Republicans have made a great deal of progress toward broad agreement on a general policy approach over the past half-decade. The GOP has been preparing for the opportunity to enact conservative health care reform for years, and it now faces both a party electorate and a health care system that will not allow for endless indecision. It is too soon to know what the final product will look like, and whether a series of reconciliation bills or some uneasy combination of partisan and bipartisan measures will emerge. But it does seem likely that a year of intense action on health care is beginning.
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Rep. Tom Price, President-elect Donald Trump’s choice to head the Department of Health and Human Services, faced a contentious Senate hearing Wednesday as Democrats questioned his ideas for the future of Americans’ health coverage and whether his personal investments in health-care companies presented conflicts during his years in Congress.
Price began by laying out central elements of his years-long attempt to replace the Affordable Care Act. In doing so, he signaled ways in which Trump’s more populist message could collide with the core beliefs of congressional Republicans. He told senators that “it is absolutely imperative” for the government to ensure that all Americans “have the opportunity to gain access” to insurance coverage.
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President-elect Donald Trump says the program he plans to institute as a replacement for the Affordable Care Act will “get private insurance companies to take care of a lot of the people that can afford it.”
“We’re going to have a plan that’s going to be great for people. And it’s going to be much less expensive. And you will be able to actually have something to say about who your doctor is and your plan,” Trump told Fox News’ “Fox & Friends” in an interview that was taped Tuesday and aired Wednesday morning. “We have to cover people that can’t afford it. And that’s what I’m talking about. And we’ll probably have block grants of Medicaid back into the states. … Nobody is going to be dying on the streets with a President Trump.”
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President Obama recently warned that if Congress junks the Affordable Care Act, “133 million Americans with pre-existing conditions” will be in jeopardy. That’s a phony figure, for several reasons. The actual number is roughly 500,000.
For starters, half of Americans get their insurance through an employer, according to the Kaiser Family Foundation. Another 34% are on Medicaid or Medicare. For all these people, pre-existing conditions are no barrier to coverage.
Pre-existing conditions mattered before ObamaCare only in the individual market, but even there few were affected. Many of these people with pre-existing conditions managed to get health coverage through the high-risk pools run by 35 states. Those pools covered about 225,000 people in 2011, according to the Kaiser Family Foundation.
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Two Republican senators are working on legislation that would let states decide whether they want to keep Obamacare or move to a different system. Sens. Bill Cassidy of Louisiana and Susan Collins of Maine both hinted on the Senate floor Tuesday about a bill that would preserve Obamacare, but only for states that choose to keep it. Cassidy said the bill would be essentially the same as a bill he introduced in the last Congress called the Patients Freedom Act. It lets states decide if they want to stay in Obamacare if it is working or leave. “The state could go with the alternative, which we will lay out, the state could opt for nothing — no Medicaid expansion and no help for lower-income folks — or the state could opt to stay in Obamacare,” Cassidy said.
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Donald Trump’s pledge to “repeal and replace Obamacare” was one of his biggest crowd pleasers. Moving forward on his broad replacement themes—expanding health savings accounts (HSAs) and state flexibility—could lead to some surprising and intriguing reforms.
During the campaign, Trump supported the familiar Republican themes of tax-free HSAs and allowing families to deduct health insurance premiums in their tax-returns. He pledged that “we must also make sure that no one slips through the cracks simply because they cannot afford [health] insurance.” This opens the door to a serious and conceivably bipartisan discussion about how to replace the complex structure of ACA subsidies and tax breaks.
In addition to redesigning subsidies, another element is an expanded role for states. The familiar Republican call to take the federal money for Medicaid expansion as a block grant and turn it into subsidies for families to buy private coverage has received plenty of the attention. But the broader theme of giving states much greater flexibility could become a different pathway to the goal of affordable and adequate health coverage for all.
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“As Republicans try to repeal the Affordable Care Act, they should be reminded every day that 36,000 people will die yearly as a result.”
— Sen. Bernie Sanders (D-Vt.), in a tweet, Jan. 12, 2017
Sanders has tweeted as a definite fact an estimate that a) assumes Republicans will gut Obamacare without a replacement b) assumes the worst possible impact from that policy and c) assumes that data derived from the Massachusetts experience can be applied across the United States.
Those are three very big assumptions. Take away any one of them, and Sanders’s claim that repeal of the law will cause 36,000 people to die a year falls apart.
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This morning, the Congressional Budget Office released a report arguing that the partial repeal of Obamacare being contemplated by Republicans would wildly increase the number of people without health insurance, in ways that are difficult to understand. Here are four problems with the CBO’s analysis.
1. The CBO’s estimates assume no Obamacare replacement
2. The CBO massively overestimates the impact of Obamacare’s individual mandate
3. The GOP repeal bill is likely to treat Medicaid differently than the CBO does
4. CBO’s 2010 estimates of Obamacare’s coverage expansion were off by more than 10 million
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A spokesman for Donald Trump sought Monday to elaborate on the president-elect’s plans to replace the Affordable Care Act, vowing that the new administration would lower health-care costs by infusing more competition into the marketplace, including by allowing insurers to sell health plans across state lines.
Trump’s goal is “to get insurance for everybody through marketplace solutions, through bringing costs down, through negotiating with pharmaceutical companies, allowing competition over state lines,” Sean Spicer, the incoming White House press secretary, said during an interview on NBC’s “Today” show.
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“What about the 20 million people who got coverage?”
Republicans are naturally concerned. Liberals have weaponized this number to stop repeal of the ACA. But should 20 million people keep a bad law on the books? To answer this question, Congress must ask two different questions.
First, is the number real? In March 2016, the Department of Health and Human Services (HHS) estimated that 20 million uninsured adults gained coverage under the ACA: 17.7 million non-elderly adults (ages 18 to 64) since October 2013, and 2.3 million young adults (ages 19-25) between 2010 and 2013.
The estimates are based on data from the National Health Interview Survey and the Gallup-Healthways Well-Being Index. The estimates are “adjusted to account for changes in general economic conditions (via employment status), geographic location, demographics and other secular trends.” Thus, the 20 million is an estimate, not a rock-solid fact.
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