Tag Archives: American Health Care Act

Memoirs of the Addams Administration 26.

Posted on by
Reply

In May 2017 the House of Representatives passed the American Health Care Act (AHCA) in an attempt to “repeal and replace” the Affordable Care Act (ACA).   Senate majority leader Mitch McConnell assigned a small group of senators to quickly re-write this legislation to deal with its flaws.  In late June 2017 they revealed their handiwork to the public.  The Senate bill sought to introduce market-based solutions to health care.  In place of the ACA’s supposed individual “mandate”[1] to buy health care insurance, the Senate bill created a “lockout”[2] intended to keep people from only buying insurance when they are sick, then dropping out when they get better.  In place of the current open-ended government spending on Medicaid, the Senate bill would cap the amount of money that the federal government would pay.  The Senate bill reduced the average premium by about 20 percent, raised the average deductible by 70 percent, allowed insurance companies to offer a wider variety of plans in place of the expansively defined set of benefits required by the ACA, and raised the permissible differential between premiums for sick people and healthy people.   It also replaced direct subsidies paid to insurance companies with smaller individual tax credits.  The ACA’s expansion of the Medicaid eligible population to include the “working poor” would be rolled back by 2024.  The Congressional Budget Office (CBO) reported that the Senate bill would cut $722 billion out of federal health-care spending over a decade and that 37 million fewer people would have health insurance by 2026.[3]

McConnell found that he could not muster enough Republicans to vote for the bill.  Some of the dissidents wanted an even more radical repeal of the ACA, while others opposed the size of the cuts to Medicaid.   McConnell “postponed” a vote on the bill until later in the summer—or maybe ‘till the cows come home.

Otherwise, little is going on in government.  Most of the real news sprang from the Supreme Court.  The Court allowed a limited version of the administration’s initial travel ban on possible terrorists to go into effect until the Court can hear full arguments in October.  It also found that a Missouri law barring public funds to a church school violated the free exercise of religion.  The Court agreed to hear cases on the constitutionality of partisan gerrymandering and religious-based refusal to serve gay people.[4]  The dismantling of the “legacy” of President Obama continued.  The Environmental Protection Agency proposed repeal of a 2015 rule that claimed for the federal government the right to regulate water quality in the tributaries and wetlands surrounding major bodies of water like the Chesapeake Bay.[5]

Even so, people filled up the early summer with nonsense.  President Trump admitted that he had no tapes of his conversations with James Comey.  CNN admitted that it had published an unsubstantiated story about President Trump’s alleged Russian contacts.    Some Democrats bit at House minority leader Nancy Pelosi after the series of disappointing losses in Congressional special elections.[6]  Others urged staying the course that has brought the Democrats so much success of late.

[1] Many younger people just ignore the mandate.  That’s why the insurance companies haven’t been able to get a sustainable mix of poor, but healthy younger people to subsidize the health costs of wealthier, but sick, older people.  Massive losses have led insurers to pull out of a rising number of state insurance market places.

[2] Anyone who went without insurance for 63 days would not be eligible to buy insurance for six months.

[3] “Republicans divided over Senate health-care bill,” The Week, 7/14 July 2017, p. 4.

[4] “Supreme Court revives Trump’s travel ban”; “The U.S. at a glance…”; “Gerrymandering: A GOP advantage?” The Week, 7/14 July 2017, pp. 5, 7, 16.

[5] “Boring but important,” The Week, 7/14 July 2017, p. 6.

[6] The Week, 7/14 July 2017, pp. 6, 7, 17.

Medicaid.

Posted on by
Reply

In 1965, fresh off a Democratic thrashing of the Republicans in the 1964 elections, President Lyndon B. Johnson had the means to push through his effort to “complete” the New Deal.[1]  This included legislation to provide government-funded medical care to four groups of the “deserving poor”: children, pregnant mothers, the disabled, and geezers who needed long-term care.  So it went from 1965 to 2014, as the one-time “war on poverty” failed to end poverty in a growing population.  By 2014, 57 million Americans were covered.  Still, at that point, one in seven Americans (14.3 percent) had no health insurance.  Then the Affordable Care Act (ACA) of 2010 kicked in, “allowing” states to use Medicaid to pay for the expenses of all able-bodied adults who earned less than 138 percent of the government’s poverty level.  This added 17 million people (about 30 percent of the 2014 total) to the Medicaid rolls. By 2016 the share of Americans without medical insurance had fallen to one in twelve (8.6 percent).  However, the cost of those covered by Medicaid ran to $574 billion a year.[2]

As part of the “repeal and replace” ACA effort, House Republican proposed to reverse the ACA’s expansion of Medicaid by 2020.  That is, they sought to return Medicaid to its original mission.  This would involve dropping 14 million people—those able-bodied people added by the expanded Medicaid of the ACA.  There also is talk of imposing a work requirement on able-bodied recipients of Medicaid.

Another part of the plan is tax cuts.  The ACA imposed $875 billion in new taxes, mostly on high income earners.  The Republicans want to roll back those tax increases.

Another part of the Republican plan would reduce the future growth in Medicaid spending by $834 billion over ten years.  The federal government would provide states with fixed amounts of money, rather than just paying whatever bills come in.  This proposal tries to address an important demographic and financial problem.  Medicaid pays for home health aides and for nursing home care for those who have exhausted their own savings.  A recent report by the World Economic Forum pointed out that the United States has the biggest gap between actual retirement savings and projected needed savings.[3]  U.S. government projections suggest that 70 percent of people will need long-term care.  The vast majority of these will need a home health-care aide, while 18 percent will need nursing home care.  Given the retirement savings gap, a huge financial cost will fall on the Medicaid system.  The Republican plan tries to address that issue.  It may not do that well, but one is surprised to see it done at all.

It is possible to see two distinct moral perspectives in the struggle over Medicaid.  Medicaid is but one front in a fight that involves Medicare, Social Security, defense, education, and taxes.  Broadly, they all touch on different conceptions of social reform and the best society.

Democrats would argue that the national government has a moral duty to its citizens.  It must break down the barriers to individual success.  Where those barriers can’t or can’t yet be destroyed, then the winners from current systems need to compensate the losers.

Republican would argue that such government action corrodes individual responsibility and creates dependency.  It harms the very people it seeks to help.  Government has a moral duty to create the conditions for individual success by fostering a dynamic economy.

It’s wishy-washy to say so, but both could be true.

[1] Julian Zelizer, The Fierce Urgency of Now: Lyndon Johnson, Congress, and the Battle for the Great Society (2015).  Really good book.

[2] “The battle over Medicaid,” The Week, 23 June 2017, p. 11.

[3] See: https://waroftheworldblog.com/2017/06/20/memoirs-of-the-addams-administration-24/

Memoirs of the Addams Administration 22.

Posted on by
Reply

It will be difficult for future historians to make sense of the commentary on the second, European, leg of President Trump’s first foreign trip.  The “usual subjects” of Mainstream Media (MSM) decried his hectoring of North Atlantic Treaty Organization (NATO) members to pay more toward the common defense while refusing to make an explicit commitment to Article 5 of the NATO Treaty.[1]  Europeans themselves seemed aghast at his sharp tongue (and in the case of the prime minister of Montenegro, his sharp elbows).[2]  German Chancellor Angela Merkel affirmed that “we have to fight for ourselves.”  She called for European nations to “shoulder emotionally charged challenges such as a common defense and security policy.”

There is reason to doubt the value of all this talk.  On the one hand, a clear-eyed assessment of American vital interests would show that non-Russian Europe and “off-shore Asia” (Japan, South Korea, Taiwan, the Philippines) are vital trading partners and allies of the United States.  It doesn’t matter what President Trump says or fails to say.  If Push comes to Shove, the United States will have to defend those areas.  In contrast, neither Russia nor radical Islam poses an existential threat to the United States.[3]  On the other hand, the European Union (EU) lacks the means and probably the will[4] to provide for its own defense against foreign foes.

In May 2017, a second version of the Trump/RyanCare squeaked through the House of Representatives.  Since then Republican Senators have been trying to sort out a better version.  The Congressional Budget Office then issued an evaluation saying that under the House plan 23 million more Americans would be without health insurance and that premiums would rise for those who are old and sick.  The first part of this isn’t troubling: at least two-thirds of the “uninsured” would be people who never wanted the insurance (let alone the premiums) in the first place.  The second part reflects what the plan itself said: older and sicker people consume a lot more health care than do the young and healthy, so they should pay for it.  Republican senators are divided over the plan.  Public opinion leans against the House plan.[5]

The appointment of former FBI Director Robert Mueller to investigate the “Russia scandal” (including how his friend, protégé, and successor at the FBI James Comey came to be fired by President Trump) means that the investigation could run on for quite some time.  People will know nothing definitive until that investigation is completed.  However, it appears than anything illegal (like collusion between the Trump campaign and the Russian government hackers who revealed all sorts of inconvenient truths about Hillary Clinton) would have to have taken place before the election of President Trump in November 2016.  Wikileaks published the stolen e-mails on 22 July 2016.  The names of Kellyanne Conway (joined Trump campaign on 1 July 2016) and Steve Bannon (joined Trump campaign in August 2016) have not so far appeared among the list of FBI targets.  Jared Kushner and Michael Flynn—who had a history of legal contacts with the Russians–tried to open a back-channel contact with the Russian government in December 2016.  Maybe, just maybe, this dog won’t hunt.

[1] “Trump in Europe: A frayed alliance,” The Week, 9 June 2017, p. 6.

[2] “How they see us: Europe loses faith in America,” The Week, 9 June 2017, p. 14.  See also: “Russia: Cheering Trump’s NATO policy,” The Week, 9 June 2017, p. 15.

[3] Russia possesses nuclear weapons, but is deterred from using them by American nuclear weapons.  Vladimir Putin has had to make do with “little green men” and cyber-attacks.   Radical Islam doesn’t seem able to conquer anywhere vital to the United States.  Saudi Arabia, Iran, and Turkey all have the means to resist radical Islamists.

[4] See: https://waroftheworldblog.com/2015/06/17/die-for-danzig-marcel-deat-mourir-pour-danzig-loeuvre-4-may-1939/

[5] “Republican health-care plan struggles in the Senate,” The Week, 9 June 2017, p. 5.

Memoirs of the Addams Administration 19.

Posted on by
Reply

In late March 2017, House Republicans had to pull the American Health Care Act (AHCA) because they couldn’t cobble together a majority from the disparate Freedom Caucus and moderate factions of the party.  In early May they took another stab at it.  This time the bill passed the House of Representatives by a razor-thin (as the cliché goes) margin.  The new and improved AHCA ended the mandate[1], but allowed insurance companies to charge extra for people who let coverage lapse and then applied in a hurry once they got sick; granted the states the right apply for waivers if they wanted to allow insurance companies to offer plans with fewer “essential services” than mandated by the Affordable Care Act (ACA)[2]; “rolled-back” the expansion of Medicaid (which observers predicted would cut 25 percent/$880 billion in health-care spending over a decade); replaced the income-based subsidies of the ACA with age-based tax credits[3]; allowed  insurance companies to charge old people much more than young people[4]; and encouraged states—through a promised $138 billion in federal subsidies–to create high-risk pools for those with pre-existing conditions that insurance companies wouldn’t touch with a ten-foot pole.[5]  The right-to-life-but-not-to-medical-care-once-born crowd insisted on defunding Planned Parenthood.[6]

Republican Senators, who live in a radically different political environment than do Republican Congressmen, didn’t like the handiwork.  Senate majority leader Mitch McConnell set up a baker’s-dozen of Republican Senators to save the party from an electoral disaster in 2018.  They are expected to sketch a fig-leaf with regard to things like Medicaid spending, and coverage of the Emma Lazarus people: “Give me your tired, your poor, Your huddled masses yearning to breathe free, Your people with pre-existing conditions.”

Is there any way to make a Republican plan work?  Yes, if you aren’t a 100 percent Democrat.  The ACA expanded entitlement programs to provide health care to the poorest Americans.  It had little effect for most Americans.  It did not create health-care insurance for most Americans, nor did it seek to rein-in the rising costs of health-care.  Most people receive their health care through their employers or through Medicare.  The Republican plan poses no serious threat to these people.  Republicans are betting that health care lite for the poor will be politically acceptable to most voters.  Are they correct?

One contested issue lies in the effect on taxes.  Democrats jeer that the AHCA will lead to a $1 trillion cut for the richest Americans over a decade.  However, the ACA imposed a $1 trillion additional tax on those same richest Americans.  This casts into doubt the claim that the mandate is necessary so that poorer young people will subsidize richer older people.[7]

[1] This is an acknowledgement that many young people don’t want or need insurance, or—if they do—resent being ordered around by the government as if they’re the hired help.  There probably are about 14 million of these timid fugitives currently on the rolls of Obamacare.  Millions more have not signed up because the Internal Revenue Service does not require that taxpayers actually submit proof of coverage.

[2] This is a concession to the people who were promised by President Obama that “if you like your insurance, you can keep it” and then had the rug pulled out from under them.  Sad to say, attention to detail proved not to be Obama’s strongest quality.  See: “Healthcare.gov roll-out.”  Lots of times “big picture” people aren’t good at this.

[3] So people in their 20s would get up to a $2,000 credits, while people in their 60s would get up to a $4,000 credit.

[4] Up to five times as much, compared to the ACA’s limit of three times as much.  However, old people consume far more health care than do young people, so the ACA appears to be a taxing of low income people to support higher income people.

[5] “Health-care reform heads to the Senate,” The Week, 19 May 2017, p. 5.

[6] Still, last time I checked, condoms were a dollar each at CVS.

[7] “American Health Care Act: The winners and the losers,” The Week, 19 May 2017, p. 6.

Memoirs of the Addams Administration 13.

Posted on by
Reply

Once upon a time, old people depended upon their savings and their families to cover the living costs of their few last years.  Then, people started to live longer and the individual safety net eroded.  We got Social Security.  Once upon a time, the business cycle visited prosperity and hardship on people in varied measure.  Then came the Great Depression.  We got Keynesian counter-cyclical spending.  Once upon a time, doctors couldn’t do much to cure illness.  Then, the combination of science and medicine opened an Aladdin’s Cave of health solutions.  These cost a lot of money, so we got Medicare and Medicaid.  Once upon a time, America was a meritocratic society and poor people had to take their lumps.  Then came the Sixties and Seventies, which altered assumptions.  The Forgotten suffered in misery, so we got the Affordable Care Act (ACA).

Lots of people didn’t like the ACA.  Moreover, the ACA has problems all its own.  Those problems appear not to be fatal or crippling.  The Congressional Budget Office (CBO) projects that, left to its own devices, the ACA will “naturally stabilize” in most of the country in a few years.[1]  President Trump, or the Republicans in Congress acting without President Trump, can shove the ACA downhill if they want it to fail.  They can do this most easily by just not enforcing the individual mandate.  That would allow about 14 million younger-and-healthier people to drop out of the system.  The loss of their premiums might fatally destabilize the ACA.

The first major step in the Trump Administration came in the effort to co-operate with the real Republicans in the legislature.  Republicans campaigned against the ACA for seven years, then got the chance to repeal-and-replace.[2]  In contrast to the Democrats’ year-long construction of the ACA and disciplined passage of the bill, the Republicans adopted a “Hey, we can put on a show, we can use my dad’s garage!” approach.  The Affordable Health Care Act (AHCA) repealed the unpopular and nonsensical individual mandate, substituted limited age-related subsidies for open-ended income-based subsidies, and cut down the Medicaid expansion.  Public opinion—especially among Trump’s core supporters—disliked the AHCA.

Well, that didn’t work.  In the House the “Freedom Caucus” didn’t like it; in the Senate moderate Republicans didn’t like it.  The two Republican factions could not agree, so the AHCA got pulled before a vote.  (See: Face, egg on.)  The ACA survived.  Bitter recriminations ensued.

The stock market’s Trump Rally turned into a slump once the AHCA went up in flames like the Hindenburg.  The botched handling of the bill’s passage revealed that the deep fissures inside the Republican Party during the Obama years have not been healed.  It also raised suspicions that neither Trump nor House Majority Leader Paul Ryan have much understanding about how to manage their business.  Those revelations, in turn, cast a pall over the prospects for the other elements of Trump’s agenda that have real relevance for business conditions.  Tax cuts, renegotiated trade deals, infrastructure spending, and sweeping deregulation now seem in peril.[3]

Is the new “realism”/”pessimism” justified?  It is if you ask Democrats, but less so if you ask Republicans.  Having messed-up one thing right off the bat, Republicans have a strong motive to do better with the next project: tax reform.[4]  They had the same motive to pass AHCA.

Democrats chortled that people like the ACA.  The like Medicare/Medicaid and Social Security too.  With defense, such entitlements are driving the growth of the deficit.

[1] “Obamacare: Will it collapse on its own?” The Week, 7 April 2017, p. 16.

[2] “The GOP’s failed Obamacare repeal,” The Week, 7 April 2017, p. 4.

[3] “Markets: Health-care failure rattles Wall Street,” The Week, 7 April 2017, p. 36.

[4] “The GOP: can ‘the party of no’ learn to govern, The Week, 7 April 2017, p. 6.

Memoirs of the Addams Administration 11.

Posted on by
Reply

This is out of sequence for reasons beyond my control.  I apologize to both my readers.

Wanting a swift and emphatic break with President Barack Obama’s administration, the Republicans introduced the American Health Care Act.[1]  One much noticed difference between the Affordable Care Act (ACA) and its proposed replacement (AHCA) came in the financial assistance offered by the government.  The ACA offered open-ended subsidies of premiums linked to income.  The AHCA offered tax-credits of $2,000-$4,000 a year linked to age.  The income ceiling for people to receive the tax credits would be $75,000 for an individual and $150,000 for couples.  The AHCA also would substantially reduce Medicaid spending after 2020.  The ACA barred insurance companies from charging older, sicker clients more than three times as much as they charged younger, healthier clients.  The AHCA would have allowed insurance companies to raise deductibles.  The ACA paid for the new entitlement for poor people by heavily taxing people who make more than $250,000 a year.[2]  To the tune of $600 billion.

Are there flaws in the ACA that would have been changed by the AHCA?  Well, premiums began to rise sharply in the last year of the Obama administration, while some major insurance companies fled the markets.  Rising premiums would mean rising subsidies to freight the budget.  Shifting from subsidies to fixed sums could help contain this problem.  Then, the AHCA allowed insurance companies to charge older, sicker clients up to five times as much as they charged younger, healthier clients.  This more closely resembles the real cost to insurance companies.

Is the cure worse than the disease?  The media were full of adverse results.  Millions could be tossed off Medicaid; diluting or removing some of the services deemed “essential” by the ACA could harm a lot of vulnerable people; and the out-of-pocket costs could go through the roof, leaving millions no choice but to do without insurance at all.

You don’t have to take the Mainstream Media’s (MSM) word for it.[3]  The Congressional Budget Office (CBO) projected that by 2026, premiums would fall by 10 percent.  The budget deficit would be reduced by $337 billion over a decade.  Ending the mandate would allow 14 million unwillingly-insured people to escape the clutches of the ACA.  After the limits on Medicaid spending cut in during 2020, another ten million would eventually drift—or be pushed–off the system.  Allowing insurance companies to charge older, sicker clients more would lead to those clients paying “substantially more” for health care.

The AHCA brought Republican factionalism into high relief.  The 20 members of the conservative House “Freedom Caucus” opposed the bill because it didn’t go far enough in liquidating the ACA.  A bunch of moderate Republican Senators opposed the bill because it went too far in liquidating the ACA.  Their differences appeared unlikely to be composed.  Then, Donald Trump won the nomination as spokesman for many discontented lower income voters.  These are just the people projected as the losers from the AHCA.  His support for the bill puzzled.

[1] “Ryancare: Who wins, who loses,” The Week, 24 March 2017, p. 16.

[2] This reality makes a mockery of the Democratic argument that the mandate is necessary because younger, healthier people have to be included in the “insurance market” so that their premiums can off-set the high costs of older, sicker Americans.  That is the same as arguing that low income, little property people have to subsidize higher income, more property people.  The reality looks like a few rich people have to subsidize many low income people.  The “$660 billion tax-cut” for the wealthy which the NYT decried is the flip side of a $600 billion tax increase imposed by the ACA.  That’s fine as social policy, but it should surprise no one that rich people fought back.

[3] “CBO report roils Ryancare debate,” The Week, 24 March 2017, p. 4.

Memoirs of the Addams Administration 10.

Posted on by
Reply

Jonathan Chait has argued that Donald Trump and a coterie of advisers “cooperated with the undermining of American democracy by a hostile foreign power [Russia].”  James Clapper, former Director of National Intelligence and no fan of President Trump, has said that “there is no evidence” of “collusion between members of the Trump administration and the Russians.”[1]  So which is it?  Chait is a partisan Democratic journalist at a time of considerable distress for the party.  Clapper is an experienced professional who had access to all they key intelligence before he left office.  All things considered, Clapper’s seems the more credible voice.

Even so, that leaves the problem of all the false denials of contacts between some Trump followers and various Russians.  Michael Flynn has been the most egregious case of this so far, but Jeff Sessions may still end up in serious trouble over his terminological inexactitude.

The Russians undoubtedly “intervened” in the election by hacking into the computers of various Democratic figures and institutions, then releasing the fruits through Wikileaks.   The results came in the revelation of information that the Clinton campaign would have preferred to keep secret because it likely would alienate many voters in a tight race.  First, how did that “undermine democracy”?  Second, would the revelation of this information by American investigative journalists not have undermined democracy?  As for the lying, part of the explanation may be the firestorm of criticism heaped on Republicans by Democrats after the election.  Another part of the explanation may be sheer stupidity.   As Jonathan Tobin has pointed out, the Benghazi witch-hunt didn’t help Republicans.

There seems to be a lot of that going around.  Recently, Breitbart News claimed that a story in the New York Times had reported that federal officials had “intercepted communications and financial transactions” between Russians and members of the Trump posse.[2]  Almost immediately, President Trump walked—stormed, really—into a door by claiming that “Obama had my ‘wires tapped’ in Trump Tower just before the victory.”  This charge elicited a hostile reaction from all across the spectrum.

Under these circumstances, many observers may be having a sigh of relief that actual legislation on important issues has begun to move forward.  Republicans launched their campaign to “repeal and replace” the Affordable Care Act (ACA) with the American Health Care Act (AHCA).[3]  In some ways, the AHCA really is “Obamacare lite.”[4]

What gets lost in the criticism of the bill is that Americans pay a lot more for not-as-good health care than do people in Western Europe and Japan.   The ACA did little to address this problem.  Arguably, it is a more important problem than the issue of people without insurance.  (They always had “catastrophic care” through emergency rooms.  I know it’s cold to say that.)  Both Medicaid and a lot of employer-provided health insurance are in effect open-ended when it comes to spending.   The fundamental dispute between Republican and Democrats is the likely effect of limiting spending.  Will insurers hold down their premiums in a less-regulated market in order to gain customers, then find ways to cram-down costs?  This is the Republican wager.  Or will insurers shred insurance for the poor in order to keep targeting the easy money?  This is the Democratic wager.  Whoever “wins,” the stakes are high.

[1] Both are quoted in “Trump and Russia: What do we really know?” The Week, 17 March 2017, p. 6.  On Chait, see https://en.wikipedia.org/wiki/Jonathan_Chait

[2] “Trump accuses Obama of illegal wiretap,” The Week, 17 March 2017, p. 4.  The story in the NYT ran on 19 January 2017.  See: https://www.nytimes.com/2017/01/19/us/politics/trump-russia-associates-investigation.html?_r=0

[3] “Republicans face a revolt over health bill,” The Week, 17 March 2017, p. 5.

[4] See: https://waroftheworldblog.com/2017/03/05/memoirs-of-the-addams-administration-9/