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Tag: Obamacare

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

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 

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?

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..

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 …

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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Healthcare’s Fake News Epidemic

Fake news has replaced responsible journalism. It’s hard to know what to believe. It wasn’t long ago that supermarket tabloids like National Enquirer were considered fake news. Now it seems the Enquirer and TMZ may be more reliable sources of accurate news than the New York Times or Washington Post.

Government agencies aren’t immune from the fake news trend either. The Congressional Budget Office describes itself as, “Strictly nonpartisan; conducts objective, impartial analysis; and hires its employees solely on the basis of professional competence without regard to political affiliation.”

I’ll bet most newspapers and television news networks say the same about their own objectivity.

The CBO analyzed the American Health Care Act of 2017, a lame effort by Republicans to repeal and replace Obamacare.  Passed by the House, it’s now on to “the greatest deliberative body in the world.”

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Senate Releases Obamacare Replacement Bill (Download)

With action expected on the legislation next week, the Senate released the full text of its proposed Obamacare replacement.

Surprise, surprise: after weeks of secret meetings and dramatic late night tweets, the legislation looks very similar to the House Bill. More soon.

SENATEHEALTHCARE

 

 

 

Jimmy Kimmel Left Out Some Important Stuff About Obamacare

Late-night comedian Jimmy Kimmel, in a recent opening monologue, spoke tearfully of his newborn son Billy, born with a serious congenital heart defect.  Heart defects in newborns, while uncommon, occur in 1 in 100 births.  The more serious ones, meaning those needing surgery in the first year, represent about a quarter of all congenital heart defects.

Jimmy’s son fell into the latter category, with Tetralogy of Fallot, bad plumbing in the heart, causing oxygen-poor blood to circulate out into the body without picking up a fresh supply of oxygen from the lungs.  Hence the newborn baby turning blue.

I have firsthand experience with this, as my youngest son was born with the same heart defect.  He needed surgery as an infant and then two additional open heart procedures before reaching adulthood.  I have walked in Jimmy Kimmel’s shoes and understand exactly what he is feeling – terror, anguish, guilt, helplessness, and hopelessness.

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Dancing on the Grave of Obamacare: Questions

I hate to interrupt the festivities, but I have a few questions. There are one or two little unknowns here. The answers to these questions are matters of life and death to many in the industry, literal life and death to many thousands of patients, organizational life and death to thousands of companies, hospitals and systems. 

Tuesday’s extraordinary events obviously present an enormous challenge for anyone who wants to think about the future of healthcare. The challenge is far more than simply trying to imagine the healthcare industry without Obamacare, or under whatever Trumpcare will turn out to be. A much more powerful effect will be come into play far earlier: the uncertainty over that future will have reshape the industry before we even get to the actual “repeal and replace” part.

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No, I Didn’t Expect That Either.
What’s Next?

As a Democrat, I can only hope this is a Dewey defeats Truman moment, but at 2.00am ET on Nov 9, President Trump with a Republican House and a open Supreme Court seat seems to be our new reality. For the health care establishment, this is a bombshell. It’s been easy for Congressional Republicans to vote to repeal the ACA when they knew Obama would veto it. But what happens next when Trump is happy to sign the “repeal”?

It’s hard to figure out what’s there in terms of putting together to “replace” either in the Congressional Republicans or in what passes for policy in what passes for the Trump camp. As Margalit Gur-Aire said on THCB recently other than one speech with some stale talking points about block grants for Medicaid and selling insurance across state lines, Trump seems to have no ideas about health care. (To be fair he doesn’t seem to have any ideas about anything, or he claims they’re a secret).

Then we have the issue of his relationship with Congress. Now he’s President he may declare a truce, but then again he might decide to tweet into oblivion Paul Ryan and the many others who wouldn’t support him. And he might of course self-immolate as he tries to manage his business, his relationship with Russia and his soon to be launched TV network–while actually having to be President.

But if he’s going to end Obamacare, Trump is going to have to worry about two things. First, he has said that he wants to repeal it but is going to make sure everyone can buy health insurance, even if they have preconditions. When the middle aged white working class who voted for Trump discover that their Medicaid and their health insurance goes away, and that insurers wont sell them insurance if they’re not a good risk, they might be unhappy.

Second, the other people who are going to be unhappy are the health care industry stakeholders. Health care is a series of complex legislative and market interactions. As a consequence of the ACA, most health insurers, providers and even pharma or device companies have made huge changes to their business strategy. Those business strategies and investment are now six years old. Like Wall Street and corporate America, Trump is going to make the health care establishment deeply uncomfortable. The question is, once big pharma, insurers and providers lean on the Administration, will anything actually change, or will we see the route towards value-based care continue?

Not only that, but the sea-change that is just starting in the shift from FFS to value-based payments from Medicare & CMS is underway because the country can’t afford continued health care cost growth. That remains the same. Eventually that reality will impinge even on a Trump administration.

So what happens next? Well it’s amateur hour and we’ve all failed to predict it thus far, so it’ll be tough to do it now. But health care will be a sideshow.

Oh, and time to repeal the frigging electoral college.

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