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What Does Congressional Gridlock Mean for the Rest of the Country?

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Joe Molloy, health policy, Congressional gridlock

By JOE MOLLOY 

Often, a Congressional gridlock is essentially good. This is because the executive arm of government is forced to consider a bipartisan approach to issues if it’s to secure the approval of both Democrats and Republicans in Congress.

The outcome of the midterm elections indicates that the Republicans have managed to retain their control of the Senate, while Democrats have secured control of the House of Representatives.

Health a Central Issue During the Midterms

According to a survey by Health Research Incorporated, the three top issues of concern during the midterm elections were health, followed by Social Security and Medicare, with 59% of the respondents irrespective of age, race or geography citing health as the most significant.

Among Trump’s electoral promises was a complete repeal and replacement of Obamacare under the Affordable Care Act (ACA) with a policy that was apparently less expensive and more effective. On his first day of office, Trump signed an executive order instructing federal agencies “to take all reasonable measures that minimize the economic burden of the law, including actions to waive, defer, grant exemptions from, or delay the implementation of any provision or requirement of the Act.”

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The November 6 Midterm Elections and Their Impact on Obamacare:Q&A

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By ETIENNE DEFFARGES

1) What is the likelihood the ACA will be repealed?

This straightforward question has a very simple answer: It depends on the results of the upcoming November 6 U.S. congressional elections.

If the Republicans retain control of both the House and the Senate, the probability that the ACA will be repealed is very high: The Republicans would be emboldened by such a victory and would most probably attempt in 2019 to repeal the health care law—again. It is worth remembering that in July of last year, the repeal of the ACA (a version of which had passed the House in May) was defeated in the Senate by the narrowest of margins, because three Republican Senators, Susan Collins, Lisa Murkowski, and the late and much regretted John McCain, voted against the repeal. This is very unlikely to happen again, although one would also have to consider the margins by which the Republican would have gained control both Chambers after these November midterms. In July of 2017, the Republicans held a 52-48 advantage in the Senate. Given ever-increasing polarization, such a margin, plus Republican control of the House, would likely spell the end of the ACA in 2019.

If the Democrats gain control of either the House of Representatives or the U.S. Senate, then the ACA will remain the law of the land. The only issue in the horizon will be the lawsuit filed in February of this year by a coalition of 20 states, led by Texas and Wisconsin. This lawsuit claims that Obamacare is no longer constitutional after the Republicans eliminated in December of 2017 the tax penalty associated with the ACA’s individual mandate. The 20 Republican attorney generals argue that without the tax penalty, Congress has no constitutional authority to legislate the individual mandate. Even if this case reaches the Supreme Court, one has to remember that the Court affirmed twice the constitutionality of the ACA, in June of 2012 and then 2015, with Chief Justice John Roberts voting with the majority on both occasions.

2) What do recent congressional changes to the ACA mean for those who buy insurance on health care exchanges?

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Please support Charles Gaba at ACASignups

By CHARLES GABA

It’s pretty rare that I ask THCB readers to go over to another blog and support that blog with money BUT, today is the day to do that. Charles Gaba has been THE leading source of information about exactly who is signing up for ACA plans on which exchange, and what impact on the ACA Trump et al have had. He’s not in academia, not on some big company or foundation payroll, just a one man band web designer who has basically torpedoed his own business to deliver what I think is a vital service. I support him and anyone interested in health policy could do a lot worse than shove a few bucks a year his way. Read on for his story & how you can help—Matthew Holt

On October 11th, 2013, I posted the following in a blog entry over at Daily Kos, where I’d been a regular contributor since 2003:

“Seriously, though, HHS should really start releasing the official (accurate) numbers of actual signups for all 50 states (or at the very least, the 36 states that they’re responsible for) on a daily–or at least, weekly–basis. I don’t care if it’s a pitifully small number. 100,000? 10,000? 100? 10? Even if it’s in single digits, release the damned numbers. Be upfront about it. Everyone knows by now how f***** up the website is, so be honest and just give out the accurate numbers as they come in.”

Two days later, on October 13th, I registered “ObamacareSignups.net” (which soon changed to ACASignups.net, not because I had a problem with “Obamacare” but because it was easier to type) and posted an announcement over at dKos, asking for some crowdsourcing assistance.

This was supposed to be just a lark…a six-month thing which would combine my passion for data analysis, politics and website development into one nerdy hobby.

Instead…well, if you’ve been following my work for any length of time, you know the rest of the story. ACASignups.net soon caught the attention of major media outlets, and it’s been cited and used as a resource ever since by media outlets spanning the ideological spectrum including the Washington Post, Forbes, Bloomberg News, Vox.com, MSNBC, the New Republic, USA Today, the CATO Institute, National Review Online and The New York Times among others, and has even received a mention (albeit an obscure one) in prominent medical journals such as the New England Journal of Medicine and The Lancet.

For awhile I pretended that this was still a “hobby”…I accepted donations, sure, and even slapped some banner ads on the site to drum up a few bucks, but in my mind, I was still officially a website developer…even though I was spending 90% of my time posting updates here instead of maintaining my business. In April 2014, at the peak of the media attention and insanity over the crazy first open enrollment period, I even came down with a nasty case of shingles whch laid me up for over a month. I was in denial for years even as the business suffered, constantly thinking that as soon as this Open Enrollment Period was over, I’d wrap things up…

My ass was effectively saved by Markos and the Daily Kos community that year, who collectively raised enough money to not only make up for my lost business in 2014, but also to allow me to keep the site operating through 2015 as well. I’m eternally grateful for that support.

In the fall of 2016, things came to a head and I realized that I could no longer continue living with one foot in each world: I had to either mothball this site and refocus my efforts on building my web development business back up…or I had to try and earn a living at it.

At the time–and I swear on my life this is true–I was planning on doing the former. My reasoning was simple: If Hillary Clinton had become President, there probably wouldn’t be that much interest in my work here going forward. There’d still be plenty of healthcare stuff to write about, but the ACA would be safely embedded into the American landscape and interest in the day to day minutiae of its developments would fade over time.Continue reading…

Misdiagnosis: Obamacare Tried to Fix the Wrong Things and Prescribed the Wrong Treatments

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David A. Hyman
Charles Silver

 

By CHARLES SILVER and DAVID A. HYMAN

Today THCB is happy to publish a piece reflecting the learnings from Charles Silver and David Hyman’s forthcoming book Overcharged: Why Americans Pay Too Much For Health Care, shortly to be published by the libertarian leaning Cato Institute. In subsequent weeks we’ll feature commentary from the right radical libertarian zone on the political game board (Michael Cannon) and from the left (Andy Slavitt) about the book and its proposals. For now please give your views in the comments–Matthew Holt

There are many reasons why the United States is “the most expensive place in the world to get sick.” In Part 1 of Overcharged: Why Americans Pay Too Much For Health Care, we show that the main reason is that we pay for medical treatments the wrong way. Instead of having consumers purchase these treatments directly, we route trillions of dollars through third-parties payers – both government and private insurers.

Relying on third party payers has many consequences — few of them good. To start with, this arrangement removes the budgetary constraint that would otherwise cap the amount consumers are willing to spend. By minimizing the direct cost of treatments at the point of sale, third party payment arrangements alter everyone’s incentives fundamentally. Consumers no longer need worry about balancing marginal costs against marginal benefits; instead, they have an incentive to use all treatments that have any potential to help, regardless of their prices. When millions of consumers act on these incentives, total spending skyrockets and consumers collectively wind up worse off, because their fixed costs spiral upward too. Heavy reliance on third party payers creates a classic failure of collective action.

It isn’t just consumers. Providers love third party payment as well. And why not? Once providers have access to the enormous bank accounts of third party payers, the sky is the limit, at least until third party payers start setting limits on the amounts they will pay and saying no to unproven and/or cost-ineffective treatments that doctors want to provide and patients want to receive.

Not surprisingly, it has turned out to be extraordinarily difficult and politically unpopular for third party payers to set such limits. Obamacare’s appeal derives largely from two requirements: health insurance plans must accept all comers, including applicants with preexisting conditions that require expensive medical treatments; and health plans must provide unlimited benefits (i.e., no annual or lifetime spending caps). From an individual consumer’s perspective, what could be better than having access to unlimited amounts of money to spend on medical needs? From society’s point of view, though, this combination is a recipe for disaster.Continue reading…

Health in 2 point 00 — Episode 12

Jessica DaMassa asks me about the AMA & digital snake oil, Israel investing in Digital Health, and the budget impact on CSRs & Obamacare in today’s edition of Health in 2 point 00 — Matthew Holt

Graham-Cassidy is Dead. It’s Back to the Drawing Board. Why Not a Two-Tier System?

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BY BRIAN JOONDEPH, MD

Remember back in 2012 when then Vice-President Joe Biden told us, “Bin Laden is dead, General Motors is alive”? The good old days. Also around the time Senators John McCain and Lisa Murkowski promised to repeal Obamacare. Along with a bunch of other Republicans seeking reelection to Congress.

Fast forward to 2017. The new catchphrase is “GOP is dead, Obamacare is alive.” At least their credibility is dead. Buried in the rubble of broken campaign promises. Not only Obamacare repeal, but also tax cuts, immigration enforcement, balanced budgets, reduced spending, and so on.

Repeal and replace, as a promise was simple enough on the campaign trail.  We heard this promise in 2010, when voters gave the House to Republicans.  We heard it again in 2012, when voters gave them the Senate.  Despite controlling Congress, Obamacare remained alive and well.  Candidate Donald Trump, along with most Republican members of Congress, promised repeal and replace last year.

Eight months into the Trump administration, Obamacare is still kicking. Congress had three bites of the apple this year and each time came up with a worm instead. This week was their third attempt to fix Obamacare. Not the promised repeal, instead only financial window dressing to keep Obamacare alive in some shape or form.

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Dear Republicans, There Are Second Acts In Washington 

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By STEVEN FINDLAY

Nazis and white supremacists.  Charlottesville.  Immigration policy and DACA.  Climate change.   In the context of these issues, there’s been much discussion of late about moral and ethical principles and American values. 

There is, of course, no moral equivalency between white supremacists and those who oppose and protest them.   People who advocate white supremacy are just plain wrong, on moral grounds. 

And the Trump administration is clearly pursuing a path on immigration policy and climate change that is contrary to the ethical standards and values of the vast majority of Americans. I would add to this list the expansion of health insurance coverage.  If anything is clear after this summer’s failed attempt by Republicans to repeal the ACA it’s that almost all Americans now support universal coverage.  

And, more to the point, people see this increasingly in moral terms. They get it. It took many years—decades—to get to this point.   But this summer’s debate clarified what our values are as a nation on access to health care via the structure of insurance, private and public.     

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Is Trumpcare Dead?
Was It Ever Really Alive?

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By JOHN IRVINE

Senators Mike Lee and Jerry Moran said yesterday that they would not vote for the Better Care Reconciliation Act, effectively killing the legislation.  As anybody who has been following this story would have predicted, President Trump reacted publicly on Twitter on Tuesday morning, vowing to let the ACA marketplace collapse and then rewrite the plan later.

Senate Majority leader Mitch McConnell attempted a quick punt this morning, calling for an immediate Senate vote on the House bill, a trick card that if it worked, would give Republicans two years to work things out.

Unfortunately for McConnell, it probably won’t.

The White House sees the failure as saying more about the political establishment in Washington than itself, which shouldn’t be all that surprising. Caught up in the drama of the Watergate-Russia emails-Trump family narrative, major media outlets like the Washington Post and the New York Times see a historic defeat rather than a temporary setback. That may or may not turn out to be true. Predictably, conservative commentators and the alt-right believe the defeat says more about the mainstream media and the Deep State than it does about the Trump Presidency. For their part, Democrats clearly think they have found their issue and can be expected to continue to exploit it using legislative Viet Cong tactics (attack on social media, melt into the jungle, lob snarky public Molotov cocktails) to punish Republicans and keep the story on the front page.

One thing is clear. Instead of repealing and replacing Obamacare, the GOP now has to rewrite and replace its own plan. Doing that would be difficult under the best of circumstances, but in the current climate in Washington it is difficult to see how it would be possible without a major shift in the political landscape.

All of this is bad news for hospitals and health plans and a frightening development for consumers, although not the really bad news some had feared. The President’s threat to let the insurance marketplace die and then “figure it out” sounds good as a rallying cry to the troops on social media, but is not the kind of thing that investors and CEOs like to hear.  Realistically though, at this point everybody knew that the uncertainty would likely continue through the year (best case) or a year or longer (worst case) as the gridlock in Washington plays out. As depressing and frustrating as it is that the uncertainty will continue, by this point the industry is used to it. Insiders will continue to look for ways to minimize risk and for business opportunities to capitalize on the uncertainty.

Trump’s plan to allow the insurance exchanges to collapse is the kind of confrontational talk Trump and his advisors relish. In theory, the idea could work. There are in fact signs that it already is, as major insurers leave the marketplace and consumers hesitate before committing to expensive insurance policies.  In reality, however, the collapsing exchanges will create a political crisis that is even worse than the current one for the administration, with news cycle after news cycle dominated by stories of terminally ill cancer patients and parents with children with horrible diseases and no insurance coverage. At this point, it will be difficult for the party doing the collapsing to point at the other side and say “It was them. They did it!”

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The BCRA Is An Improvement Over Obamacare. Here’s Why..

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ANISH KOKA, MD

Dr. Jha writes on these pages in typically stirring fashion about his views on the recent health care kerfuffle and rightly so fingers what the real focus of our efforts should be: Cost.  He ends by slaying both sides because of their refusal to confront the hospital chargemonster – the fee schedule hospitals make that remarkably only really applies to the uninsured.

Unfortunately, the solution proposed ensures hospital fee schedules for the uninsured are no greater than Medicare reimbursements, which is far from perfect.  Consider that the Medicare reimbursement for a stent placed to an ischemic limb is in the range of $15,000.  While this makes for a less daunting bill for the uninsured, in reality for the vast majority of folks that are uninsured $15,000 is about as far away as $150,000.

But my major disagreement with the good Dr. Jha relates not to his attempt to slay the chargemaster, but his underappreciation for the attempts made in the GOP bill to control health care spending.  A conservative mantra about the why of health care costs focuses on the existence of deep pocketed third party payers that make costs opaque to patients.  Attempting to have patients understand what they’re being charged has been conservative dogma, and there are a number of studies that suggest patients with health saving accounts are more cost conscious when they interact with the health care system.  Dr. Jha glosses over this important point – This is the Republican attempt to bend the cost curve!  And at least to this physician who’s lived through the last eight years, a plan that has a considerably greater chance of success than any number of failed acronyms designed so far by enlightened theorists from the Acela corridor.

HSA chart

The policy experts are hard to convince about HSAs, and point to the above chart as evidence of the uselessness of HSAs.

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Repeal and Replace. Repeal and Replace. Repeal …

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By BRIAN JOONDEPH, MD

Repeal and replace.  Simple enough on the campaign trail.  We heard this promise in 2010, when voters gave the House to Republicans.  We heard it again in 2012, when voters gave them the Senate.  Despite controlling Congress, Obamacare remained the law of the land.  Candidate Donald Trump, along with most Republican members of Congress, promised repeal and replace last year.

Republicans now have their largest electoral majority in nearly a century, and repeal and replace is spinning its wheels, like an old Pontiac stuck in the snow.

Some think a grand bill is still possible, particularly Senate majority leader Mitch McConnell.  Others are skeptical.  Senators Rand Paul and Mike Lee favor a two-pronged approach: repeal first then repeal later.  Herein lies the problem.  Republicans can’t agree on anything.

Democrats had no such problem in 2010 when they passed Obamacare.  The Bernie coalition didn’t get a single-payer plan as they wanted.  Some wanted higher Medicaid reimbursement for their states, as in the “Cornhusker Kickback.”  But they came together and passed Obamacare, each Democrat getting most but not all of what he wanted.

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