Longer-Term Effects of the Better Care Reconciliation Act of 2017 on Medicaid Spending

Longer-Term Effects of the Better Care Reconciliation Act of 2017 on Medicaid Spending

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In CBO’s assessment, Medicaid spending under the Better Care Reconciliation Act of 2017 would be 26 percent lower in 2026 than it would be under the agency’s extended baseline, and the gap would widen to about 35 percent in 2036 (see figure below). Under CBO’s extended baseline, overall Medicaid spending would grow 5.1 percent per year during the next two decades, in part because prices for medical services would increase. Under this legislation, such spending would increase at a rate of 1.9 percent per year through 2026 and about 3.5 percent per year in the decade after that.

CBO and the staff of the Joint Committee on Taxation do not have an insurance coverage baseline beyond the coming decade and therefore are not able to quantify the legislation’s effect on insurance coverage over the longer term. However, the agencies expect that after 2026, enrollment in Medicaid would continue to fall relative to what would happen under the extended baseline.

On the basis of consultation with the budget committees, CBO’s just-released cost estimate for the bill measured the costs and savings relative to CBO’s March 2016 baseline projections, with adjustments for legislation that was enacted after that baseline was produced. For consistency, this longer-term analysis uses CBO’s extended baseline published in July 2016. CBO analyzed these longer-term effects at the request of the Ranking Members of the Senate Budget Committee and the Senate Finance Committee.

Related CBO Publications:

The CBO Report is Out—We’re Still Screwed!

— as Posted at the Website of the Congressional Budget Office on June 26, 2017


View the full CBO Report Here


The Congressional Budget Office and the staff of the Joint Committee on Taxation (JCT) have completed an estimate of the direct spending and revenue effects of the Better Care Reconciliation Act of 2017, a Senate amendment in the nature of a substitute to H.R. 1628. CBO and JCT estimate that enacting this legislation would reduce the cumulative federal deficit over the 2017-2026 period by $321 billion. That amount is $202 billion more than the estimated net savings for the version of H.R. 1628 that was passed by the House of Representatives.

The Senate bill would increase the number of people who are uninsured by 22 million in 2026 relative to the number under current law, slightly fewer than the increase in the number of uninsured estimated for the House-passed legislation. By 2026, an estimated 49 million people would be uninsured, compared with 28 million who would lack insurance that year under current law.

Following the overview, this document provides details about the major provisions of this legislation, the estimated costs to the federal government, the basis for the estimate, and other related information, including a comparison with CBO’s estimate for the House-passed act.

Effects on the Federal Budget

CBO and JCT estimate that, over the 2017-2026 period, enacting this legislation would reduce direct spending by $1,022 billion and reduce revenues by $701 billion, for a net reduction of $321 billion in the deficit over that period (see Table 1, at the end of this document):

  • The largest savings would come from reductions in outlays for Medicaid—spending on the program would decline in 2026 by 26 percent in comparison with what CBO projects under current law—and from changes to the Affordable Care Act’s (ACA’s) subsidies for non-group health insurance (see Figure 1). Those savings would be partially offset by the effects of other changes to the ACA’s provisions dealing with insurance coverage: additional spending designed to reduce premiums and a reduction in revenues from repealing penalties on employers who do not offer insurance and on people who do not purchase insurance.
  • The largest increases in deficits would come from repealing or modifying tax provisions in the ACA that are not directly related to health insurance coverage, including repealing a surtax on net investment income and repealing annual fees imposed on health insurers.

Pay-as-you-go procedures apply because enacting this legislation would affect direct spending and revenues. CBO and JCT estimate that enactment would not increase net direct spending or on-budget deficits in any of the four consecutive 10-year periods beginning in 2027. The agencies expect that savings, particularly from Medicaid, would continue to grow, while the costs would be smaller because a rescinded tax on employees’ health insurance premiums and health plan benefits would be reinstated in 2026. CBO has not completed an estimate of the potential impact of this legislation on discretionary spending, which would be subject to future appropriation action.

Effects on Health Insurance Coverage

CBO and JCT estimate that, in 2018, 15 million more people would be uninsured under this legislation than under current law—primarily because the penalty for not having insurance would be eliminated. The increase in the number of uninsured people relative to the number projected under current law would reach 19 million in 2020 and 22 million in 2026. In later years, other changes in the legislation—lower spending on Medicaid and substantially smaller average subsidies for coverage in the non-group market—would also lead to increases in the number of people without health insurance. By 2026, among people under age 65, enrollment in Medicaid would fall by about 16 percent and an estimated 49 million people would be uninsured, compared with 28 million who would lack insurance that year under current law.

Stability of the Health Insurance Market

Decisions about offering and purchasing health insurance depend on the stability of the health insurance market—that is, on the proportion of people living in areas with participating insurers and on the likelihood of premiums’ not rising in an unsustainable spiral. The market for insurance purchased individually with premiums not based on one’s health status would be unstable if, for example, the people who wanted to buy coverage at any offered price would have average health care expenditures so high that offering the insurance would be unprofitable.

Under Current Law. Although premiums have been rising under current law, most subsidized enrollees purchasing health insurance coverage in the non-group market are largely insulated from increases in premiums because their out-of-pocket payments for premiums are based on a percentage of their income; the government pays the difference between that percentage and the premiums for a reference plan (which is the second-lowest-cost plan in their area providing specified benefits). The subsidies to purchase coverage, combined with the effects of the individual mandate, which requires most individuals to obtain insurance or pay a penalty, are anticipated to cause sufficient demand for insurance by enough people, including people with low health care expenditures, for the market to be stable in most areas.

Nevertheless, a small number of people live in areas of the country that have limited participation by insurers in the non-group market under current law. Several factors may lead insurers to withdraw from the market—including lack of profitability and substantial uncertainty about enforcement of the individual mandate and about future payments of the cost-sharing subsidies to reduce out-of-pocket payments for people who enroll in non-group coverage through the marketplaces established by the ACA.

Under This Legislation. CBO and JCT anticipate that, under this legislation, non-group insurance markets would continue to be stable in most parts of the country. Although substantial uncertainty about the effects of the new law could lead some insurers to withdraw from or not enter the non-group market in some states, several factors would bring about market stability in most states before 2020. In the agencies’ view, those key factors include the following: subsidies to purchase insurance, which would maintain sufficient demand for insurance by people with low health care expenditures; the appropriation of funds for cost-sharing subsidies, which would provide certainty about the availability of those funds; and additional federal funding provided to states and insurers, which would lower premiums by reducing the costs to insurers of people with high health care expenditures.

The agencies expect that the non-group market in most areas of the country would continue to be stable in 2020 and later years as well, including in some states that obtain waivers that would not have otherwise done so. (Under current law and this legislation, states can apply for Section 1332 waivers to change the structure of subsidies for non-group coverage; the specifications for essential health benefits [EHBs], which set the minimum standards for the benefits that insurance in the non-group and small-group markets must cover; and other related provisions of law.) Substantial federal funding to directly reduce premiums would be available through 2021. Premium tax credits would continue to provide insulation from changes in premiums through 2021 and in later years. Those factors would help attract enough relatively healthy people for the market in most areas of the country to be stable, CBO and JCT anticipate. That stability in most areas would occur even though the premium tax credits would be smaller in most cases than under current law and subsidies to reduce cost sharing—the amount that consumers are required to pay out of pocket when they use health care services—would be eliminated starting in 2020.

In the agencies’ assessment, a small fraction of the population resides in areas in which—because of this legislation, at least for some of the years after 2019—no insurers would participate in the non-group market or insurance would be offered only with very high premiums. Some sparsely populated areas might have no non-group insurance offered because the reductions in subsidies would lead fewer people to decide to purchase insurance—and markets with few purchasers are less profitable for insurers. Insurance covering certain services would become more expensive—in some cases, extremely expensive—in some areas because the scope of the EHBs would be narrowed through waivers affecting close to half the population, CBO and JCT expect. In addition, the agencies anticipate that all insurance in the nongroup market would become very expensive for at least a short period of time for a small fraction of the population residing in areas in which states’ implementation of waivers with major changes caused market disruption.

Effects on Premiums and Out-of-Pocket Payments

The legislation would increase average premiums in the non-group market prior to 2020 and lower average premiums thereafter, relative to projections under current law, CBO and JCT estimate. To arrive at those estimates, the agencies examined how the legislation would affect the premiums charged if people purchased a benchmark plan in the non-group market.

In 2018 and 2019, under current law and under the legislation, the benchmark plan has an actuarial value of 70 percent—that is, the insurance pays about 70 percent of the total cost of covered benefits, on average. In the marketplaces, such coverage is known as a silver plan.

Under the Senate bill, average premiums for benchmark plans for single individuals would be about 20 percent higher in 2018 than under current law, mainly because the penalty for not having insurance would be eliminated, inducing fewer comparatively healthy people to sign up. Those premiums would be about 10 percent higher than under current law in 2019—less than in 2018 in part because funding provided by the bill to reduce premiums would affect pricing and because changes in the limits on how premiums can vary by age would result in a larger number of younger people paying lower premiums to purchase policies.

In 2020, average premiums for benchmark plans for single individuals would be about 30 percent lower than under current law. A combination of factors would lead to that decrease—most important, the smaller share of benefits paid for by the benchmark plans and federal funds provided to directly reduce premiums.

That share of services covered by insurance would be smaller because the benchmark plan under this legislation would have an actuarial value of 58 percent beginning in 2020. That value is slightly below the actuarial value of 60 percent for “bronze” plans currently offered in the marketplaces. Because of the ACA’s limits on out-of-pocket spending and prohibitions on annual and lifetime limits on payments for services within the EHBs, all plans must pay for most of the cost of high-cost services. To design a plan with an actuarial value of 60 percent or less and pay for those high-cost services, insurers must set high deductibles—that is, the amounts that people pay out of pocket for most types of health care services before insurance makes any contribution. Under current law for a single policyholder in 2017, the average deductible (for medical and drug expenses combined) is about $6,000 for a bronze plan and $3,600 for a silver plan. CBO and JCT expect that the benchmark plans under this legislation would have high deductibles similar to those for the bronze plans offered under current law. Premiums for a plan with an actuarial value of 58 percent are lower than they are for a plan with an actuarial value of 70 percent (the value for the reference plan under current law) largely because the insurance pays for a smaller average share of health care costs.

Although the average benchmark premium directly affects the amount of premium tax credits and is a key element in CBO’s analysis of the budgetary effects of the bill, it does not represent the effect of this legislation on the average premiums for all plans purchased. The differences in the actuarial value of plans purchased under this legislation and under current law would be greater starting in 2020—when, for example, under this bill, some people would pay more than the benchmark premium to purchase a silver plan, whereas, under current law, others would pay less than the benchmark premium to purchase a bronze plan.

Under this legislation, starting in 2020, the premium for a silver plan would typically be a relatively high percentage of income for low-income people. The deductible for a plan with an actuarial value of 58 percent would be a significantly higher percentage of income—also making such a plan unattractive, but for a different reason. As a result, despite being eligible for premium tax credits, few low-income people would purchase any plan, CBO and JCT estimate.

By 2026, average premiums for benchmark plans for single individuals in most of the country under this legislation would be about 20 percent lower than under current law, CBO and JCT estimate—a smaller decrease than in 2020 largely because federal funding to reduce premiums would have lessened. The estimates for both of those years encompass effects in different areas of the country that would be substantially higher and substantially lower than the average effect nationally, in part because of the effects of state waivers. Some small fraction of the population is not included in those estimates. CBO and JCT expect that those people would be in states using waivers in such a way that no benchmark plan would be defined. Hence, a comparison of benchmark premiums is not possible in such areas.

Some people enrolled in non-group insurance would experience substantial increases in what they would spend on health care even though benchmark premiums would decline, on average, in 2020 and later years. Because non-group insurance would pay for a smaller average share of benefits under this legislation, most people purchasing it would have higher out-of-pocket spending on health care than under current law. Out-of-pocket spending would also be affected for the people—close to half the population, CBO and JCT expect—living in states modifying the EHBs using waivers. People who used services or benefits no longer included in the EHBs would experience substantial increases in supplemental premiums or out-of-pocket spending on health care, or would choose to forgo the services. Moreover, the ACA’s ban on annual and lifetime limits on covered benefits would no longer apply to health benefits not defined as essential in a state. As a result, for some benefits that might be removed from a state’s definition of EHBs but that might not be excluded from insurance coverage altogether, some enrollees could see large increases in out-of-pocket spending because annual or lifetime limits would be allowed.

Uncertainty Surrounding the Estimates

CBO and JCT have endeavored to develop budgetary estimates that are in the middle of the distribution of potential outcomes. Such estimates are inherently inexact because the ways in which federal agencies, states, insurers, employers, individuals, doctors, hospitals, and other affected parties would respond to the changes made by this legislation are all difficult to predict. In particular, predicting the overall effects of the myriad ways that states could implement waivers is especially difficult.

CBO and JCT’s projections under current law itself are also uncertain. For example, enrollment in the marketplaces under current law will probably be lower than was projected under the March 2016 baseline used in this analysis, which would tend to decrease the budgetary savings from this legislation. However, the average subsidy per enrollee under current law will probably be higher than was projected in March 2016, which would tend to increase the budgetary savings from this legislation. (For a related discussion, see the section on “Use of the March 2016 Baseline” on page 15.)

Despite the uncertainty, the direction of certain effects of this legislation is clear. For example, the amount of federal revenues collected and the amount of spending on Medicaid would almost surely both be lower than under current law. And the number of uninsured people under this legislation would almost surely be greater than under current law.

Intergovernmental and Private-Sector Mandates

CBO has reviewed the non-tax provisions of the legislation and determined that they would impose intergovernmental mandates as defined in the Unfunded Mandates Reform Act (UMRA) by preempting state laws. Although the pre-emptions would limit the application of state laws, they would impose no duty on states that would result in additional spending or a loss of revenues. JCT has determined that the tax provisions of the legislation contain no intergovernmental mandates.

JCT and CBO have determined that the legislation would impose private-sector mandates as defined in UMRA. On the basis of information from JCT, CBO estimates that the aggregate cost of the mandates would exceed the annual threshold established in UMRA for private-sector mandates ($156 million in 2017, adjusted annually for inflation).

Resources and Related Links

On the AHCA Secrecy and the Character of our Country

by Barack Obama, POTUS-44

Our politics are divided. They have been for a long time. And while I know that division makes it difficult to listen to Americans with whom we disagree, that’s what we need to do today.

I recognize that repealing and replacing the Affordable Care Act has become a core tenet of the Republican Party. Still, I hope that our Senators, many of whom I know well, step back and measure what’s really at stake, and consider that the rationale for action, on health care or any other issue, must be something more than simply undoing something that Democrats did.

We didn’t fight for the Affordable Care Act for more than a year in the public square for any personal or political gain – we fought for it because we knew it would save lives, prevent financial misery, and ultimately set this country we love on a better, healthier course.

Nor did we fight for it alone. Thousands upon thousands of Americans, including Republicans, threw themselves into that collective effort, not for political reasons, but for intensely personal ones – a sick child, a parent lost to cancer, the memory of medical bills that threatened to derail their dreams.

And you made a difference. For the first time, more than ninety percent of Americans know the security of health insurance. Health care costs, while still rising, have been rising at the slowest pace in fifty years. Women can’t be charged more for their insurance, young adults can stay on their parents’ plan until they turn 26, contraceptive care and preventive care are now free. Paying more, or being denied insurance altogether due to a preexisting condition – we made that a thing of the past.

We did these things together. So many of you made that change possible.

At the same time, I was careful to say again and again that while the Affordable Care Act represented a significant step forward for America, it was not perfect, nor could it be the end of our efforts – and that if Republicans could put together a plan that is demonstrably better than the improvements we made to our health care system, that covers as many people at less cost, I would gladly and publicly support it.

That remains true. So I still hope that there are enough Republicans in Congress who remember that public service is not about sport or notching a political win, that there’s a reason we all chose to serve in the first place, and that hopefully, it’s to make people’s lives better, not worse.

But right now, after eight years, the legislation rushed through the House and the Senate without public hearings or debate would do the opposite. It would raise costs, reduce coverage, roll back protections, and ruin Medicaid as we know it. That’s not my opinion, but rather the conclusion of all objective analyses, from the nonpartisan Congressional Budget Office, which found that 23 million Americans would lose insurance, to America’s doctors, nurses, and hospitals on the front lines of our health care system.

The Senate bill, unveiled today, is not a health care bill. It’s a massive transfer of wealth from middle-class and poor families to the richest people in America. It hands enormous tax cuts to the rich and to the drug and insurance industries, paid for by cutting health care for everybody else. Those with private insurance will experience higher premiums and higher deductibles, with lower tax credits to help working families cover the costs, even as their plans might no longer cover pregnancy, mental health care, or expensive prescriptions. Discrimination based on pre-existing conditions could become the norm again. Millions of families will lose coverage entirely.

Simply put, if there’s a chance you might get sick, get old, or start a family – this bill will do you harm. And small tweaks over the course of the next couple weeks, under the guise of making these bills easier to stomach, cannot change the fundamental meanness at the core of this legislation.

I hope our Senators ask themselves – what will happen to the Americans grappling with opioid addiction who suddenly lose their coverage? What will happen to pregnant mothers, children with disabilities, poor adults and seniors who need long-term care once they can no longer count on Medicaid? What will happen if you have a medical emergency when insurance companies are once again allowed to exclude the benefits you need, send you unlimited bills, or set unaffordable deductibles? What impossible choices will working parents be forced to make if their child’s cancer treatment costs them more than their life savings?

To put the American people through that pain – while giving billionaires and corporations a massive tax cut in return – that’s tough to fathom. But it’s what’s at stake right now. So it remains my fervent hope that we step back and try to deliver on what the American people need.

That might take some time and compromise between Democrats and Republicans. But I believe that’s what people want to see. I believe it would demonstrate the kind of leadership that appeals to Americans across party lines. And I believe that it’s possible – if you are willing to make a difference again. If you’re willing to call your members of Congress. If you are willing to visit their offices. If you are willing to speak out, let them and the country know, in very real terms, what this means for you and your family.

After all, this debate has always been about something bigger than politics. It’s about the character of our country – who we are, and who we aspire to be. And that’s always worth fighting for.

Coverage Losses Under the Senate Health Care Bill Could Result in 18,100 to 27,700 Additional Deaths in 2026

—byy Ann Crawford-Roberts, Nichole Roxas, Ichiro Kawachi, Sam Berger, and Emily Gee

AP/Wilfredo Lee | Demonstrators protest during a health care demonstration outside the offices of Rep. Carlos Curbelo (R-FL), Thursday, May 4, 2017, in Miami.

One Republican member of Congress, defending the GOP health care plan—the American Health Care Act (AHCA)—suggested that concerns that the loss of health care coverage leads to death are overblown. However, the scientific literature on the effects of insurance coverage on mortality shows that the coverage losses from the AHCA would result in tens of thousands of deaths.

The secret Senate bill was finally released today, and it is broadly similar to what passed in the House: It ends Medicaid expansion and makes further deep cuts to the program; eliminates the individual mandate; and reduces funding that helps low-income Americans afford health coverage. The Congressional Budget Office (CBO) has not yet released its score of the Senate bill, although it is expected to do so early next week.

The CBO, however, has released a score of the House’s version of the AHCA, which is largely similar to the Senate bill. The score projected that, by 2026, 23 million more Americans would be uninsured under the House bill compared to the Affordable Care Act (ACA). Using estimates of mortality rates from Massachusetts’ experience with health reform, we estimate the number of additional deaths resulting from coverage losses from the Senate bill under three scenarios: one scenario in which coverage losses from the Senate bill are the same as under the House version, and two scenarios in which those coverage losses are modestly reduced by changes from the House bill.

  • Assuming that 15 million fewer people would have coverage in 2026, we estimate that the coverage losses from the Senate bill would result in 18,100 additional deaths in 2026.
  • Assuming that 19 million fewer people would have coverage, we estimate that the coverage losses from the Senate bill would result in 22,900 additional deaths in 2026.
  • Assuming that 23 million fewer people would have coverage, we estimate that the coverage losses from the Senate bill would result in 27,700 additional deaths in 2026. If coverage losses from the Senate bill matched those from the House bill, it would result in 217,000 additional deaths over the next decade.

Allocating these coverage losses among the states, this analysis also presents estimates of additional deaths by state.

Health insurance is associated with improved health and reduced mortality

A significant body of research has demonstrated the health benefits associated with health insurance expansion, including reducing the rate of death among the population. One study found that state Medicaid expansions that preceded the ACA were associated with a significant reduction in mortality. A recent analysis of these pre-ACA Medicaid expansions demonstrated a 6 percent decline in all-cause mortality due to Medicaid expansion. Another analysis showed that following implementation of the ACA’s provision that allows young adults to remain on a parent’s health insurance until age 26, mortality rates decreased among Americans ages 19 to 25. In particular, mortality caused by diseases amenable to health care dropped among young adults, while trauma-related mortality did not. And a study of patients with cancer between the ages of 20 to 40 found a statistically significant association between insurance coverage and reduced mortality from any cause.

The result most relevant to the ACA and its repeal comes from a study examining the effects of the Massachusetts health care reform on all-cause mortality and on mortality due to causes amenable to health care. The study found that expanding insurance coverage was associated with a 2.9 percent decrease in all-cause mortality and a 4.5 percent reduction in deaths from causes amenable to health care. Because Massachusetts’s reform was used as the model for the ACA and included a coverage mandate, Medicaid expansion, and private insurance expansion through the individual market, the data is more representative of the effects of ACA insurance gains than studies looking solely at Medicaid expansion or narrow demographic groups. Furthermore, observers have noted that the study’s quasi-experimental study design is of high quality and the “next best thing” to a randomized control study.

Other parts of the scientific literature have shown how having health insurance, unsurprisingly, results in better health. A recent study of three years of ACA data demonstrated that uninsured people who gained coverage through the ACA experienced a 23 percent increase in self-reported “excellent” health. One analysis found that the ACA coverage expansion was associated with reductions in self-reported “fair” or “poor” health and days with activity limitations due to ill health. Another analysis showed that ACA insurance gains were associated with an increased share of respondents reporting excellent health. And a recent study of ACA-facilitated Medicaid expansions found that they modestly improved self-reported health.

Other insurance expansions produced similar results. Massachusetts’ insurance expansion was associated with improvements in self-reported general, physical, and mental health. Data from the Oregon Health Insurance Experiment showed that expanding Medicaid was associated with improved self-reported physical and mental health and reduced depression.

Insurance coverage also improves children’s health and access to care. Research shows that when parents have insurance coverage, their children are more likely to be covered, maintain stable coverage, and receive needed care. According to the Institute of Medicine’s systematic review, insured children are more likely to gain access to well-child care and immunizations, appropriate care for asthma, and basic dental services, as well as have fewer avoidable hospitalizations, improved asthma outcomes, and fewer missed days of school.

Taken as a whole, the research strongly suggests that health coverage has a significant positive effect on health. However, a few studies have found more limited health impacts of insurance expansion. While the Oregon study found improvements in self-reported health, it did not detect clinical improvements other than depression reduction. Another study showed no changes in self-reported health resulting from the ACA, although a subgroup analysis did show improved self-assessed health among older nonelderly adults, especially in expansion states. And an early observational study of the ACA’s Medicaid expansion comparing low-income adults in expansion and nonexpansion states found no differences in self-reported health between the groups.

There may be several reasons for these outlier results. The studies in question looked at time frames too short or sample sizes too small to capture more significant health impacts. In addition, insurance is a necessary but not sufficient factor to receive quality health care. Receiving high-quality health care requires access to providers, institutions, and services; access to consistent primary care and referral services; choice of providers and institutions; and the delivery of high-quality services. It also requires that insurance policies cover basic and vital services.

The effects of the repeal bill on mortality

Drawing on the Massachusetts experience, we estimate that there would be one excess death for every 830 people who lose coverage as a result of the AHCA. The CBO projections of coverage reductions under the House version of the AHCA would equate to 217,000 additional deaths over the next decade, including 27,700 additional deaths in 2026. (see Table 1) To put this in perspective, that is approximately the number of people in the United States who died from opioid overdoses in 2014 and about twice the number of deaths by  that same year.

We also estimate the additional deaths in 2026 resulting from coverage losses from the Senate bill under three scenarios: one assuming coverage losses equivalent to the House bill and two scenarios that show modest reductions in coverage losses. If the Senate bill results in coverage losses of 19 million that would result in 22,900 additional deaths in 2026. If the Senate bill results in coverage losses of 15 million that would result in 18,100 additional deaths in 2026.

In addition, drawing on the Center for American Progress’ estimate of state-level coverage reductions in 2026 under the House version of the AHCA, we estimate additional deaths by state in 2026 as a result of coverage losses from the Senate bill under the three scenarios. Under the scenario assuming coverage losses of 23 million, annual additional deaths would range from 36 in North Dakota to 3,111 in California in 2026. Under the scenario assuming coverage losses of 19 million, annual additional deaths in 2026 would range from 30 in North Dakota to 2,570 in California. Finally, under the scenario assuming coverage losses of 15 million, annual additional deaths in 2026 would range from 24 in North Dakota to 2,029 in California.

Conclusion

Given the overwhelming weight of evidence, there should be no debate: Health care coverage has an impact on whether Americans live or die. Our data estimates show that under any of the scenarios we analyzed, a significant number of American lives are at stake in this debate. Legislators considering whether to support this bill should keep in mind and soberly consider the catastrophic effect the AHCA would have on so many Americans and their families.

Methodology

We calculated national excess deaths per year by dividing the estimated coverage losses by the estimated numbers needed to treat (NNT) to prevent one death, based on analyses of the Massachusetts health care reform. “Treatment” in this instance refers to the number of individuals who would need to receive insurance coverage in order to prevent one extra death. The Massachusetts study found that there was one fewer death for every 830 people who gained coverage; that NNT was consistent with a 30 percent relative reduction in individual-level mortality for persons gaining insurance.

We estimate that there would be one excess death for every 830 people who lose insurance coverage, which assumes that the Massachusetts result would be symmetric for health insurance gains and losses. Of note, our approach is similar to that taken by the White House Council of Economic Advisers to calculate the mortality reductions from the ACA.

Our estimate of the national number of excess deaths each year under the AHCA is then equal to the CBO-projected coverage reduction under the House bill divided by 830. We calculated state level estimates by applying the same methodology to state-level health insurance losses from the Center for American Progress’ state-level analysis, which combines data from the CBO, the Kaiser Family Foundation, the Centers for Medicare and Medicaid Services, and the American Community Survey to calculate anticipated insurance losses by coverage type.

We also included estimates of the number of excess deaths in 2026 if national coverage losses under the Senate bill were 15 million or 19 million that year. For our state-level estimates, we assume that each state’s coverage reductions and excess deaths are 65 percent and 83 percent of our estimates of the effects under the House-passed bill, respectively.

Recent debate sheds light on different approaches to estimate the mortality impacts of insurance loss. Bearing this debate in mind, we designed our approach using the most accurate, rigorous studies. We base our calculations on estimates of AHCA-related coverage losses from the CBO and the Center for American Progress, and on Benjamin D. Sommers, Sharon K. Long, and Katherine Baicker’s 2014 quasi-experimental study of the effects of Massachusetts Health Care Reform on mortality. We chose this study due to its sample size and power, and because Massachusetts’ health reform, which expanded both private and public coverage, was used as the model for the ACA.

One limitation of our analysis is that the same NNT was applied to all states, although the estimate was derived from the Massachusetts’ health care reform. There are demographic and health care infrastructure differences between Massachusetts and other states. The Massachusetts population has a higher per capita physician rate, lower baseline mortality rate, higher income and baseline insurance coverage rates, fewer racial and ethnic minorities, and more women, compared to national averages. Some of these factors suggest that Massachusetts may have a higher NNT than other states, meaning that our estimate of the number of excess deaths under the AHCA would be too low, while other factors suggest the state may have a lower NNT.

In addition, the NNT was calculated from mortality decreases associated with insurance expansion. There is uncertainty as to whether withdrawing insurance will cause the equal and opposite effect of providing insurance. Lastly, our estimates capture only the impact of increased uninsurance under the AHCA and do not take in to account possible mortality effects among people who would remain insured but lose certain benefits or encounter worse access to care due to the bill.

We calculated a 95 percent confidence interval around our estimates of excess mortality. The confidence interval contains the range of reasonable values that include our estimate of excess mortality, with 95 percent confidence. Within this range the best estimate for the actual number of excess deaths is the point estimate. The point estimate is the mean and represents our best prediction for annual excess mortality rates, given the current evidence and available data. For instance, in the year 2026 and assuming 23 million more people are uninsured, we estimate that 27,711 excess deaths will occur, and we are 95 percent confident that the true number of annual excess deaths will be between 9,583 and 46,000.


Ann Crawford-Roberts is a medical student at the Icahn School of Medicine at Mount Sinai and a graduate of the Harvard T.H. Chan School of Public Health. Nichole Roxas is a medical student at the University of Rochester School of Medicine and Dentistry and a graduate of the Harvard T.H. Chan School of Public Health. Ichiro Kawachi is a professor of social epidemiology and the chair of the Department of Social and Behavioral Sciences at Harvard T.H. Chan School of Public Health. Sam Berger is the senior policy adviser at the Center for American Progress. Emily Gee is the health economist for the Health Policy team at the Center.


This material [the article above] was created by the Center for American Progress Action Fund. It was created for the Progress Report, the daily e-mail publication of the Center for American Progress Action Fund. Click here to subscribe. ‘Like’ CAP Action on Facebook and ‘follow’ them on Twitter

NOW is THE Time!

We’re in danger of losing our health care. The Senate is inching closer to passing a devastating health care bill. If they do, then millions of people will see their health care coverage disappear. But you can do something about it.

Nevada is particularly important in the fight to save our health care. Why? Because our senator, Dean Heller, is a deciding vote on the Senate bill.

You have a critical part to play, and there is no time to waste. As a constituent, you have the power to influence Senator Heller’s vote on health care.

The over 600,000 Nevadans who rely on Medicaid would be most adversely affected as Nevada is poised to lose approximately $5 billion in federal Medicaid funds by 2028 if the Senate health care bill passes. This would harm 300,000 children, 13,000 seniors, and 42,000 people with disabilities in Nevada.

But that’s only what we actually know today.  Are you insured through an employer plan?  You do know that employers shop insurers country-wide for the best policy prices they can find, right?  Have you heard this bill allows States to seek waivers of  EHBs (Essential Health Benefits, like maternity coverage, ER visits, Xrays,  cancer screenings, etc.)?  What do you think will happen to the healthcare insurance coverage you now have once your employer, like everyone else’s employer starts shopping “EHB-waivered” states for their insurance policies to save money, while holding what you pay constant or even charging you a larger percentage of the cost, all to pad their bottom line?

  • Read the over-glorious summary from the Senate Budget Committee glossing over the dreadful impacts.
  • Browse the actual bill text.
  • View a section by section summary by the Congressional Research Service here.

TrumpedUpCare harms us all and we can’t let that happen!  The clock is ticking with an expected vote no later than next  Thursday.  Call Senator Heller’s offices today and often (call all of them).  Let him know that if he takes a meat cleaver to our healthcare, he might as well take a meat cleaver to his 2018 campaign, because he’s done!

202-224-6244 (DC)
702-388-6605 (LV)
775-686-5770 (Reno)
775-738-2001 (Elko)

Term: 2013-2018

Heller’s High (or should I say Low) Water on Healthcare

In case you haven’t heard, Senator Dean Heller supports MASSIVE cuts to Medicaid.  In fact, Senator Heller has drug the proverbial tea and has expressed his support for PHASING OUT the Medicaid expansion over the next 7 years.

After weeks of denying, fudging and wriggling, Heller is finally admitting he’s ready to end the Medicaid expansion covering more than 138,000 Nevadans—including children—since Obamacare became law.  THAT is unacceptable. Senator Heller was elected to look out for Nevadans, but he’s instead ripping the rug out from those who count on Medicaid.

“I support seven, I support seven,” Heller told reporters on his way into a healthcare working group meeting in the Capitol. “So do a number of us, including [Sen. Rob] Portman [R-Ohio] and others who have been working on this.”

Full story here.

Apparently Heller figures blame won’t fall back on him if they just “slowly” take Medicaid away from over 130,000 Nevadans and millions across the U.S.  … over a 7 year time frame. What folks need to understand is, that without Federal “matching funds” which enable States to open up the Medicaid insurance program to those whose incomes are below or just above the poverty line, it will be detrimentally consequential. Thirty-one states chose to expand Medicaid, and, as a result, 11 million to 12 million newly eligible people were finally able to obtain health insurance.  If federal matching funds are withdrawn, most states will likely return to the more restrictive eligibility rules for Medicaid eligibility ― effectively wiping out the coverage gains, leaving millions of low-income Americans with worse access to health care and more exposure to crushing medical bills.  In other words, it’s the equivalent of legislating a “death panel” where access is denied or expensive procedures/surgeries are denied as funding will not be available and people WILL die.

At a time when the Nevada Legislature is seriously considering a “Medicaid for All” healthcare delivery model that would let Nevadans buy into a “public” delivery system to assure Nevadans can more effectively access healthcare coverage, it appears that Senator Heller has chosen to throw his constituents under the first bus he can find.  Even Governor Brian Sandoval, a Republican who doesn’t support blocking healthcare coverage access for so many Nevadans, has shared his concern about rolling back the Medicaid expansion.

We can’t let Heller and his spokespeople get away with playing loose with the truth, calling this “fake news,” and blaming it on Democrats.  He made the comment and it’s on tape!

We must defeat Senator Heller in 2018. Nevadans can’t afford to lose the Medicaid expansion.

Related posts:

Senate Repeal Bill Would Still Eviscerate Coverage and Protections for People with Pre-Existing Conditions

A doctor checks a patient in a primary care clinic located in a low-income neighborhood, March 2017.

— by Thomas Huelskoetter and Emily Gee
Recent reports indicate that the emerging Senate version of the American Health Care Act (AHCA) may not include the House version’s provision permitting states to waive the Affordable Care Act’s (ACA) community rating provision, which prevents insurers from charging sick people higher premiums than healthy people.

Even without community rating waivers, the Senate bill would still critically weaken protections for people with pre-existing conditions. By allowing states to waive the ACA’s essential health benefits (EHB) requirements, it would enable insurers to effectively screen out sick people by excluding certain services.

As a result, people with pre-existing conditions in waiver states would face significantly higher costs and find it much harder to find insurance plans that actually covered treatment for even relatively common conditions such as mental health problems or diabetes. The Center for American Progress estimates that in the individual market, 5.3 million enrollees with pre-existing conditions would live in states that waive EHBs and thus see their protections eroded.

In addition, the problem would be particularly acute for older Americans, who would face much higher premiums under the AHCA, as well as for millions of low-income Medicaid enrollees, who would lose comprehensive coverage due to the AHCA’s $834 billion in cuts to that program.

Essential health benefits waivers would raise costs for people with pre-existing conditions

The ACA’s EHB standards ensure that insurance plans in the individual and small-group markets cover a comprehensive set of medical benefits, including mental health care, maternity care, hospitalizations, and prescription drugs. Prior to the ACA, significant percentages of plans in the individual market failed to cover many of these services.

The emerging Senate repeal bill would allow states to waive EHB requirements and replace them with a narrower set of benefits. In waiver states, many insurers would drop coverage for more expensive conditions that were no longer required.
The consequence of this would be significant cost increases for people who need these services. As the Congressional Budget Office (CBO) explains:

People living in states modifying the EHBs who used services or benefits no longer included in the EHBs would experience substantial increases in out-of-pocket spending on health care or would choose to forgo the services. Services or benefits likely to be excluded from the EHBs in some states include maternity care, mental health and substance abuse benefits, rehabilitative and habilitative services, and pediatric dental benefits. In particular, out-of-pocket spending on maternity care and mental health and substance abuse services could increase by thousands of dollars in a given year for the nongroup enrollees who would use those services.

Additionally, EHB waivers would substantially weaken the ACA’s ban on annual and lifetime dollar limits on coverage, since this ban only applies to essential health benefits. Thus, even people who found insurers willing to cover benefits that were no longer required would still be affected, since those insurers would be free to impose annual or lifetime limits on those benefits. Patients with expensive pre-existing conditions that required treatment would then be at risk of hitting these limits and being forced to pay out of pocket.

The effects of the EHB waivers would be widespread. Although the CBO did not attempt to guess which states would pursue waivers, its score of the final House bill projects that about half of the population would be in states that would choose to waive EHBs. Enrollment in the individual market currently consists of 12.2 million people on the marketplace and an estimated 6.9 million off of the marketplace, totaling about 19.1 million enrollees. Under the CBO’s projection, half of this, or about 9.6 million individual market enrollees, would live in waiver states. Since data show that 55 percent of individual market enrollees have pre-existing conditions, this would translate to about 5.3 million enrollees with pre-existing conditions living in waiver states.

EHB waivers would lead to a race to the bottom on benefits

In EHB waiver states, people with pre-existing conditions would see their protections drastically eroded. Insurers would still be formally banned from rejecting sick people and charging them different rates. However, the lack of comprehensive EHB requirements would open the door for insurers to discriminate systematically against sick people.

Enrollees with expensive pre-existing conditions would need more comprehensive benefits and be less likely to buy bare-bones plans, since the latter would force them to pay for many treatments out of pocket or purchase expensive coverage riders. As a result, insurers would know that offering essential benefits would attract sicker enrollees, while offering more bare-bones coverage would be more attractive to healthier enrollees.

Ultimately, this could lead to a downward spiral in plan benefits as insurers competed to attract healthy enrollees and discourage sick people from enrolling. Insurers would not be making decisions on which benefits to cover in a vacuum; they would nervously be expecting their competitors to reduce benefits, which would push sick enrollees toward any insurers still offering more comprehensive benefits. Insurers that did continue to offer comprehensive benefits would be forced to increase their premiums significantly.

Thus, insurers would likely engage in a race to the bottom to avoid attracting the sickest enrollees. This would also affect healthy people, who would see fewer plan options offering comprehensive benefits than prior to the ACA.

Age tax and repeal of Medicaid expansion would compound these effects

The House version of the AHCA would also have loosened the ACA’s age rating band to permit insurers to charge older enrollees five times more than younger enrollees. The emerging Senate plan would reportedly also allow states to waive the ACA’s current 3-to-1 age rating band. In other words, the AHCA would effectively impose an age tax on older Americans, who would need to pay much more to obtain coverage than they would under current law.

In states that opted for both of these waivers under the Senate bill, the effects of this age tax on premiums would compound the negative impact of the EHB waivers, since older enrollees are more likely to have pre-existing conditions.

There are an estimated 5.1 million enrollees ages 55 to 64 covered through the individual market, both on the ACA marketplace and outside it, and estimates show that 84 percentof enrollees in this age group have at least one pre-existing condition that would have resulted in them being denied coverage or being charged more prior to the ACA.* Nationally, CAP estimates that 4.3 million people ages 55 to 64 would be at risk from both the age tax and the loss of pre-existing conditions protections; under the CBO’s projection, about 2.2 million of these would live in waiver states.

Similarly, people with pre-existing conditions who were made newly eligible for Medicaid under the ACA’s Medicaid expansion would also be worse off under the Senate bill. The Senate repeal bill calls for Medicaid expansion funding to be phased out over time, forcing financially strapped states to cut back eligibility for the program. Millions of people with pre-existing conditions in the expansion population could find themselves uninsured and unable to obtain affordable insurance that covers their pre-existing conditions or covered by plans that leave them exposed to high out-of-pocket costs for needed services.

More than 11 million people are currently enrolled in Medicaid thanks to the ACA expansion, which extended Medicaid eligibility to people with incomes up to 138 percent of the federal poverty level, and survey data show that about 48 percent of people in that income range have pre-existing conditions. Thus, CAP estimates that nationwide, about 5.4 million newly eligible Medicaid expansion enrollees have pre-existing conditions; under the CBO’s projection, about 2.7 million of these would live in waiver states.

In addition, CAP has previously estimated that 900,000 elderly people who receive coverage through both Medicaid and Medicare would lose Medicaid due to the AHCA’s caps on federal funding for traditional Medicaid. Without Medicaid, these beneficiaries would receive fewer benefits and face higher cost sharing—making it harder to afford treatment for pre-existing conditions.

Conclusion

The House version of the AHCA would gut protections for people with pre-existing conditions in multiple, interconnected ways. Even without waivers for community rating, the emerging Senate repeal bill would still undermine protections and trigger a race to the bottom as insurers in EHB waiver states reduced their benefits in order to discourage sick people from enrolling. Millions of people with pre-existing conditions in these states would face higher costs and struggle to find affordable plans that cover the services and treatments they need.


Thomas Huelskoetter is the policy analyst for the Health Policy team at the Center for American Progress. Emily Gee is the health economist for the Health Policy team.

* Data from the Centers for Medicare & Medicaid Services show that 3.3 million people ages 55 to 64 enrolled in marketplace coverage for 2017 and accounted for 27 percent of total enrollment. We assume that 27 percent of people enrolled outside the marketplace are also in that age range. The U.S. Department of Health and Human Services estimated that 6.9 million people are enrolled in individual market coverage outside the marketplace.


This material [the article above] was created by the Center for American Progress Action Fund. It was created for the Progress Report, the daily e-mail publication of the Center for American Progress Action Fund. Click here to subscribe. ‘Like’ CAP Action on Facebook and ‘follow’ us on Twitter

So — What Did It Take to Buy Rep. Mark Amodei’s Vote FOR passage of #AHCA

It’s amazing the difference a week can make.  Last week Rep. Mark Amodei was a “NO” on passage of the American Health Care Act (AHCA), H.R. 1628. I’m not sure what he was offered to buy is “YEA” vote, but it must have been good, for him that is, because it certainly is good for any of us:

Position on April 28, 2017

Position on May 4, 2017

Rep. Amodei’s flip is morally reprehensible and opprobrious. 

Rep. Amodei clearly looked at nothing except how the insurance industry might be affected.  He did little if anything to explore how passage might impact those Nevadans who have what that same insurance industry calls “pre-existing conditions” and who the insurance industry don’t want to have to insure.  Senator Sherrod Brown of Ohio masterfully took to time to detail how that impacts real people:

So what is a pre-existing condition? Let’s put it like this – you may pay more for healthcare under their plan if you’ve been affected by:

AIDS/HIV, acid reflux, acne, ADD, addiction, Alzheimer’s/dementia, anemia, aneurysm, angioplasty, anorexia, anxiety, arrhythmia, arthritis, asthma, atrial fibrillation, autism, bariatric surgery, basal cell carcinoma, bipolar disorder, blood clot, breast cancer, bulimia, bypass surgery, celiac disease, cerebral aneurysm, cerebral embolism, cerebral palsy, cerebral thrombosis, cervical cancer, child-bearing age, colon cancer, colon polyps, congestive heart failure, COPD, Crohn’s disease, cystic fibrosis, DMD, depression, diabetes, disabilities, Down syndrome, eating disorder, enlarged prostate, epilepsy, female, glaucoma, gout, heart disease, heart murmur, heartburn, hemophilia, hepatitis C, herpes, high cholesterol, hypertension, hysterectomy, kidney disease, kidney stones, kidney transplant, leukemia, lung cancer, lupus, lymphoma, mental health issues, migraines, MS (muscular schlerosis), muscular dystrophy, narcolepsy, nasal polyps, obesity, OCD, organ transplant, osteoporosis, pacemaker, panic disorder, paralysis, paraplegia, Parkinson’s disease, pregnancy, restless leg syndrome, schizophrenia, seasonal affective disorder, seizures, sickle cell disease, skin cancer, sleep apnea, sleep disorders, stent, stroke, thyroid issues, tooth disease, tuberculosis, and ulcers. To name a few. And chances are, you or someone you know has dealt with something (or multiple things) on this list.

If this bill were to become law (which hopefully the Senate will prevent), many people with “pre-existing conditions” will become ineligible to participate in the ordinary insurance programs which they’ve been accustomed to purchasing or participating in.  They’ll be instead, relegated to “sick people plans” which are called “high risk pools.”  Since all the people in those pools will be “sick people” — people who have one or more serious conditions with more expensive drug and treatment costs —premium costs to join such a pool will be much more costly and actual, deliverable benefits will be limited or even rationed.

Rep. Amodei also failed to consider how premium costs will be calculated —> by age.  Claiming that the older one gets, the more likely one is to require receipt of benefits for all those premiums you’ve paid over the years.  So, once you hit your 50s, the bill allows insurance companies to you FIVE times more for the same policy they sell to a 25 year old.  That’s not just going to impact the “individual insurance market” — that’s also going to massively impact the “employer-provided insurance market.”  How do you realistically think that’s going to impact an employer’s aging workforce members.  One of two things are going to happen.  (1) Employers will stop providing insurance altogether (and pocket the money they used to used to subsidize your insurance as their profit without raising your wage/salary a dime. Or (2), they’ll work at making the workplace so hostile for older workers they’ll quit.

Rep. Amodei also didn’t consider that by allowing States to “waiver out” of all kinds of things — like what is covered and whether limits can be placed on deliverable benefits.  What that essentially means is that we could see a race to the bottom as some States wishing to capitalize on the employer-provided market could create all kinds of “waivered plans” that make the ‘junk insurance plans” of the pre-ACA years look like premium plans.  It’s not inconceivable that we could see plans that don’t cover maternity care, or contraception, or emergency room visits or seriously restricted networks.  So when they say … “Hey, don’t worry, you’ll be able to keep your doctor” … Worry!

Then there’s those ACA subsidies that many folks used to be able to purchase insurance.  Those have been flattened to limit the Federal Govt’s liability going forward.  On the surface, that doesn’t necessarily sound all that bad, but if you make $50K/yr, that flat amount is one thing, but if you make minimum wage or less, say $15K/yr or less that flat-rate subsidy won’t come close to enabling them to purchase healthcare insurance and they’re not going to qualify for Medicaid.

To pay for Medicaid, it requires $200B+.  The House GOP allocated a whole romping, stomping $8B in their bill to cover Medicaid.  What that means is they’ll be forcing States to “ration” health care and in the process, become death panels by denying healthcare to the sickest of the sick to be able to pay for healthcare for the less sick.

This bill is supposedly a “reconcilliation” bill, which means it MUST be scored by the Congressional Budget Office (CBO) as to it’s costs.  The CBO has not yet completed a rescoring of this latest iteration of the bill.  Thus, Rep. Amodei voted on a bill for which he had no idea as to it’s costs OR it’s impact on his Nevada constituents.  

Lastly, Rep. Amodei ignored the massive tax breaks that will be doled out to those who make well over $200,000/yr.  Basically, they’re cutting benefits to older and poor  Americans to give BILLIONS of dollars to the rich, making America sicker and putting many in graves prematurely in the process.  This bill does absolutely NOTHING to improve healthcare, it’s delivery, or it’s efficacy.  It does however, pad the wallets of the rich at our peril.

Oh … and I almost forgot … none of what the GOP alone passed in this bill would apply to members of Congress.

What do you say we terminate Mr. Amodei’s employment in 2018 and see if he can get insurance on his own?

What We Know & Don’t Know About Reconciliation & AHCA

— Vickie Rock

Press Secretary Sean Pricer made a big deal about the size of the American Health Care Act (AHCA) in comparison to the Patient Protection and Affordable Act (PPACA) which is also called the ACA or by its GOP nickname, “Obamacare.”  But he asked people to do was to compare apples to asparagus.  One is an actual healthcare bill, the other is “reconciliation” bill, a gimmick that the Republicans are using to remove revenue and expenses from the original legislation (the one on the right).

So what is “reconciliation”?

Reconciliation is a legislative process of the US Senate which allows consideration of a “budget bill.” The process limits debate to 20 hours and eliminates any opportunity to filibuster the bill. Reconciliation also exists in the US House, but because the House regularly passes rules that constrain debate and amendments, the process has had a less significant impact.

A reconciliation budget resolution directing one or more committees to submit legislation changing existing law in order stated spending and revenue requirements. But most notably, the reconciliation process can only be used to change laws that are scored by the Congressional Budget Office, in other words, those that cost money or are implemented as taxes. And, if you’ll remember, the Supreme Court, on June 28, 2012, ruled that ObamaCare a “tax” and not a mandate, and therefore declared it “constitutional.”

Since the ACA is a “tax” … and since the Republicans control both houses of Congress and the Presidency, they’ve decided to go after the tax and revenue side of ACA using a gimmick that allows them to repeal all of the “money” side of the bill using a simple majority vote and then fight to kill all the provisions that really help Americans using regular legislative bills (hence, their discussions of steps 1, 2, and 3).

They’ve proposed their AHCA reconciliation bill and now the Congressional Budget Office (CBO) has weighed in on the bill with their analysis, albeit a bit light in a few areas of concern.  Here’s what we don’t yet know:

1. The analysis is a bit light on what might happen  regarding employer-based healthcare benefits.  Because the bill would use “age-rating” to set premium costs and allow insurance companies to charge 5-times as much for premiums for older workers as for younger workers, that’s going to make a huge difference to employers as employees age.
  a. Will employers begin dropping healthcare benefits en masse?
  b. Will employers use this as yet another excuse to gouge employees by either ending healthcare benefits without raising their wages/salaries or employing their own age rated cost-sharing schemes?
  c. Will workplace environments become hostile for aging workers as they attempt to force out older “expensive” workers in favor of younger “cheaper” new hires?
  d. Will employers use this as an excuse to drop all healthcare benefits for retirees or price the premium cost-sharing out of their reach?
2. How badly will Rural Hospitals be affected by the capping/cutting of not just Medicaid funding, but the repeal of all funding supporting Rural Hospitals in general? We’ve already seen on rural hospital in Tonopah, NV close its doors.  How many more will follow in their footsteps?

Here’s what we do know:

1. Because this is a ‘reconciliation’ bill, it does nothing to change provisions that have no tax revenue/expense basis.  For example, insurance companies would still  be required to provide coverage to any applicant, would not be able to vary premiums to reflect enrollees’ health status or to limit coverage of preexisting medical conditions, and would be limited in how premiums could vary by age.   Prohibitions on annual and lifetime maximum benefits would still apply. In addition, insurers would also still be required to cover specified categories of health care services, and the amount of costs for covered services that enrollees have to pay out of pocket would remain limited to a specified threshold.
2. Healthcare provider organizations and the medical community as a whole, AARP, American Medical Assoc, American Nurses Assoc, American Hospital Assoc, and National Physicians Alliance have all come out against passage of the AHCA.  On the other hand, a number a “conservative groups” have expressed support:  National Taxpayers Union, Americans for Tax Reform, Center for the American Experiment, Citizens Against Government Waste, Independent Women’s Voice, Institute for Liberty, Log Cabin Republicans, Market Institute, and the Small Business & Entrepreneurship Council, none of which provide an ounce of healthcare to anyone.
3. We know that a large number of rural communities across this nation have just one insurance provider serving their community.  Speaker Ryan has proclaimed this bill will miraculously increase competition throughout the nation.  However, there is absolutely nothing in the reconciliation bill to incentivize corporations to actually do business in Rural America, where they have not created healthcare networks and left millions of Americans will few if any choices for coverage.  The GOP have touted the AHCA has just step #1 in a three step process, but there is absolutely nothing but air with respect to steps #2 and #3, and how those steps would improve or denegrate healthcare choices for coverage even further.
4. Premium costs will still RISE, however, the analysis indicates the ‘average’ premium cost will be 10% less than what the increase would have been under the ACA, once the older, sicker population has been priced out of the market.
5. Medicaid will see some major cuts ( reduction of $880 billion in federal outlays ) and turned into block grants to the states for them to administer.  Specifically, beginning in 2020, the federal government would establish a limit on the amount of reimbursement it provides to states. That limit would be set by calculating the average per-enrollee cost of medical services for most enrollees who received full Medicaid benefits in 2016 for each state.  Given that capping of benefits to the states, we can anticipate those cuts will lead to some serious healthcare rationing, and potentially, “death panels” in various states as those who are sick, but who can’t pay for the care they need, turn to their State’s Medicare program which has insufficient funding to meet demand.
6. Because the reconciliation bill changes the means by which premium rates are structured, premiums for older people can be charged at 5X the rate of premiums charged to younger people.  Faced with the choice between giving their money to insurance companies who need return even less than 60% of their premium payments in the form of actual healthcare reimbursements, lower income older Americans will find themselves driven out of the market altogether when they can no longer pay the rent, put food on the table, pay for utilities, pay for a car and fuel to be able to get to work, AND let the healthcare insurance company suck the life out of them.
   
   
7. Monies withdrawn from support of the Medicaid program, instead of being applied toward reducing our Nation’s national debt  will instead be used to laud massive tax breaks for the upper 2% of the population. In addition, it repeals other provisions that impacted the wealthy:
a. Repealing the surtax on certain high-income taxpayers’ net investment income;
b. Repealing the increase in the Hospital Insurance payroll tax rate for certain high-income taxpayers;
c. Repealing the “cadillac” tax on some health insurance benefits plans
8. The bill creates a new mandate, this time for insurers, requiring them to levy a 30% surcharge on premiums for people who enroll in insurance in the nongroup or small-group markets if they have been uninsured for more than 63 days within the past year.
9. The bill repeals the metal scale [bronze(60%), silver(70%), gold(80%) and platinum(90%)] for insurance policies and will allow insurers to once again provide plans having an actuarial value below 60%. The question then becomes ‘what’ does the GOP have planned for steps #2 and #3.  Since the reconciliation bill is unable to repeal the requirements  to cover 10 categories of health benefits that are defined as “essential” under current law, it would be challenging for insurers to drop actuarial values for what they cover below 60%. Thus, what are their Step#2 and #3 plans to stiff Americans?
10. Buyer BEWARE!  The onus will be shifted to individuals whoare shopping for insurance to pay attention to the details and not look just at the price.  Plans would be harder to compare, making shopping for a plan on the basis of price alone, much more difficult. In addition, with more plans that are eligible for subsidies offered directly from insurers or directly through agents and brokers and not through the marketplaces’ central websites, shopping for and comparing plans could once again become much harder, depending on insurers’ decisions about ‘how’ they choose to market their plans.
11. Currently, premium tax credits vary based on geography (how much services cost in the buyers region) and age for a given income level.   Beginning in 2020, under the legislation, the size of a premium tax credit would vary merely by age, and disregard income and geography.  Such policy would force people to become “under-insured” and once again, potentially increase the volume of health-related bankruptcies, especially for  people living in high-cost areas would be responsible for a larger share of the premium.
12. The GOP who continually rales that Congress should NOT be in the business of picking “Winners and Losers” just did exactly that using the reconciliation bill with which to do that.  They declared Planned Parenthood and the women who seek healthcare at their clinics:  “Losers.”  Planned Parenthood will no longer be permitted to bill Medicaid for the healthcare services they provide to many any low income women across this nation who seek care at their clinics, unless of course, they bow down to Evangelical jihadist demands to never, ever, ever, ever again perform a single solitary abortion in any of their facilities.  So much for separation of Church and State.
 “Planned Parenthood hits the GOP’s bullseye definition in the AHCA of a “nonprofit,” an “essential community provider … primarily engaged in providing family planning and reproductive health services and related medical care,” an abortion care provider, and the fiscal year 2014 recipient of more than $350 million in Medicaid funds that can’t be used for abortion care due to the discriminatory Hyde Amendment.” — Rewire
13. The CBO report anticipates that some employers would choose not to offer coverage and turf their employee base out into the individual market. It also optimistically  anticipates those same employers would instead increase “other forms of compensation” in return. (I’m sorry, but I’m not so optimistic as to those alternative increases.) Additionally, the CBO anticipates the number of people no longer receiving employer-based healthcare will grow from 2 million fewer people in  2020, to 7 million fewer people.
 
14. Who loses if this bill should pass?  Currently, around 9.5 percent of Americans younger than 65 are uninsured  How does that change?  Here’s the bottom line, the CBO report estimates that should this bill be enacted, 48 million people under age 65, or roughly 17 percent of the non-elderly population, would be uninsured in 2020. That figure would grow to 52 million, or roughly 19 percent of the non-elderly population, in 2026.
 
 

 

Those are just a few of the points I gleaned from reading the GOP’s American Health Care Act and the CBO Report.  I encourage you to read them as well and then take action to make sure your members in Congress know where you stand.

Sources and related posts:

Even Without CBO Score, the Republican Healthcare Plan Gets Bad Marks

Multiple American Healthcare Act (AHCA) analyses show millions losing coverage while costs increase for vulnerable Americans

At least 15 million people risk losing health coverage under the Republican plan, according to one estimate. (Photo: Thomas Altfather Good/flickr/cc)

As the Trump administration continued on Friday to downplay a forthcoming cost analysis of the GOP’s healthcare plan, independent assessments of the proposal revealed the likelihood of large coverage losses and cost increases to hit voters who supported President Donald Trump the hardest.

The Congressional Budget Office (CBO) is expected to release its report on the American Healthcare Act (AHCA) on Monday. In advance of that, top administration officials including press secretary Sean Spicer have been “questioning the agency’s track record,” in what some described as “a preemptive effort to undermine faith in the agency’s assessment, which—when it finally appears—is unlikely to validate GOP boasts that their plan will provide better access to care.”

Health and Human Services Secretary Tom Price joined the chorus on Friday morning, telling “Fox & Friends” that the CBO has “been woefully underperforming when it comes to evaluating health systems. And that’s not because they’re bad folks. It’s because it’s challenging stuff.”

But should the CBO report indeed reflect poorly on AHCA, that assessment will be supported by separate analyses of the legislation that came out this week.

A report from the Center for Health Policy at the Brookings Institution and the University of Southern California’s Schaeffer Center for Health Policy and Economics released Thursday drew upon prior CBO estimates and analysis to assess how CBO will likely expect this legislation to impact insurance coverage.

Pointing to widespread “coverage losses associated with curtailing federal funding to Medicaid expansion states” in addition to other factors, it predicts the CBO “will likely estimate that at least 15 million people will lose coverage under [AHCA] by the end of the ten-year scoring window. Estimates could be higher, but it is unlikely they will be significantly lower.”

What’s more, according to data journalist Nate Cohn of the New York Times, the system of tax credits established under the GOP plan leaves rural, older, and white working-class voters—many of whom voted for Trump—the most financially vulnerable.

Citing data from the Kaiser Family Foundation and the Cooperative Congressional Election Study (CCES), a large survey of tens of thousands of Americans on healthcare and voting, Cohn reported Friday:

[T]he Republican plan offers less assistance to older and lower-income Americans, especially in rural areas, according to the Kaiser data. These groups generally backed Mr. Trump. Most of all, President Trump’s white working-class supporters often make enough money to be ineligible for Medicaid, but not enough to afford costly health insurance that might even become more expensive under the Republican plan.

The plan would hit older and rural Americans hardest because it wouldn’t provide a larger tax credit to people with more expensive plans. Older Americans pay the highest premiums, and the law would allow insurers to raise premiums for older customers even further.

And Cohn’s analysis didn’t even take into account the direct impact on those benefiting from the Affordable Care Act’s (ACA) Medicaid expansion—though Cohn notes that “Trump led by 49-46 percent among Medicaid beneficiaries in the nine red expansion states that have voted Republican in the last two presidential elections.”

Reporting on Cohn’s analysis for the Washington Post, Greg Sargent said the numbers leave “little doubt” that Trump “scammed many of his working-class supporters.”

“Trump strongly indicated” to those voters “that he would not adopt a typical Republican’s ideological stance on healthcare that would leave many of them stranded,” Sargent wrote. “But now he has.”

And he has done so while handing a giant tax break to wealthy individuals and insurance and drug companies and greatly expanding tax-sheltering opportunities for high-income people through health savings accounts (HSAs), as the Center on Budget and Policy noted in one of several AHCA analyses it published this week. Those changes, the group noted, come at a cost of almost $600 billion.

“At the same time,” the center’s Chye-Ching Huang wrote Wednesday, “the plan would seek to offset the cost of these windfall tax breaks by ending the ACA’s Medicaid expansion, radically restructuring the entire Medicaid program by converting it to a per capita cap, and dramatically scaling back the subsidies that low- and moderate-income families use to purchase affordable healthcare, as well as other coverage changes that would undermine the health and financial security of millions of households.”