• No majority support for any single approach to reform
  • 44% want to keep ACA but make significant changes
  • Slight majority of Americans (53%) approve of the ACA

“The Senate Republican health care bill, the Better Care Reconciliation Act of 2017, is on thin ice, with about ten Republican Senators expressing reservations about the bill. Can Mitch McConnell get 50 senators to yes? What are the implications for the future of health care in America if he can—or can’t?

To help answer these questions, we’re fortunate to be joined by Grace-Marie Turner, the most influential health care scholar in the conservative movement.”

. . .

Sioux Falls Specialty Hospital in South Dakota is regularly full. Its doctors and nurses often have to work longer hours or perform elective surgeries such as hip or knee replacements on weekends.

“In many cases, patients have to wait forever,” said Dr. R. Blake Curd, an orthopedic surgeon and the hospital’s CEO. “We don’t have the physical capacity to take care of them.”

He would like to expand the hospital by adding beds or rooms, but he isn’t allowed to do so because of the Affordable Care Act, or Obamacare. The law largely bans the expansion of hospitals such as Curd’s, which are partly owned by doctors. New physician-owned hospitals also cannot be set up unless they forego government reimbursement from Medicare or Medicaid.

. . .

A new government report explains why Republicans, after nine years of opposing Obamacare, are having such a hard time repealing it.

The answer: It’s pretty much about the money. It’s not about providing Medicaid coverage to low-income adults.  Some moderate Republicans who profess concern for the needy are actually trying to shift more of the cost of providing them Medicaid coverage from their states to the federal government.  They’re holding out for more federal cash for their states. And they just might get it – from Senate Democrats.

Obamacare made an offer to states that agreed to extend Medicaid eligibility to childless, nondisabled, low-income adults: The federal government would pay 100 percent of the medical bills for this new category of “expansion adults.” That percentage would slowly decline, but never fall below 90 percent. The District of Columbia and 31 states jumped at the offer.

The federal government pays a much lower federal matching percentage for every other category of recipients, including children, blind and disabled adults, pregnant women, and the frail elderly. That matching rate varies from 50 percent in states with relatively high per capita incomes (California, for example) to nearly 75 percent in the poorest state (Mississippi).

The Senate bill to “repeal and replace” Obamacare would leave the Medicaid expansion in place, but would ultimately eliminate the higher federal reimbursement for their care.  The federal government would bear the same share of medical assistance for nondisabled, childless adults as it does for pregnant women and people with disabilities.  It slowly phases out the current Medicaid reimbursement policy that discriminates on the basis of age, gender, pregnancy, and disability.

Some Senate Republicans are clinging to this inequitable arrangement that provides a sweet deal for their states.

. . .

 

Republican senators Ted Cruz and Mike Lee are pushing for an amendment to the Senate GOP’s Better Care Reconciliation Act (BCRA) that would substantially alter the current landscape of health-insurance regulation. They believe their amendment, which aims to give insurers much more freedom to offer any kind of product they want to customers, would go a long way toward restoring a free market to health care, and would result in lower premiums for millions of consumers.

The strong commitment of these senators to this particular amendment, and the insistence on its inclusion in the Senate bill by conservative groups, reveals a broad misunderstanding among conservatives of what is wrong with health care in the United States, and what is needed to build a market-driven system.

. . .

The biggest problem with Obamacare is that it expanded health coverage through Medicaid, a program with notoriously poor access to doctors, because Medicaid pays doctors far less than private insurance. The Senate Republican health care bill aims to change that, by giving states the ability to offer an innovative new model to their poorest residents: direct primary care.

The fact that people enrolled in Medicaid have poor access to physicians is well-documented in the literature (see here and here and here). To take one example, kids with acute asthma attacks on Medicaid only had a 45 percent chance of securing a doctor’s appointment, compared to 100 percent of those with private insurance.

. . .

For the better half of a decade, lawmakers in Washington have been experimenting with the nation’s healthcare policy in an attempt to bring coverage to all Americans, while controlling costs and sustaining quality. The Affordable Care Act was the climax of such attempts.

While the ACA did bring some positive ideas to the table—such as giving more Americans the ability to enjoy health insurance and protecting people with pre-existing conditions from predatory premiums—it fell short in many other aspects.

. . .

Senate Republicans returning from a July 4 recess are so divided over a health-overhaul bill that they are also struggling to agree on what to do if they fail to pass their legislation.

Some conservative lawmakers say an implosion of the Republican legislation would give them a chance to return to their goal of fully repealing the Affordable Care Act, putting off until later a decision about what system to put in its place. Others, including Senate Majority Leader Mitch McConnell (R., Ky.), are considering the possibility of legislation to shore up the law’s marketplaces where individuals buy health coverage, action that would involve working with Democrats.

. . .

Democrats loudly complain that people will lose health insurance if the Affordable Care Act is repealed. They never mention those who lose jobs because the ACA remains.

The ACA includes a penalty on employers that fail to provide “adequate” insurance for full-time workers. Thanks to the ACA, hiring the 50th full-time employee effectively costs another $70,000 a year on top of the normal salary and benefits.

. . .

According to widespread media reports, Senate Republicans are considering an amendment to the proposed Better Care Reconciliation Act from Texas Senator Ted Cruz under which, if a health insurer offered at least one Obamacare-like plan with community rating, it could also offer a plan in which healthier people would pay lower rates than the sick. Although this proposal might please conservatives otherwise worried that the BCRA is but “Obamacare-lite” and although it might mollify some moderates  — if you like your Obamacare you can kind of keep it — it creates an “income cliff.”  People who need expensive medical care will be far worse off if they make more money. Some additional modifications to the Republican bill could reduce this problem, but they are likely to be some combination of ineffective or expensive.

. . .