much of anything. The 'skinny repeal' bill would have repealed individual mandates, and according to the non-partisan Congressional Budget Office raise premiums by 20% by 2018, and leave 16 million more Americans uninsured by 2026. John McCain cast the deciding vote sending the Skinny Bill to the pre-dug grave it richly deserved.
The following is an edited version of my June 10th blog (of the same name) and my July 19th “Let Obamacare Fail” blog. When the Affordable Care Act (ACA or Obamacare) passed in 2010 through a Democratic Congress and was signed by a Democratic President, there was no exception. The “just expand Medicare and offer it to the people” faction was shot down by the big insurance carriers who did not want to face additional competition from a government-provided alternative. That universal insurance “mandate” was both (i) a necessary part of creating a sufficiently large risk pool and (ii) to placate insurance carriers that they would grow their business as a result. The big pharmaceutical special interests were terrified that large new health insurance exchanges would have the effective bargaining power to force those behemoths to drop their prescription drug prices. So the ACA exchanges were barred from challenging those hyper-expensive drug prices; they had to pay full price.
Is this the end of the story about the GOP’s seven year effort to destroy Obamacare, literally forcing passage of their obviously inadequate AHCA (the GOP-proposed “replacement” American Health Care Act that is deeply punitive for anyone with expensive medical issues from preexisting conditions) and lower-income Americans, even with the various (failed) Senate reconciliation efforts (e.g., the Better Care Reconciliation Act, the “Skinny Repeal” and various proposed add-ons)?
Their goal – and the clearly-announced current goal of the Trump administration – was/is to subvert the ACA by not enforcing its provisions – particularly funding from both user and government sources – literally forcing the system to fail. By sending mixed messages to insurers, the second vector is to destabilize the overall insurance marketplace, pretty much eliminating the ability of big medical insurance carriers to plan and sustain viable operations within the existing networks of healthcare exchanges.
GOP ACA repeal-advocates faced trending reports that Obamacare was stabilizing, that those massive premium increases in states with limited operating healthcare providers in that exchange network were fading from the headlines. But rather than accepting this as good news, Republican ACA repeal-advocates, with massive assistance from the Trump administration, simply redoubled their efforts to push insurance carriers out of the system. They turned the solid ground of a working healthcare system into a quicksand of unpredictability.
Insurance companies, doctors, hospitals, and healthcare organizations at every level joined millions of constituents to decry the each of these GOP proposals. Town hall meetings became intolerable venues for Republican member of Congress visiting their home base. Many GOP governors raised their voices in protest, literally making it impossible to pass the GOP “repeal and replace” or even a naked “repeal” bills; the necessary GOP Senate majority would never materialize.
But the Donald Trump administration has been anything but subtle in their commitment to make sure that the ACA fails. The President’s sabotaging tools include refusing to reimburse insurance companies for reducing low-income customers’ out-of-pocket costs to making sure that the Department of Health and Human Services fails to enforce the mandate that most Americans have health coverage, thus decimating the basis for insurance companies to remain in the system. By constantly trashing the ACA and threatening its extinction, Mr. Trump creates (still active) an atmosphere where insurance companies can no longer plan their own futures, an intolerable situation for them.
“The Trump administration already cancelled $5 million in ads that advertised the upcoming enrollment season, and the president is now threatening to withhold federal payments that help reduce insurance premiums — particularly for low-income people — and keep companies in the market…
“‘If the President refuses to make the cost sharing reduction payments, every expert agrees that premiums will go up and health care will be more expensive for millions of Americans,’ [Senate Minority Leader, NY Democrat Charles] Schumer said in a statement. ‘The president ought to stop playing politics with people's lives and health care, start leading and finally begin acting Presidential.’”, July 29th.  On July 29th, Trump tweeted: “If a new HealthCare Bill is not approved quickly, BAILOUTS for Insurance Companies and BAILOUTS for Members of Congress will end very soon!” With the Skinny Repeal down in flames, the chances of such a plan materializing anytime soon are between slim and none, and the President knows that. By ignoring the legal requirements of the ACA, however, the President believes he can force that healthcare plan to fail.
Simply, Trump believes that no matter why the ACA might fail (even if it is through his overt sabotage), (a) he can blame the Democrats and (b) therefore, Americans will eventually beg for the inferior healthcare package that was so soundly rejected by the Senate in recent days. So he is simply going to make sure it fails… and is hardly shy in saying so. Senate Majority Leader Mitch McConnell, a savvy politician, seems to have accepted that repeal of the ACA and that it is time simply to “Move on.” However, it is increasingly likely that if Trump does force that sabotage by not adhering to the ACA, he and the GOP will “own” the chaos that would follow, as much as he believes he can shift the blame to the Dems.
The healthcare reality in this country is pretty nasty. Even with the ACA, a dramatic improvement from what preceded passage of that statute, here’s what we still face today, even with more people covered under the ACA: “In 2015, the United States spent almost three times on healthcare as the average of other countries with comparable incomes, according to data from the Organization for Economic Cooperation and Development, also known as OECD, a group of 35 countries, the majority of which have advanced economies, that works to promote economic development.
“And despite spending more, the U.S. results don’t necessarily yield better health. Both Italy and Britain, for example, spent at least $5,000 less per person than the United States on healthcare, and yet the population of each of those countries has a higher life expectancy at birth than the United States…
“[The] the United States spends more on healthcare than any other country, including those belonging to the OECD… ‘[But] we definitely have worse health outcomes,’ said David Squires, president of the Commonwealth Fund, a private foundation based in New York that carries out independent research on healthcare issues.
“‘It doesn’t appear that people in the U.S. use more healthcare in general. We go to the doctor less often than people in other countries and get hospitalized less, so it’s not like we are making greater use, but we are paying more for the things we do use,’ he said…. Despite investing heavily in healthcare, Americans live shorter lives than people in 30 other countries, data from the World Health Organization showed.” Los Angeles Times, July 19th. We spend a whole lots more for the same treatments and prescriptions. Without greater access to controlled healthcare, we will continue to fall in those comparisons. Let the ACA fail and those negative statistics will overwhelm us. But that Trump’s plan: make sure the ACA fails, with more than a push and a shove from his administration. The President has repeatedly tweeted and stated openly and publicly that his administration will not support many of the provisions of the ACA
The Chicago Tribune (June 7th) explains, starting with the latest carriers to throw their hands up in frustration: “A major shoe dropped in the battle to preserve the Affordable Care Act on Tuesday [6/6], as Anthem, the nation’s second-largest health insurer, announced it is withdrawing entirely from the individual market in Ohio.
“The move will leave 18 counties without an insurer in the ACA exchanges, leaving an estimated 10,500 Anthem customers high and dry — most of them in Appalachia, among the poorest parts of the state.
“Anthem said in its announcement that the principal causes of its withdrawal are ‘the shrinking individual market as well as continual changes in federal operations, rules and guidance.’… That’s a reference to the uncertainty surrounding President Trump’s vagueness about whether he will approve subsidies for deductibles and co-pays for the poorest Obamacare enrollees and whether his administration will continue enforcing the ACA’s individual mandate in 2018.
“The ‘increasing lack of overall predictability,’ Anthem said, ‘simply does not provide a sustainable path forward to provide affordable plan choices for consumers.’… Anthem’s action in Ohio is its first withdrawal from a state thus far, but bodes ill for customers in the 13 other states where it offers ACA plans, including California.” Other carriers either followed suit or threatened to withdraw based on this Trump-effort to destabilize the insurance market.
Senate Minority Leader, Chuck Schumer (D-NY) and Majority Leader Mitch McConnell (R-KY) may now be willing to sit down and hash out a workable solution to this healthcare debacle, the path John McCain so eloquently argued in his July 25th Senate speech, appearing after significant surgery addressing his advanced cancer treatment: “Why don’t we try the old way of legislating in the Senate, the way our rules and customs encourage us to act. If this process ends in failure, which seem likely, then let’s return to regular order.”
What can be done? Republicans want more market competition? That makes particular sense in states where there only one healthcare exchange (or less) is available. Allow states with two or fewer exchange carriers to combine with other such less-populated states to create cross-border coverage. How about allowing healthcare exchanges use their bargaining power to reduce pharmaceutical prices… and let Americans purchase their prescriptions from certified nations where quality control is not an issue: European Union, UK (when it leaves the EU), Switzerland, Canada, Australia, New Zealand and Japan. If the GOP wants to eliminate the individual mandate, then they have to maintain Congressional funding of insurance shortfalls and perhaps increase deductibles on people who drop out of coverage or just wait until they are sick or injured to buy a policy.
Do we need reasonable access to healthcare after decades where over 45 million American were not covered? Look at the above mortality rates that we faced at the beginning of the implementation of Obamacare. We had the highest in the developed world. This would suggest that any body of government officials trying to reduce healthcare coverage in the United States are effectively a new incarnation of a death panel. Will bi-partisan cooperation save the day? Will that joint cooperation really happen? Is Donald Trump simply on the wrong side of history?
I’m Peter Dekom, and we should all hope that a bi-partisan effort to solve our healthcare crisis happens… and that it is just the beginning of an end to Congressional gridlock… or it will get a whole lot worse for all of us.

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