Today, after years of hearings and speeches and debates, the Paul Ryan-led House of Representatives has done something it has not done before: it has released a comprehensive, 37-page proposal to reform nearly every federal health care program, including Medicare, Medicaid, and Obamacare. No proposal is perfect—and we’ll get to the Ryan plan’s imperfections—but, all in all, we would have a far better health care system with the Ryan plan than we do today.
The first thing to know about the Ryan-led plan — part of a group of proposals called “A Better Way” — is that it’s not a bill written in legislative language. Nor is it a plan that has been endorsed by every House Republican.
Instead, it’s a 37-page white paper which describes, in a fair amount of detail, a kind of “conversation starter” that House GOP leadership hopes to have with its rank-and-file members, and with the public, in order to consolidate support around a more market-based approach to health reform.
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House Speaker Paul Ryan’s policy plan for health care, as expected, leans heavily on market forces, more so than the current system created by Obamacare. The proposal contains a host of previously proposed Republican ideas on health care, many of which are designed to drive people to private insurance markets.
Importantly for conservatives, as part of a full repeal of the Affordable Care Act, the current law’s mandates for individuals and insurers would disappear under the GOP plan. It would overhaul Medicare by transitioning to a premium support system under which beneficiaries would receive a set amount to pay for coverage. The plan also would alter Medicaid by implementing either per capita caps or block grants, based on a state’s preference.
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Medicaid payments to hospitals and other providers play an important role in these providers’ finances, which can affect beneficiaries’ access to care. Medicaid hospital payments include base payments set by states or health plans and supplemental payments. Estimates of overall Medicaid payment to hospitals as a share of costs vary but range from 90% to 107%. While base Medicaid payments are typically below cost, the use of supplemental payments can increase payments above costs. Changes related to expanded coverage under the Affordable Care Act as well as other changes related to Medicaid supplemental payments could have important implications for Medicaid payments to hospitals. This brief provides an overview of Medicaid payments for hospitals and explores the implications of the ACA Medicaid expansion as well as payment policy changes on hospital finances.
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Kentucky Governor Matt Bevin is making good on his campaign promise to close the doors on Kynect, the state’s Obamacare exchange. While Democratic former Governor Steve Beshear and a handful of Obamacare supporters have made waves about that decision, it has raised a bigger question: Does it make sense to run a state-based exchange?
Kynect is causing higher premiums for most residents of Kentucky, is not fiscally sustainable, and serves almost exclusively as a channel for Medicaid enrollment — Gov. Bevin is prudent to push to switch to the federal exchange.
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In state capitols across the country, health care lobbyists and consultants are pushing a relatively unknown provision of the Affordable Care Act: Section 1332. According to some proponents, these waivers will “turbocharge state innovation” and will provide states with an “exit strategy” from the ACA. But is the hype true? Will Section 1332 waivers be as truly transformative to our health care system as suggested?
As policy practitioners who work daily with state policymakers around the country, we have seen proponents be overly dismissive—or perhaps even unaware—of the large practical and political challenges surrounding the implementation of these waivers. A serious, objective examination of the new Section 1332 federal guidance sparks far more questions than answers for policymakers.
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The Oklahoma Health Care Authority (OHCA) has proposed a plan to “rebalance” Medicaid eligibility in the Sooner State. Although OHCA’s “plan” so far consists of only a single page of bullet points, what little that is already known makes clear that the plan would gut the existing Insure Oklahoma program and replace it with Obamacare’s Medicaid expansion by another name. Oklahoma policymakers should quickly reject OHCA’s latest proposal to expand Obamacare and refocus their efforts on improving the program for the most vulnerable.
Thousands of kids and adults with intellectual and developmental disabilities in Oklahoma are already sitting on Medicaid waiting lists to get the home and community-based services that they desperately need.
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Smaller insurers with experience in Medicaid, such as Centene Corp. and Molina Healthcare, are outperforming the broader insurance industry on the federal health exchanges. Their success is putting a spotlight on their business model as the Obama administration and other insurers seek to stabilize the fledgling individual market.
If Medicaid-like plan features become the norm, consumers and medical providers would be substantially affected. Such plans are often popular in the exchanges for their low premiums, but consumers have criticized limits on their access to medical providers such as doctors. And physicians fault the plans for low reimbursement rates.
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Although she promises to tinker with the Affordable Care Act (see below) Clinton is not proposing to fix any of its largest problems.
So what does Hillary Clinton propose to do about Obamacare? Spend more money. She proposes (1) to limit out of pocket costs to 5% of family income by offering a tax credit of up to $5,000 for spending above that amount, (2) to limit premium expenses to 8.5% of income, (3) to fix the family glitch, whereby dependents who are offered unaffordable coverage at work are barred from the exchange and (4) to spend more money to enroll people in Medicaid.
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Obamacare has caused health insurance premiums to skyrocket. It has caused millions of Americans who liked their health plans to lose their health plans. It has caused doctor and hospital networks to narrow. Now the Wall Street Journal reports that the Obamacare exchanges in Alabama and Alaska will each have one—that’s right, one—insurer offering plans. We’re moving toward “single insurer” health care.
In short, Obamacare is wrecking the private health insurance market.
The Congressional Budget Office says that the Obamacare subsidies for private insurance will cost $43 billion this year alone. That’s an average of $5,375 per person for those who have been added to the private insurance rolls—or $21,500 per family of four. Meanwhile, the typical 36-year-old (or younger) who makes $36,000 a year (or more) gets $0 under Obamacare.
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Using a combination of subsidized premiums for Marketplace coverage, an individual mandate, and expanded Medicaid eligibility, ObamaCare has increased insurance coverage rates. The authors of this study assess the relative contributions to insurance changes of these different provisions in the law’s first full year.
Their four key findings include:
- Insurance coverage was only moderately responsive to price subsidies, but the subsidies were still large enough to raise coverage by almost one percent of the population; the coverage gains were larger in states that operated their own health insurance exchanges (as opposed to using the federal exchange).
- The exemptions and tax penalty structure of the individual mandate had little impact on coverage decisions.
- The law increased Medicaid coverage both among newly eligible populations and those who were previously eligible for Medicaid (the “woodwork” effect), with the latter driven predominantly by states that expanded their programs prior to 2014.
- There was no “crowdout” effect of expanded Medicaid on private insurance. Overall, we conclude that exchange premium subsidies produced roughly 40% of the ACA’s 2014 coverage gains, and Medicaid the other 60%, of which 2/3 occurred among previously-eligible individuals.