Thursday, March 02, 2017

The ACA and You

One of the things -- a primary mover, in fact -- that is driving this new liberal activism is the Republican Congress and their attempts to repeal the Patient Protection and Affordable Care Act, aka Obamacare. And as long as they can come up with something that works as well or better than the ACA, then I’m all for it.

I have little faith, though.

The thing is, though, that argument and debate, especially in the online milieu, have become so heated and vitriolic that actual facts are having a hard time getting through. Add to that trump’s very successful (so far) term as Distractor In Chief, as well as Sean Spicer’s gleeful willingness to tell the entire press corps to fuck off, and trying to get legit information on this topic becomes about as easy as raising the Titanic with a fishing pole.

Well, I’m here to help. What follows is a (relatively) brief guide to what the ACA is, followed by a discussion of Republican proposals to replace it. I am going to do my best to remain objective about all of this, but my natural snark is sometimes uncontrollable, so don’t be surprised and/or offended if I resort to calling specific members of Congress out as douchewhistles.

First, the ACA.

Basically, the idea behind the Affordable Care Act was simple: make it a requirement that everyone gets health insurance, even young, healthy people (especially young, healthy people ... we’ll get to that), and add some regulations that prevent insurance companies from gouging or denying coverage, and the end result will be better care at a lower cost for everyone.

The way it works is this. First, new rules are put into place that provide the following benefits that did not exist before:

People could no longer be denied coverage due to a pre-existing condition.Prior to this rule, I would now be ineligible for insurance (I had a minor stroke a few days ago, which immediately puts me in a category of high risk). It’s not that insurance would have been too expensive, it’s that I would not have been able to get it at all. Thanks to this rule, however, I can now get insurance if I need to (fortunately I already had insurance, so this isn’t an issue ... but in the past the insurance company could have dropped me altogether as a result of my condition).

In addition, prior to the ACA, merely being a female was considered to be a pre-existing condition and coverage could be significantly more expensive -- or denied altogether -- as a result.

Lifetime caps on benefits have been removed.There have been documented cases of people using up their lifetime benefits before they are out of diapers. Children born with severe abnormalities -- conjoined twins, say, or a severe heart defect -- could burn through their insurance caps in a matter of days, leaving them stuck for the remainder of their lives. The ACA removed this limitation.

Children could stay on their parents’ policies until age 26.Prior to the ACA, children were only eligible to stay on their parents’ policies in certain very specific circumstances, such as total disability or partial disability over a certain percentage, or if they were full-time students living at home. However, since most people in their early twenties are in no position to get insurance of their own for a variety of reasons -- unable to work at a job that provides benefits because they are full-time students, a lack of work and credit history, and so on -- this rule has proven to be one of the more popular provisions of the ACA.

Second, there’s the individual mandate. Republicans in Congress leapt on this as a way to derail the whole thing, claiming that it was an unconstitutional tax. Their argument was based on Article I, Section 8, Paragraph 1 of the Constitution which states, in part, that “[t]he Congress shall have Power To lay and collect Taxes, Duties, Imposts and Excises ...”).

Actually, their argument was not that the mandate itself was unconstitutional, but that the subsequent penalty for failure to maintain insurance was. And there was some validity to this argument. After all, the penalty was to be paid as part of an individual’s income taxes, and the IRS was the agency responsible for collecting the penalty, so this was enough of an argument for the Supreme Court to grant certiorari and hear the case.

Which they did, in 2010. In a 5-4 decision, the Court found that the individual mandate was indeed constitutional. This had conservatives furious, and they then put considerable resources into convincing the American public that it was a complete boondoggle. This was partially successful in that they managed to bolster this belief in the people who were already sympathetic, and they may have even moved the needle slightly among the people who were undecided. For people who were in favor, however, the Republican grandstanding and bellowing did nothing but further cement the view that the GOP was the party of old rich white guys who wanted everyone else to be as miserable as possible.

The other part of the mandate that did not get the press it deserved was that it would have the effect of lowering the overall risk level. Previously, young healthy people tended to skip getting insurance because ... well, they were young and healthy. If these folks were required to get insurance, however, that meant that the insurance companies would be collecting premiums from people who were extremely unlikely to have a need for that insurance, which meant that they could lower premiums across the board while keeping revenues stable, thus making insurance more affordable for everyone.

The result of all this was that the young healthy people continued to not sign up for insurance in droves, the premiums did not go down as much as expected, and the Republicans used this as a hook on which to hang their “Obamacare is a disaster” hat.

Unfortunately, the Court also granted the states the option to decline to participate in the exchanges and the Medicaid expansion (more on this in a bit)

Third, there were the subsidies. The idea here was that the government would help the poorest of the poor by providing direct subsidies for the purpose of obtaining insurance. Republicans wanted tax credits, but Democrats recognized that requiring poor people to pay the full price throughout the year and then get a refund was not realistic ... many of these people did not have the resources to make that kind of purchase in the first place

Fourth, the ACA created exchanges where the insurance companies could compete for business in each state. Theoretically this would drive down prices as companies competed against each other for subscribers. However, this was undermined by the Supreme Court decision that allowed states to opt out of the exchanges. In these cases, consumers had to go to the website and spend a few hours smacking their monitor in frustration because it didn’t work ... apparently because the brainstems the federal government hired to build that website also built such engineering marvels as the Yugo, the Washington D.C. Beltway, and New Coke.

Fifth, the Medicaid expansion. The new rule was that Medicaid would be made available at no charge to people earning 138% of the federal poverty line for their family size or less. Again, though, the Supreme Court decision undermined this. As a result, there was a gap in which people earned too much to qualify for Medicaid, but not enough to actually buy insurance.

This gap was used by the Republicans as a talking point to demonstrate the failure of the ACA. Granted, it was kinda like throwing nails all over the road and then blaming everybody for having faulty tires, but whatever. Far be it from Congress to let facts get in the way of a good sound bite.

Despite all these setbacks and problems, the ACA went live, and as a result there are 20 million more people with insurance than when it all began. However, Republicans in Congress have spent every single day bleating about Obamacare being a failure, it’s killing people, there are death panels (which don’t exist), it’s driving people into bankruptcy (not true ... the number of bankruptcy filings due to medical expenses has dropped significantly for the first time in history), it’s causing premiums to rise (again, not true ... that is controlled by the insurance companies). They have also introduced something like 75 bajillion bills to repeal it.

Interestingly, President Obama himself told the Republicans that if they could come up with a better idea, he would sign it. Naturally, this was taken by the far right as proof that Obama is a Muslim atheist communist socialist terrorist foreigner from Kenya who is out to steal our women and rape our jobs, or something like that. I’m not really sure, it was just too absurd to follow.

In a normal world, the Republicans would have taken this as a challenge and crafted a bill to present for his signature. Even if it was so horribly crafted that there is no way he would sign it, they could have at least used it for publicity value to show that they were indeed trying to be bipartisan but that grouchy ol’ Nancy Pelosi was just being too mean and not letting them do their jobs.

Given that this was not a normal world, however, they decided to go with a different approach: squawk even louder about how horrible Obamacare was, and introduce another 47 gazillion bills to repeal it.

Which is where we stood on November 7, 2016.

All that changed the next day when Vladimir Putin and Mitch McConnell installed donald trump as President. Now the Republicans had unprecedented control over government: 33 state houses, 32 governorships, majorities in both Houses of Congress, and the White House. With this they were suddenly given the ability to implement their agenda pretty much unimpeded, and boy howdy did they ever hit the ground running.

The very first thing the new Congress passed was a budget resolution defunding parts of the ACA. They were on track to do a full repeal, but then a funny thing happened on the way to the inauguration: the American people got loud and told them to knock it off. More specifically, they demanded that no repeal happen until a replacement had been put together. And even though it galled Republicans to have to do something as grimy and plebeian as bending to the will of their constituents, they began to create a new health care plan.

Which they did. Sort of. It’s not really a plan per se, it’s more of a change in nomenclature to try to disguise just how royally everyone is going to be anally violated if this thing passes. It’s so bad that Paul Ryan and his cronies have hidden the plan in the basement of the House of Representatives and won’t let anyone see it (source:

In all fairness, Ryan says that it is still under development (not his words), and that it would be premature to publicize the specifics until such time as they are nailed down. Fair enough. Here’s what we do know, or at least have reasonable confidence that we know, about certain provisions of the Republican plan.

Block GrantsApparently, Republicans love block grants. They want to reduce everything to block grants: Medicaid, TANF (Temporary Assistance for Needy Families), SNAP (Supplemental Nutritional Assistance Program) contributions, and so on. Which begs the question: what the hell is a block grant, anyway?

In a nutshell, a block grant is simply another way of allocating funds. Let’s take Medicaid. Currently, Medicaid is funded according to a formula called the Federal Matching Assistance Package (FMAP, because if it doesn’t have an acronym it’s not real). Basically this means that for every dollar a state spends on Medicaid spending, the federal government matches this with a dollar of its own. This open-ended structure allows funding to ebb and flow according to the actual needs on the ground.

Under Ryan’s plan, FMAP would be replaced by a fixed dollar amount that would be granted to the states. This amount could only be adjusted through legislation meant to address that specific need; otherwise the amount of money stays the same regardless. While this may be “fiscally responsible” (it really isn’t, but we'll let that slide for now), it means that states are then unable to cope with drastic changes such as a flu epidemic or a natural disaster (for example, in a September 19, 2005 report the Center on Budget and Policy Priorities estimated spending for disaster relief efforts alone in post-Katrina Louisiana, including increased Medicaid spending, to be between $150 billion and $200 billion over five years).

Health Savings AccountsOn paper, Health Savings Accounts (HSAs -- again with the acronyms) are a great idea. People can contribute pre-tax dollars to be used for medical expenses, including over-the-counter medicines, reading glasses, and the like. This is a fabulous benefit -- provided you have the financial resources to stash money in a tax-sheltered account. Unfortunately, thanks to conservative economic principles like trickle-down economics, fewer and fewer people have those resources to begin with, so these are not utilized.

Tax CreditsThe problem with tax credits is that they are a method of reimbursement as opposed to being a subsidy. Again, if someone has the financial resources to buy health insurance with no assistance, a tax credit is a ice little benefit. It does absolutely nothing to help those who can’t afford it in the first place, though, which is something that the ACA was attempting to address with its premium subsidies.

Continuous Coverage ExclusionThis is a particularly pernicious part of the Republican plan that has the potential to royally screw over millions on a semi-permanent basis. The way it works is this: under Ryan’s plan, people would receive generous tax credits and so on as long as they maintain coverage. If something happens, however -- losing a job, for example -- that causes someone to lose coverage, and there is a gap in coverage, then insurance companies would then have the ability to deny coverage for pre-existing conditions, or to jack up premiums to stratospheric levels, or any number of other consumer-unfriendly practices. But, with the GOP being more focused on the fiscal bottom line of insurance companies, this is seen as a win.

Essential Health Benefits StandardsThis is basically the minimum standard that all insurance plans are required to meet. Any health plan offered through either the state exchanges or the federal marketplace must cover the following:

  • Ambulatory patient services (outpatient care you get without being admitted to a hospital)
  • Emergency services
  • Hospitalization (like surgery and overnight stays)
  • Pregnancy, maternity, and newborn care (both before and after birth)
  • Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
  • Prescription drugs
  • Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care (but adult dental and vision coverage aren’t essential health benefits)
  • Birth control benefits
  • Breastfeeding benefits

These last two really get conservatives in an uproar because, you know, boobies and vaginas (GASP!). As a result, the new plan does away with these requirements and instead offers “guidelines” that insurance companies can choose to ignore if they desire.

Preventative Health Benefits StandardsIn addition to the essentials mentioned above, ACA plans are required to cover a list of preventative services (too many to list here) at no charge to the policyholder. The Republican plan would do away with this provision, allowing insurance companies to go back to the old days where they could charge co-pays -- or exclude these services altogether.

The fundamental problem with the Republican plan -- any Republican plan, really -- is that is makes very basic assumptions: that healthcare is a consumable good, that Americans are better served by being able to shop around for the best deal, and that more choices are better when it comes to health care. These assumptions are completely false, for a number of reasons.

First, healthcare is not a consumable good like a new refrigerator or a round of miniature golf. In the vast majority of cases, health care is obtained under circumstances that can sometimes be labeled as “dire.” For example, in 2012 I had to go to the ER for a torn Achilles tendon. I got a letter from the insurance company saying that they were not going to cover the crutches because, even though the hospital itself was in-network, the supply house from which they got the crutches was not and therefore were not covered. According to the rep I spoke to on the phone, it was my responsibility to do my research and specify to the hospital that I wanted them to give me crutches from a place that was in-network.

It should be pointed out that, at the time, it was around 1 AM on Christmas Eve, I was alone and had driven myself to the ER and therefore had to literally crawl across the parking lot because, you know, TORN ACHILLES TENDON, and temps were in the 20s. When I tried to point out that these were slightly less than ideal conditions under which to conduct market research, I was shut down.

It is situations like these that make it very easy to understand that obtaining health care services is not like getting someone to clean your house. Most cases involve the unexpected -- car accidents, a broken ankle on an uneven sidewalk, a sudden case of food poisoning. Expecting folks to research every possible scenario so they can specify which ambulance service they use to take them to a specific hospital and be seen by a specific doctor who participates in the plan, then telling the hospital which medical supply house, pharmacy, and outside professionals to use is just plain unrealistic. Yet Republicans expect people to do just that.

Second, health plans, with their coverages, exclusions, co-pays, deductibles, and so on are insanely complicated. In addition, no two health plans even have the same parameters, making it virtually impossible to do an apples-to-apples comparison. For example, one plan may have a $15 deductible that applies to scheduled office visits only and a $30 copay all other times, except for ER visits which have a flat $150 copay regardless of whether or not the deductible has been met, with a 10% co-insurance payment, but the co-pays go away after a $3,000 annual deductible for each individual in the family has been met, while another has a $50 copay on everything but preventative services and a $250 copay for emergency services (waived if admitted) with no co-insurance but a $12,500 deductible applied to the family as a whole but with a $400 individual deductible that must be fulfilled before the family deductible kicks in, and both plans have different requirements as to which out-of-pocket expenses are applied to the deductible.

How are you supposed to compare these two things, especially when you are essentially being asked to predict the future and determine what your medical issues are going to be for the entire year?

And therein lies the basic problem with the GOP plans. Despite the rhetoric and chest-beating, these plans do not have, as their primary goal, supporting the health of the American public. Rather, the main focus here is on giving the insurance companies a windfall, a portion of which will then be passed along to Republicans in Congress in the form of massive campaign donations.

It is vitally important that everyone reading this -- Democrat, Republican, liberal, conservative -- take a good hard look at what the GOP is going, and what they intend to do, and how what they want to do will be beneficial for almost nobody outside of the top 1%, then pick up the phone and call your elected representatives in Congress and tell them you are not going to support them gutting your health care.

We can do this, folks. Together we have stopped the GOP on numerous issues, and we can stop them on this ... but ya gotta be involved. Ya gotta be persistent.

Above all, you have to be LOUD.

My two cents.

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