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SEARCHING FOR THE HOLY GRAIL
The first Trump/GOP attempt at replacing Obamacare was stillborn. Their second attempt,
euphemistically called the Better Care Reconciliation Act, was released in draft form by Senate Republicans
on 22 June 2017. On its surface, this second bill appeared to contain many of the features one might desire in an
Obamacare replacement. Is it the Golden Grail - the “ideal” health care plan?
The undeniable truth is: There is no such thing as an “Ideal Health Care
Plan”! The “ideal” health care plan falls into the same category as the Tooth Fairy and Santa Claus –
it’s a fairy tale.
Obamacare, or the Affordable Care Act (ACA) as it’s more formally known, has
proven to be a failure and it needs to go. “Obamacare has limited choices for patients, driven up costs for
consumers, and buried employers and health care providers under thousands of new regulations. It forced people
into expensive plans they did not want and put the government in charge of one of the most personal decisions
families will ever make.” (Ref. 1) Patients, with their doctors,
should make their own health care decisions free from government interference. The latest Republican plan attempts
to address the demands of many Americans for the repeal the Affordable Care Act which has resulted in “skyrocketing
premium rates and decreased coverage choices as insurers fled the market.”
(Ref. 1) For many Americans, the ACA has proven to be a pack of
expensive untruths and broken promises.
A report put out by the non-partisan Congressional Budget Office (CBO) on the new
Republican ACA replacement “estimated that 22 million more people would be uninsured by 2026 under the Senate
Republican health care plan than under {Obamacare}, with 15 million more uninsured people in the next year
alone.” (Ref. 2) This should come as a surprise to no one! The
GOP plan removed the Obamacare mandate requiring everyone to get health care coverage, thereby providing everyone
with the option of not purchasing health care insurance. As a result, not everyone would opt to purchase health
care coverage and, as the CBO report said, the number of uninsured would go up. But, this is what freedom of choice
means! If you don’t want health care insurance, the GOP plan would not force you to buy health care
insurance.
The GOP plan could “result in a reduction of the cumulative federal deficit by $321 billion
by 2026, largely due to cuts in Medicaid spending, according to the CBO's report.”
(Ref. 2)
Is the newest Republican attempt to replace Obamacare the “ideal” health care plan
everyone is searching for? Not Likely! Was Obamacare the “ideal” health care plan everyone was searching for?
Certainly Not! Is there likely to be such an “ideal” health care plan? Guaranteed Not! So, what’s to be
done?
The Republican draft bill is said to be ”better than the status quo because it contains
provisions to reduce insurance premiums and promote access to insurance in the short run, cut taxes, and provide
major Medicaid reform that will help refocus the program on those most in need.”
(Ref. 3) While supposedly better than Obamacare, some
conservatives want more – “To undo more of Obamacare’s damage, the Senate should go further by expanding
states’ regulatory reform options to encourage continuous coverage and further roll back Obamacare mandates. The
Senate should also provide additional Medicaid reforms to improve the program for beneficiaries and taxpayers
alike.” (Ref. 3)
OBAMACARE
Some of the more significant problems in Obamacare were its “federal control over state
health insurance markets {that have} proven to be a costly and painful experiment, resulting in soaring premiums
and skyrocketing deductibles for enrollees. One factor {that drove} up costs was Obamacare’s preemption of state
authority for insurance markets and its imposition of costly new federal benefit mandates and regulations. This
unnecessary move short-circuited the ability of states to adopt different approaches or to modify rules to
accommodate changing circumstances.
“Obamacare’s structure of new federal health insurance regulations and subsidies was
designed to provide lower-income individuals in need of medical care with comprehensive coverage at little cost
to the recipients. Obamacare also applied those same regulations, but not the subsidies, to the broader individual
and small employer health insurance markets.
“Americans with unsubsidized coverage through individual-market or small-employer policies
have borne the brunt of the premium increases and coverage disruption caused by Obamacare’s insurance market
regulations. They are the ones most in need of relief from Obamacare. Additionally, Obamacare’s mandates
aggravate{d} the cost problem by discouraging young persons from enrolling in coverage, leaving the insurance pools
with older and less healthy enrollees and ignoring the needs and preferences of customers.
“The Centers for Medicare and Medicaid Services (CMS) reported that in the federally
supervised health insurance exchanges (39 states), between 2013 and 2017, average monthly premiums
increased from $232 to $476—a 105 percent increase. [Emphasis mine] CMS concluded that insurance plans’
high premiums and the lack of affordability in these markets {was} the main reason that individuals are cancelling
or terminating their coverage. Between 2014 and 2017, about one million individuals per year dropped their
coverage.
“Soaring health insurance costs {hammered} customers in non-group coverage, leaving those
customers to navigate the wreckage of severely damaged individual markets. Health plan withdrawals {were}
contributing to rapidly declining market competition and thus restricting consumer choice. In 2018, according to a
recent . . . report, about 45 percent of U.S. counties will have either one or no insurers offering coverage
in the Obamacare exchanges. [Emphasis mine]
“Meanwhile, customers {were} discovering that their coverage choices {were} increasingly
limited to plans with high deductibles and narrow physician networks.
“Obamacare’s excessive regulatory regime directly contributed to this state of
ffair. . .” (Ref. 3)
Another destructive aspect of Obamacare was the increased cost of Medicaid. “Medicaid is a
means-tested health care and social services program for low-income children, pregnant women, and aged or disabled
individuals. {Under} Obamacare . . . Medicaid eligibility {was expanded} to include able-bodied adults
without children. Indeed, the Medicaid expansion has accounted for over 80 percent of the net increase in total
(both public and private) health insurance enrollment since Obamacare’s coverage provisions went into effect at the
beginning of 2014.” [Emphasis mine] (Ref. 3)
THE BETTER CARE RECONCILIATION ACT
The Republican Better Care Reconciliation Act “takes steps to better target
Medicaid’s safety net to those who most need it to ensure that Medicaid reforms work for the long haul and provide
access to better care.
“The Senate bill (like the House bill) would end the open-ended entitlement of states to
federal Medicaid funding. It would cap federal contributions to Medicaid spending, with the federal government
instead allocating federal monies to state Medicaid programs on a set, per capita basis for the different covered
Medicaid populations: children, the elderly, the disabled, and able-bodied adults, including those made newly
eligible for Medicaid under Obamacare. The per capita funding amounts for a state would be determined based on
average spending by the state for each category of enrollees, with total funding reflecting the number of enrollees
in each category in the state.
“The Senate’s per capita cap funding approach is a major reform, consistent with policies
recommended over the years by conservative health policy experts.
“It represents a major improvement over existing federal payment arrangements and allows
states greater flexibility in the administration of the Medicaid program. The per capita approach also
offers the benefits of giving states stronger incentives to eliminate waste and fraud in the program; preventing
states from gaming federal reimbursement formulas; and better targeting resources to the needy and most vulnerable
to improve results.” [Emphasis mine] (Ref. 3)
AN IMPROVED BETTER CARE RECONCILIATION ACT
On net, the Better Care Reconciliation Act is better than the status quo because
it contains provisions to reduce insurance premiums and promote access to insurance in the short run, cuts taxes,
and provides major Medicaid reform that will help refocus the program on those most in need. But, to undo more of
Obamacare’s damage, Congress and the Administration need to go further by expanding states’ regulatory reform
options to encourage continuous coverage and further roll back Obamacare
mandates. [4]
There are still more ways to improve the Better Care Reconciliation Act. For
example, improvements could be made to the Medicaid provisions to ensure that the program helps those most in
need.
“First, Medicaid tends to provide less access to providers and poorer quality of care than
private insurance. Many Medicaid enrollees cannot find a doctor to take care of them because the reimbursement rates
and the regulatory system discourage physician participation in the program. Low-income able-bodied adults cycling
on and off of Medicaid as their employment and incomes fluctuate experience disruption in their health care
coverage. Enabling those individuals to instead access mainstream private insurance coverage would improve
continuity of coverage and access to higher quality care.
“Therefore, the Senate should convert existing Medicaid and Children’s Health Insurance
Program (CHIP) funding for able-bodied adults and children into a premium-support program so those beneficiaries can
enroll in private health insurance plans—and thus be able to secure access to the same doctors and medical
professionals as their fellow citizens. This would help them obtain the same basic coverage and care as more
affluent individuals, while also augmenting efforts to create more stable insurance markets. Such a reform would
increase their access to the quality care that they need, and would increase the number of younger and healthier
persons enrolled in the nation’s private health insurance pools.
“Second, an effective per capita approach requires that federal contributions grow over
time at rates that are realistic and consistent with achievable expectations for the ability of states to moderate
future spending. . .
- - -
“. . . {T}he Senate should revise the indexing provisions in the bill to better match them
to the historic and projected growth rates of the different beneficiary groups . . .
“Variations in growth rates largely reflect variations in the mix of services consumed by
different groups of beneficiaries. While per capita growth in the cost of acute-care medical services reflects
changes in medical technology and practices, growth in the cost of personal care services is almost entirely a
product of changes in wage rates. Thus, costs have grown the fastest for non-elderly, non-disabled adults
and children because Medicaid is paying mainly for acute medical services for those individuals. Conversely,
Medicaid costs have grown the slowest for aged enrollees because the program is mainly paying to provide them with
social services (with all of their acute medical care separately paid for by Medicare).
[Emphasis mine]
”Third, {improvements could be made} to ensure {that} states have the flexibility they
need to manage their Medicaid programs. {This could mean} steps {to give states} explicit authority to set and
manage eligibility for their Medicaid programs through a range of means such as asset tests.
“Moreover, {improvements} should ensure that Medicaid focuses—as soon as possible—on the
most vulnerable by removing Obamacare’s excess federal funding for newly eligible able-bodied adult
recipients. . .
“Importantly, the Senate should recognize that the current bill’s proposal to give states
an option for setting work requirements on able-bodied Medicaid recipients will not be particularly
effective.
- - -
“Most states will simply ignore the option. Its enforcement is very difficult in a society
that provides emergency medical care to all. Medicaid work requirements could be circumvented easily by simply
dropping out of the program and seeking emergency medical care when needed, at which point the individual would be
re-enrolled in Medicaid, with the potential to repeat the cycle again. There are far better options for pursuing
work requirements in other welfare programs that have been consistently ignored by Congress.
“Repeal the Cadillac Tax. . . .
“{An improved Better Care Reconciliation Act} should couple repeal of the
Cadillac tax with a critical reform of the tax treatment of employer-based health care in the form of setting a
limit on the amount of pre-tax contributions to employer-sponsored health insurance.
“Economists across the political spectrum have long argued that the current policy of
providing an unlimited exclusion from taxation for income received in the form of employer-sponsored health
benefits is a major systemic driver of health care costs. By its special treatment of employer-based coverage,
the policy also undermines portability of coverage, contributes to the opacity of health care costs, distorts
health care markets, and limits consumer choice and competition, and is regressive in its application to American
workers and their families.
“A cap is an appropriate correction for these economic distortions. Capping pre-tax
contributions would encourage employers and workers to seek better value for money spent on health care without
the rigidity of the Obamacare excise tax, which effectively forces employers to limit the scope of health benefits
plans. Such a policy would be consistent with the pre-tax funding limits set in law for other employee benefits,
such as contributions to retirement savings, group term-life insurance, and dependent care expenses.
“Moreover, capping the exclusion can be coupled with a reform to let individuals with
employer-sponsored benefits choose whether they want to use the existing tax exclusion or the new tax credit. This
option would especially benefit lower-wage workers, who likely would benefit more by opting for the tax credit and
may be more likely to accept offers of employer-sponsored coverage. Moreover, employers in lower-wage industries may
be induced to offer coverage.
“Finally, {we} should go further in helping Americans save for health care through Health
Savings Accounts (HSAs), which allow individuals to save money for their health expenses in an account they own and
control, without losing the money at the end of the year. These accounts are a marked improvement over other
tax-privileged choices like Flexible Savings Accounts, in which the user has to “use or lose” the money
annually. . .
“HSAs offer two significant advantages. First, account holders are able to exercise more
direct control over how their health care dollars are spent and have the ability to pocket the savings from
obtaining better value care (as opposed to savings accruing to their insurer). Second, they give Americans both
an incentive and a mechanism to save for future health expenses.
“Two key problems with HSAs limit their usefulness. Individuals must buy a high-deductible
insurance policy to contribute to the accounts, and they are limited in their ability to save in these accounts.
The {Better Care Reconciliation Act} addresses the latter issue by increasing allowable contribution
amounts for HSAs.
“{An improved {Better Care Reconciliation Act} should go further and permit HSAs
to be used with any type of insurance plan, not just high-deductible policies. They also should ensure HSAs can be
used as repositories for contributions from public or private sources in order to assist lower income individuals to
finance health insurance and medical care. These changes also would ensure neutrality with respect to any incentives
for spending on health insurance versus spending on medical care directly.” (Ref. 3)
An improved {Better Care Reconciliation Act} should create enough incentives for
continuous health care coverage—either directly or by permitting states to use a waiver process. This is important
to limiting the adverse selection and gaming effects that have driven up premiums under Obamacare.
In addition, states should be permitted to experiment with different approaches for
incentivizing continuous coverage. Additional options should be encouraged, such as allowing states to authorize
insurers to prohibit preexisting condition exclusions only for those individuals who can demonstrate continuous
coverage during the prior year. Also, there should be flexibility for insurers to impose on those who do not
maintain continuous coverage additional cost-sharing requirements (e.g., higher deductibles) for a limited period
of time.
Additionally, Obamacare’s requirement to cover specified preventive services with no cost
sharing charged to enrollees should be ended. Prior to Obamacare, plans typically covered most of those services
already, obviating the need to mandate coverage. Also, a number of those so-called preventive services are actually
diagnostic tests or procedures, and allowing insurers to set patient co-pays is an appropriate way to manage
utilization.
THE NEXT STEPS
Today (28 June 2017), some nine Republican senators have balked at voting for the current
version of Better Care Reconciliation Act. So be it! Let them work to revise the bill to make it more
compatible with their thinking. Today (28 June 2017), not one single Democratic senator (out of a total of 48
Democratic senators) has said he/she will vote for the current version of the Better Care Reconciliation
Act. This is totally unacceptable! This is nothing more than irresponsible behavior and a
demonstration of what is wrong with American politics today. There certainly has to be more than a few Democratic
senators who recognize the problems with Obamacare, the need for its repeal and replacement and who should be
willing to work with their Republican counterparts to come up with a replacement that they could support. It might
not meet all their wants, but it would be better than what they and the American people now have. Isn’t it about
time that our politicians in Washington stopped acting like politicians and started acting like representatives of
the American people?
In 1830, Jeremiah Evarts, an outspoken opponent to the forced removal of native American
Indians to lands west of the Mississippi, wrote, in reference to the advent of party politics in America, “Now
what can we do, when men will act in this manner? . . . The question is already as plain in the Senate as any
question of human conduct can possibly be. Not one question of theft, robbery, or murder, in ten thousand, is so
perfectly free from all doubt or cavil . . . yet is expected that men will vote by platoons, in regular rank
and file, according to party drilling, [Emphasis mine], on this question of public faith. I have never
before seen such a commentary on human depravity.” (Ref. 5)
With the impasse along party lines over health care here in America, nearly 190 years later, the prescient foresight
of Evarts, unfortunately, is all too evident. The failure of America’s elected representatives to compromise and the
emergence of unbending partisan politics less than half a century after the signing of the Declaration of
Independence began the fight over state’s rights and secession, ultimately resulting in the bloody American Civil
War. Where will acrimonious and uncompromising partisan politics take us in this 21st century?
“It {will be} just as calamitous for Republicans to implement a health care plan without a
single Democratic vote as it was when Democrats pushed through the Affordable Care Act eight years ago without a
single Republican vote.
- - -
“{Senate Majority Leader Mitch McConnell should} - with Trump’s backing and support —
. . . reach across the aisle and issue a sincere invitation to Democrats to participate in crafting a fix to the
Affordable Care Act, which absolutely needs fixing. This is an opportunity for Trump to do what Obama couldn’t, to
put in place a bipartisan health care plan.
“There are popular aspects of Obamacare — no denial of pre-existing conditions, the ability
to keep children covered until age 26 and expansion of Medicaid coverage to the poor — that appeal to many
epublicans. And there are aspects of Obamacare — lack of choice, significant increases in health insurance costs
and costly and bureaucratic employer mandates — that Democrats know need to be fixed.
“Health care represents about one-sixth of the American economy. It is too important an
issue to be decided by 2018 election calculus. There is a path toward bipartisan compromise. Let’s hope someone —
anyone — in Washington has the courage to lead down that path.” (Ref. 6)
Democrats must realize that they no longer hold majorities of any kind in the Capitol. If Congressional
Democrats wish to serve their constituents and all Americans, they will need to make compromises to ensure that
American citizens get what they need, even if it’s not what Democrats want. In a similar vein, Republicans must
realize by now, that they can’t railroad an unacceptable health care bill through Congress, even if they do hold
majorities in both houses. It is evident that members of their own party will step up and oppose a health care bill
that they feel is unacceptable to their constituents.
The answer to the ongoing and vexing question of what to do about reforming the existing
health care law – Obamacare - is for all sides to lock themselves in a room and work out the hard compromises
needed to arrive at a less-than-ideal health care plan – but one which fixes the more glaring deficiencies of
Obamacare. This less-than-ideal plan will not totally satisfy everybody, but it should satisfy more Americans than
Obamacare or the current GOP plan. Our politicians need to abandon their “it’s my way or the highway” approach to
their differences and get back to a give-and-take approach to arrive at a meaningful improvement. They need to tackle
the health care issue with a “let’s arrive at the best compromise possible” attitude. Unfortunately, “compromise”
has become such a dirty word in politics today that nothing is being accomplished. BUT, compromise
is the only way to end the perpetual gridlock in our nation’s capital. Nobody can expect to get everything they say
they want. Instead, it’s time to consider what’s best for the majority of Americans in the most practical context,
rather than continually trying to find some unattainable and unworkable ideal. Our pollical leaders need to be
locked away in a room and not allowed out until they have come to a workable compromise health care plan.
Failure to agree should not and cannot be an option! Failure to come to an agreement should be
viewed as grounds for removal from elective office. The American people are fast becoming frustrated with the
seemingly eternal political stalemate in our government – healthcare being just the latest example of this
unacceptable behavior by our elected representatives. The electorate wants action, answers, and, most important,
the electorate wants fixes and they want them now. What we don’t want is more rhetoric, more obfuscation, and a
continuing impasse. Hopefully, there are those in our political rank and file who will roll up their sleeves and
find realistic and significant answers to the healthcare dilemma. We urge them to come up with the solutions that
can make it through our partisan legislative bodies, be signed into law by the president, and become an affordable
and workable health care program.
Republican Senator John McCain has urged Republicans and Democrats to reach a compromise on
health care. When the Democrats rammed through Obamacare, they did it on a strictly partisan basis. Similarly,
Republicans did not include Democrats in the formation of an Obamacare replacement. [7]
“We’ve got to go back and address this issue on a bipartisan basis and we can’t wait until
people are without health care,” . . . “We’ve got to have some bipartisanship around here, otherwise we’re not going
to get much done.” (Ref. 7)
In times past, during election years, politicians would take the pledge –“No more Taxes!”
Today, they need to take a new pledge – “We'll stay in session until a health care compromise is reached!”
Obamacare was and is a disaster. The current Republican replacement plan may or may not be
a final solution. But, our elected officials can and must reach agreement on what is the best practical Obamacare
replacement. They must do it now and not kick the problem down the road.
Even with the passage of an improved Better Care Reconciliation Act, there will
still be significant work remaining to undo all the damage of Obamacare and resolve the problems in the American
health care system that preceded it. This cannot be accomplished in one giant step. Future efforts will need to be
part of an ongoing process at both the state and federal levels. The health care issue in America will not be
resolved in one fell swoop. Congress and future administrations will have to address issues left out of the bill
and to correct those unavoidable mistakes that will be made. Costs can only be contained with additional reforms -
at both the state and federal levels - that will create more consumer-driven market incentives for medical providers
to offer better value care and empower consumers with options to seek better value.
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References:
- Analysis: Fight to save health care bill likely lost cause for GOP , Kimberly Atkins,
Boston Herald, Page 10,
15 March 2017.
- Vote on Senate health care bill delayed amid lack of support, Meghan Kendally and Mariam Khan,
ABC News,
27 June 2017.
- Better than the Status Quo, Senate Health Care Bill Still Misses Major Opportunities,
Edmund Haislmaier,
Robert Moffit, Robert Rector and Marie Fishpaw, The Heritage Foundation,
26 June 2017.
- Here's the latest on Obamacare repeal, Ed Feulner, info@heritage.org,
29 June 2017.
- American Lion: Andrew Jackson in the White House, Jon Meacham,
Random House Trade Paperbacks,
Page 143, 2009.
- Editorial: Work together on health care, J-W editorial staff,
Lawrence Journal-World, 28 June 2017.
- John McCain suggests a bipartisan compromise must be reached on health care, Rebecca Shabad,
CBS News,
28 March 2017.
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