"Collapse and Replace"

 

"President Trump has said himself on numerous occasions that Republicans could simply let Obamacare die on its own, allowing Democrats to continue to pay the political price for it. But then he always clarifies that the GOP won't do that.

"I actually talked with [House Speaker] Paul [Ryan] and the group about just doing nothing for two years, and the Dems would come begging to do something because ’17 is going to be catastrophic price increases ... and they will come to us,” Trump said in January at a Republican retreat, adding: "If we waited two years, it will explode like you’ve never seen an explosion."

That idea was also pushed Wednesday by a sometime Trump foe, Sen. Lindsey Graham (R-S.C.). On Hugh Hewitt's radio show, Graham suggested letting Obamacare "collapse" on its own. "Here’s what I would prefer he do," Graham said of Trump. "If he can’t get us in a good spot where we all feel comfortable, we’ve improved Obamacare dramatically, which we told people we would: Let it collapse."

When Hewitt pushed back on the idea, Graham added: "Democrats are not going to lift a finger to help President Trump. I would do collapse-and-replace if you can't get a good, solid fix to Obamacare using reconciliation.""   Washpost

 ---------------

Graham supporting Trump?  Cats and dogs sleeping together?  How can this be?

Do the Republicans really have a choice?  They are in complete disarray internally with regard to the terms of  a replacement law.  There are various bits of tax law embedded in the present Affordable Care Act (Obamacare).  This supposedly blocks Trump proceeding to a proposal to revise the federal tax code, a measure IMO essential to Trump's hope for an economic boom.

If I were Trump, I would let Obamacare die a seemingly inevitable death and move on to tax reform.  pl 

https://www.washingtonpost.com/news/the-fix/wp/2017/03/16/let-it-die-what-if-the-gop-just-waited-for-obamacare-to-wither-on-the-vine/?utm_term=.26fe8dd06f08

Comments

[r whitman]

Obamacare wont die on its own. That's just Republican propaganda. While its not flourishing it still has plenty of users. Most of the premium increases are negated by subsidies. Those users in counties where there is only one insurance company have the best of all possible worlds--a single payer system like Medicare or Tricare or the VA with the premiums subsidized.

Do not believe the Republican mantra that that that the ACA will die on its own.

[Edward Amame]

Except that Lindsey G is full of sh*t. The latest CBO report disagrees that the ACA's imploding (they say it's stabilizing). It's covering more than 20 million people at a lower cost than originally projected. The problems it faces could be addressed pretty inexpensively but won't because this is all politics all the time here in the USA in 2017. Col Lang's prescription for GOP butt-saving certainly would have made sense politically -- it's what the GOP basically did as the oppo party to try to make it fail -- except that the GOP spent 7 years demonizing it and now they're stuck between a rock and a hard place. "Who knew governing could be so difficult!?" Couldn't have happened to a more deserving crew.

As for what Pres Trump will do: not lead. My prediction is that he will do what he thinks is good for Pres Trump and leave Ryan or whoever out to dry if that's what it takes. There will be no attempt to work with Dems.

[Dante Alighieri]

I agree with Mr whitman that Obamacare isn’t gonna die. That is a typical Trumpian delusion, which has many more delusions in its tow. It is striking how much those delusions resemble the Obama delusions with reverted signs. Why is it so hard to tell you Americans you didn’t elected The Savior? Is it really so hard to see?

[asx]

Obamacare will not implode quick enough to give Trump a clean sheet for tax code reform. And RyanCare is a clear rollback of the entitlement levels with even the CBO projecting a $300B+ reduction in federal deficit over 10 years. It is a hard sell politically. We need a fix ASAP or we will see an alaming increase in mortality for the under-65 crowd which will get culled before reaching the promised Medicare land.

I am disappointed that there is no attack on predatory pricing of medical services in the works. Any Obamacare variant will need some/all of the following to be viable.

1) Separation of Basic Preventive and Wellness based health services from chronic/palliative/end-of-life health care. Allow young and healthy people access to a health system that will keep them healthy without forcing them to subsidise high risk customers. This should cover regular medical check ups and broken bones. Full disclosure: I am neither young nor without health issues.

2) Pricing protection for uninsured a la carte customers. The practice of billing $500 for a regular check up and getting paid $90 by the insurers hurts walk in customers. If someone uninsured can pay at the point of service, they should not have to pay more than the insurance company average for the same service.

3) Allow importation of drugs and medical professionals from Canada and other countries which have a well regulated system for healthcare. The U.S. customer and government being the largest, should not meekly pay retail prices for any drug/provider as a subsidy for the industry.

For the Trumpists, apply the same logic we are using for our NATO partners. Why should we pay more to the manufacturer for a drug than Canadians or Germans? Aren't we subsidizing their healthcare costs, in addition to their defense?

Team up with Bernie crowd and identify which medical service/device/drug has seen astronomical price inflation without significant new R&D effort in that area. Our costs are what has made medical tourism a fast growing industry.

4) Recognize that a weed epidemic is better than the current opiod epidemic. Get off the high horse and end the war on weed. And start a war on prescription opiods and its peddlers.

5) Sessions and team need to drop the hammer on medical malpractices in billing and bogus unneeded services. And FTC should require all advertisements about public health to clearly list the sponsors. Mammograms do not exist to provide livelihood to the lab techs.

6) No mention of Taut reform in RyanCare as a way to trim costs.

[turcopolier]

EA

So, if the GOP (temporarily) abandoned the effort to repeal the ACA, the Democrats would accept that? pl

[Karl Kolchak]

...Graham said of Trump. "If he can’t get us in a good spot where we all feel comfortable..."

Ironically, getting powerful men in a good spot where they feel comfortable is how political whore Graham got his Senate seat in the first place.

[Lars]

I agree with all the wishful and wrong thinking. For better or worse, healthcare policy is now owned by Mr. Trump and the GOP, even if they do nothing. Should they decide to create a bi-partisan solution with wide support in both parties, they could get this issue settled for a long time. But the chances that will happen is slim to none.

[Eric Newhill]

Sir,
I agree. I don't understand what the Republicans are trying to do. The ACA will be dead at the end of 2018 if things are left to the current course.

As always, I qualify my comments on healthcare by stating that I have worked almost 20 years as an actuary/healthcare economist for both not-for-profit Blue Cross/Blue Shield companies and for profits. The last 6 years for one of the major nationwide carriers and currently, and in 2016, on that company's ACA/Obamacare products. My team is in the cost driver and financial data. We analyze that stuff and report to the executives.

The ACA is absolutely dying on its own. Our CEO has been meeting with Trump and the result is that talking about not carrying ACA products in 2018. Read into that what you wish. There is more I could say about this, but am not at the liberty to do so. The other big players have already pulled out or are prepared to do. We are losing way too much money on the ACA and if we increase premiums anymore - which we'd have to - then we will be stuck with even more adverse selection and moral hazard with healthier people priced out of the market and deciding to forego coverage.

Most of our members are not subsidized (premiums) or are subsidized at insignificant levels.

The only viable replacement is a combination of the following: 1. Federal aid to expand Medicaid 2. Put people with serious, chronic, expensive conditions (e.g. end stage renal disease, hemophilia, aids) on Medicare, regardless of age. 3. Remove ACA benefit requirements so that individuals and small groups can purchase affordable high deductible catastrophic policies. These should be combined with pre-tax/tax free health savings accounts (HSAs).

Maybe....just maybe the ACA could continue more or less as is **if** the feds reinstated the reinsurance program at set the reinsurance back to $45k (was $45k, then $90K in 2016 and ceases to exist in 2017) and they tweaked the risk adjustment program (reimburses carriers for taking on higher risk) to give back more to carriers. However, doing so will hit the federal budget hard and I don't see that happening (apparently neither does our CEO).

Everything else discussed is bunk and hot air.

[Edward Amame]

Col Lang

I think the Dems would be happiest if efforts to sabotage it stopped post haste and instead efforts were made in good faith to try to make improvements where needed, but that will never happen. If the ACA were allowed to proceed as is, even temporarily, they'd probably breathe sighs of relief. But I'm not sure that can happen either.

Essentially the CBO's saying that the current Ryan bill that would become Trumpcare will benefit young urban Hillary voters and harm older rust belt Trump voters. Trump's in a bad position. He needs to say the hell with ideology and stand up to the GOP. Maybe he should listen to the advice of his friend/editor at NewsMax who suggests he go bi-partisan and push for an upgraded Medicaid system that would become the country's blanket insurer for the uninsured.

[r whitman]

The Dems are as screwed up and poorly led as the Repubs.

[Robert C]

It won't die. In 5-10 years data may be available indicting decreased morbidly and mortality in those who chose to sign up compared to those who didn't .

[Eric Newhill]

Edward,
I think it is more like 12.5 million that are enrolled in the ACA in 2017 - not 20 million.

The problems it faces could be addressed inexpensively? I am curious as to what you think the problems are and how they would be addressed and how you have assigned a cost to your solutions.

I don't know exactly what the CBO says and don't much care. The problem from where I'm sitting is that the private insurance companies that carry the product are losing money hand over fist on the ACA. As in paying out much more to cover the members' medical expenses than they have coming in from premiums + federal govt cost offsetting programs like reinsurance (sunsetted in 2017) and risk adjustment. Therefore, the private companies will cease to carry the ACA products. This cessation has already begun and will hit big time in 2018.

Premium increases occur to try to make up for the above mentioned loss. However, that is a double edge sword. If premiums increase too much, then the only people willing to pay them are those that know they will be incurring cost in excess of the premiums. That is an actuarial death spiral and we in the industry are aware that we have already entered into it. Hence, simply decline to carry the ACA.

It was the no pre-existing conditions exclusions law and wide enrollment periods that really did the harm combined with minimal penalty for not having insurance. The healthy are far better off simply paying the little penalty. Those with pre-existing conditions could sign up, get the care they needed and then drop coverage. Repeat as needed. That is not insurance; anathema to it actually.

I don't recall stepping over dead bodies on the way to the store all the way back in 2012 before the ACA. People with pre-existing conditions could always get insurance, they just had to wait a period of time being receiving insurance paid for care on those conditions. I don't know why there's going to be a massive die-off of Americans now if the ACA is repealed or fails. That's another one you can explain to me.

[turcopolier]

Eric Newhill

I have said before that I personally favor a single payer system like that of Canada or France. What is the French system like? pl

[Eric Newhill]

Sir,
I know little to nothing about the French system. Personally, I think the Australian system does a pretty good job. I know a lot about it. Sound economic principles applied there.

I too think that a single payer system would be best *if Americans would come to understand and agree, before implementation, that they are going to be getting a Ford Taurus and not the Cadillac that many are used to*.

In fact, I think it is permitted for me to say that, at least in the company I work for, it is recognized at the top level, that the current US system, such that it is, is not sustainable. Furthermore, we would like to work with the govt to bring about the inevitable change in a rational manner. I believe that the future will be a socialized system with all citizens covered administered by private companies. This would look like Medicare Advantage for all. The US, as you know, is a big, populous and regionally diverse country - unlike France - and the private companies' expertise in contracting acceptable rates with providers is needed. This makes sense to me. When will it happen? No idea, maybe within ten years to fifteen years.

[turcopolier]

Eric Newhill

Perhaps our Australians could explain their system. pl

[Nancy K]

I agree completely, single payer is the way to go. Members of congress should also have the same insurance as the rest of us. We could all pay according to how much we make or don't make or it could be taxpayer supported much like Medicare is now.
It is just wrong that in a nation as rich as we are and as so called advanced that people can die due to lack of or inadequate medical care.

[Edward Amame]

Eric Newhill

Yup, UnitedHealthcare got clobbered but 2016 was the first year where policies got priced based on real info, since exchanges didn't exist prior to 2014. Bad strategic decisions got worked out via course changes or getting the hell out of the market. So 2017 looks like it could be (have been?) better and some insurers are even making $$$ on Obamacare.

How could problems get take addressed inexpensively? Adding the public option would be a good start.

[Edward Amame]

Eric Newhill

If what you wish for came to pass I'd be thrilled, but I don't see that happening in this country until pragmatism trumps ideology.(pun intended) No new "entitlements" and all.

[petrous]

R Whitman,
you are correct. The implosion & death are at best exaggerations or maybe a bit of wishful thinking. The main aim is to scare participants away (both providers & users). Ads were pulled before the inscription period ended exactly to ensure that. It has problems and needs some tweaks to be sure. Yet it is not on its death bed.

http://www.vox.com/policy-and-politics/2017/3/14/14921594/obamacare-implosion-ahca

[petrous]

Gentlemen
Here is an excellent article, non partisan, with data and excellent charts about what ails our healthcare system and where we stand and which way we might head if we want to improve it.

http://www.moneyandbanking.com/commentary/2017/3/12/improving-us-healthcare-and-coverage

[Fool]

EA

Counterpoint: one could argue that the ACA, being a pretty bad bill all things considered, cost the Democrats. (Something that's been lost amidst the post-election hysteria is that during the same week of Comey's infamous October surprise ACA premiums jumped an avg of 25%.) Maybe, then, the Dem's sigh of relief is that now the ball is in the Republicans hands; the latter made their bed -- campaigning against ACA across the board -- and now they have to sleep in it.

Second, I notice here and above you cite the CBO's findings. In fairness, though, the CBO as an agency is pretty ideological (neoliberalism), which tends to reflect in its prescriptive forecasting (generally: austerity). This is particularly so in their analysis of healthcare, which they view as essentially a consumer good ("choice") as opposed to a natural right that a country owes its citizens (among other ideological assumptions about the fed budget).

In any case, i think we agree: to hell with ideology. An expansion of medicare/medicaid would be practical.

https://www.washingtonpost.com/national/health-science/average-premiums-for-popular-aca-plans-rising-25-percent/2016/10/24/3adbb734-9a12-11e6-b3c9-f662adaa0048_story.html
http://www.nakedcapitalism.com/2014/02/jeff-madrick-cbo-cant-trusted.html

[doug]

This is really what needs to be done. The current state of American healthcare is a prime example of socialism meets capitalism with many actors at the trough. All with big financial interests and lobbying money to toss around.

The socialism aspect is from government induced insurance tax benefits for employers and employees so the cost is both not visible and subsidized by the tax structure. Also, the poor are covered by Medicaid and the young, lower, middle class just opts out knowing that they will not be turned away from emergency care which is government mandated regardless of insurance or whether you can pay. Sure you can be billed at ridiculous markups for walk in or emergency care. Far above what insurance pays. OTOH, few people without insurance wind up paying their bills and even when they show up as a collection on credit reports medical collections are not considered the same as other collections and don't as negatively affect people's ability to obtain credit. So overall is there any cost decisioning that goes into it? No. You can see this if you are ever getting treatment in a hospital. No one has any idea what any cost is. They just offer treatment options. You can choose to do this or that and later someone will send you a bill but good luck trying to get that at the time.

And on the capitalist side insurance companies may want to hold down some individual cost, but collectively, they benefit from rising overall costs since their net profit is generally capped at a percentage of the total billings made.

The incentives of big pharma are obvious and basically the rule is that any treatment that shows even the smallest "benefit" is brought into the system of insured (and uninsured) provided treatments.

Small deductible, single payer base line medical care with overall fiscal limits to limit treatments to those that have a proven benefit. AKA outcome based medicine. Roll it into medicare and let the private sector insurance handle whatever added medical/dental/eye/birth control, etc. a citizen wishes to be covered for.

[Eric Newhill]

I should add, in fairness, that although I think Trump is the best thing that's happened in US politics in a long time, his statements about "phase 2" erasing "state lines" and promoting "competition" is pure misguided BS.

Competition for what? All major insurance carriers are already competing for market share across state lines.

Additionally, insurance costs what it does because that's what healthcare services cost. It's not that insurance companies are gouging profits out of members. In fact, the activities of insurance companies lower the cost, typically reimbursing providers at 50% to 60% of what they bill (and what is paid by the uninsured). Care management and utilization management activities further reduce cost and improve quality. The insurance companies keep some of that savings as profits.

Surely he can't mean that providers are going to compete across state lines with sick people in Ohio traveling to Idaho to get a better deal on their knee replacement.

So what does it mean? I think it's just empty free market ideology air talk.

[Richard]

Yes, the problem with all the health care proposals that are being discussed is that they fail to address the issues of collusion, anticompetitive practices and predatory pricing. The health care, insurance and pharmaceutical lobbies have been very effective so far in preventing any fundamental changes.

As long as you do not start to work on these problems, US health care costs will continue growing at the rate that you have observed in the previous years (I think the average cost increase is around 6 percent every year) until you reach the point where people cannot afford it anymore and have to choose between paying for healthcare or other essentials. It doesn't matter if you have Obamacare, Trumpcare/Ryancare or a single payer system, eventually the system will implode. You can play around with the system so that richer or healthier people subsidize poorer and less healthy people more and that can buy you a few more years of time, but that does not change the eventual outcome.

[bob g]

-- Obamacare was self-destructing the day before Donald Trump was elected, and the Republican victory, with their talk of "repeal and replace," has only accelerated things.

Aetna's CEO recently said that the Obamacare insurance exchanges are in a "death spiral."--

http://healthpolicyandmarket.blogspot.com/2017/02/obamacares-insurance-exchanges-are-self.html