Tuesday, January 17, 2017

Trump promises policies in every pot. Here's why those pots will be emptied by repeal without replacement.

There is no sign of a meaningful replacement plan from the party of Got Only Promises which is hell-bent on repeal of the Affordable Care Act. But, to the rescue, Trump vows ‘insurance for everybody’ in Obamacare replacement plan, the Washington Post reports. Is he really on board with a universal, single payer plan? Let’s see what he promises and then look at the reality.

Will doctors accept “beautifully covered”?

Let’s start with a single payer plan. Is that what Trump plans?

“It’s not going to be their plan,” he said of people covered under the current law. “It’ll be another plan. But they’ll be beautifully covered. I don’t want single-payer. What I do want is to be able to take care of people,” he said Saturday.

OK, scratch that.

How about universal coverage?

… House Speaker Paul D. Ryan (R-Wis.) and other Republicans have been talking lately about providing “universal access” to health insurance, instead of universal insurance coverage.

OK, scratch that too.

What else is Trump going to roll out?

President-elect Donald Trump said in a weekend interview that he is nearing completion of a plan to replace President Obama’s signature health-care law with the goal of “insurance for everybody,” while also vowing to force drug companies to negotiate directly with the government on prices in Medicare and Medicaid.

Trump declined to reveal specifics in the telephone interview late Saturday with The Washington Post, but any proposals from the incoming president would almost certainly dominate the Republican effort to overhaul federal health policy as he prepares to work with his party’s congressional majorities.

Trump’s plan is likely to face questions from the right, after years of GOP opposition to further expansion of government involvement in the health-care system, and from those on the left, who see his ideas as disruptive to changes brought by the Affordable Care Act that have extended coverage to tens of millions of Americans.

Trump said his plan for replacing most aspects of Obama’s health-care law is all but finished. Although he was coy about its details — “lower numbers, much lower deductibles” — he said he is ready to unveil it alongside Ryan and Senate Majority Leader Mitch McConnell (R-Ky.).

“It’s very much formulated down to the final strokes. We haven’t put it in quite yet but we’re going to be doing it soon,” Trump said. He noted that he is waiting for his nominee for secretary of health and human services, Rep. Tom Price (R-Ga.), to be confirmed. That decision rests with the Senate Finance Committee, which hasn’t scheduled a hearing.

That would be the guy who hates government in health care.

“We’re going to have insurance for everybody,” Trump said. “There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.” People covered under the law “can expect to have great health care. It will be in a much simplified form. Much less expensive and much better.”

Without details, it’s hard to see how Trump will avoid the trap of simplified health care with a simplified insurance plan. After six years and 60 votes to repeal ACA, the Republicans in Congress have no idea either.

Republican leaders have said that they will not strand people who gained insurance under the ACA without coverage. But it remains unclear from either Trump’s comments in the interview or recent remarks by GOP leaders on Capitol Hill how they intend to accomplish that.

Let the free market fairy do it

Along the same lines, Trump promises health care for all regardless of ability to pay.

“We’re going to have insurance for everybody,” Trump said. “There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.” People covered under the law “can expect to have great health care. It will be in a much simplified form. Much less expensive and much better.”

But the details seem to come down to “marketplace” ideas. Also in the Post, Trump spokesman says Obamacare replacement will harness marketplace competition. But Sean Spicer offers no new spice, only stale ideas the Republicans have been touting for years.

A spokesman for Donald Trump sought Monday to elaborate on the president-elect’s plans to replace the Affordable Care Act, vowing that the new administration would lower health-care costs by infusing more competition into the marketplace, including by allowing insurers to sell health plans across state lines.

Trump’s goal is “to get insurance for everybody through marketplace solutions, through bringing costs down, through negotiating with pharmaceutical companies, allowing competition over state lines," Sean Spicer, the incoming White House press secretary, said during an interview on NBC’s “Today” show.

From Scriber’s dictionary of Republican ideas:
Marketplace solutions. Noun. A fictitious substitution for meaningful policy.

Trump declined to provide specifics during the weekend interview and Spicer offered few details either.

Asked whether Trump’s replacement plan amounts to an expansion of government health care, Spicer insisted Monday it does not, saying access would be improved and costs would be driven down through marketplace competition.

The fundamental question that these folks don’t ever answer is whether health care is a right or a privilege. If it’s a right, then coverage must be universal. If it is a privilege, then you get it if you can afford it.

Promises, promises

Trump makes health care promises he’ll never be able to keep argues Steve Benen (MSNBC/MaddowBlog).

Trump is establishing some fairly specific benchmarks: universal coverage, “much lower deductibles,” and a simpler and less expensive system in which all Americans are “beautifully covered.”

If it sounds a bit like the president-elect is describing a single-payer system – which he used to support until he condemned his own ideas – you’re not the only one who noticed. That said, Trump specifically told the Post, “I don’t want single-payer.”

So how exactly does he intend to keep these promises, which are wildly at odds with his own party’s approach to the issue? Trump didn’t say, though he insisted the details of his reform plan are nearly complete.

It’s as if he’s never heard of the problem of politicians who over-promise.

Look, you don’t have to be a health-care wonk to know Trump is establishing benchmarks he simply cannot meet. There is no scenario in which Republicans can create a system with universal coverage and lower deductibles unless they were prepared to dramatically increase government investments into the system.

In other words, if GOP policymakers wanted to move “Obamacare” to the left, then maybe it could achieve these goals, but (a) they intend to do the opposite; and (b) even if they did boost health-care spending, they’d run into Trump’s related promise to make the system less expensive.

Republicans face an uncomfortable choice: they could give up on trying to gut the ACA or they can start owning up to the fact that a whole lot of Americans are going be much worse off under their alternative plan.

Instead, the party is led by an incoming president who’s publicly making promises he’ll never be able to keep. Indeed, he’s not alone. Kellyanne Conway recently said no one who currently has insurance should worry about losing it under Trump’s approach. House Speaker Paul Ryan (R-Wis.) has made similar comments.

Other GOP members of the House and Senate leadership have made related commitments, as have assorted Republicans in both chambers.

But making promises is easier than keeping them.

A variety of other Republicans, however, recognize the dangers of these promises. CNN’s Jake Tapper asked Sen. Rand Paul (R-Ky.) yesterday, for example, whether the senator can guarantee that the 400,000 Kentucky residents who’ve gained coverage through the ACA will remain covered after Republicans are done repealing the law. Paul offered a lengthy answer, which never actually answered the question.

Repeal and delay: “A total disaster”

There is talk of the Republicans repealing ACA now and delaying its effects until a replacement plan is hatched. A former health insurance CEO, J. B. Silvers, predicts The G.O.P.’s Health Care Death Spiral in a New York Times op-ed.

From my point of view as a former health insurance company chief executive, “total disaster” would also describe any Republican repeal-and-delay plan. Although my former colleagues in the insurance industry are too cowed by the president-elect to say so, Republican insistence on repeal without having a meaningful replacement at the same time will drive most insurers out of the individual market and leave the 10 percent of Americans now covered by some aspect of the A.C.A. without coverage — especially if Medicaid expansion is rolled back as well.

The proportion of uninsured Americans, which has dropped to less than 9 percent, the lowest on record, will at least double. By April, when filings from insurance company plans and premiums for 2018 are due, there will be a sizable exit — of insurers running away from the greatly increased and unpredictable risk and of individuals not able to afford insurance without the subsidies.

Of course, the A.C.A. has a number of flaws, and repair is critical. But delay is not an option if the replacers really want to use private insurers to meet society’s goals of access, affordability and quality in health care. All known Republican alternatives envision heavy reliance on the same insurers that are now ready to bolt and leave a total mess rather than a defective but repairable market.

After they leave, the damage will spread to doctors and hospitals, whose bad debt will skyrocket when patients miss copays and drop coverage while providers and hospitals still must continue care.

This is not speculation but based on my experience in the industry and as a member of the board of a public hospital that stands to lose substantial Medicaid payments if the state expansions are rolled back.

Here is what Silvers thinks must happen.

Obamacare, or any plan that replaces it that is reliant on private insurers and individual enrollment, will succeed only under the following conditions: a meaningful incentive to purchase insurance (the individual mandate or equivalent); help to make it affordable; risk reduction for insurers to stabilize premiums; and enough funding to pay for it all.

If any replacement plan doesn’t include these elements, private insurance will revert to the chaos of the pre-A.C.A. market. In business, managing risk is important; in insurance, it is everything. Whoever plays games with it — knowingly or inadvertently — is playing with fire.

If we manage this risk badly through repeal and delay, the damage to insurers, individuals, hospitals and professionals will be profound.

Congressmen walk run away

Steve Benen reports on reactions of Republicans in Congress when challenged about replacement plans.

Vox asked Sen. Cory Gardner (R-Colo.) whether the GOP plan will cover as many Americans as the Affordable Care Act. He said he intends to support a plan that will “actually work for the American people.” Asked specifically about coverage, the conservative senator “turned around and walked away.”

Benen also reports that a Colorado Republican flees constituents with health care concerns.

In 2012, Rep. Mike Coffman (R-Colo.) lashed out at President Obama in the ugliest of ways. “I don’t know whether Barack Obama was born in the United States of America,” the congressman said, adding, “But I do know this, that in his heart, he’s not an American. He’s just not an American.”

So it’s no surprise that this guy hates the ACA - aka Obamacare.

By all appearances, it was quite a scene. The five-term Republican congressman, representing Colorado’s most competitive district, set up an event at the Aurora Central Library the day after vowing to repeal “Obamacare” in an op-ed. What he and his staff didn’t know was that roughly 200 people who support the Affordable Care Act would show up, eager to ask how and why Coffman intended to undermine their health security.

And when that became apparent Coffman split without meeting with those people as promised.

“The fire is just starting to spread.”

Of course, the broader significance of this extends well beyond one Colorado congressman who fled his own constituents. What stood out about the event in Aurora over the weekend was the fact that voters showed up to voice their concerns about the Republican agenda, which in turn put a conservative lawmaker on the defensive.

Indeed, by some measures, Coffman’s troubles on Saturday were the opening salvo in a larger political fight: there were events held all over the country yesterday, with diverse groups of Americans publicly rallying in support of the ACA and against Republican plans to gut the successful reform law.

In the immediate aftermath of Trump’s election, there were significant protests in areas nationwide, and it was only natural to wonder whether that spirit of activism would continue in the months that followed. The GOP crusade to target Americans’ health benefits provides exactly the kind of motivation needed to get concerned voters off the couch.

It’s not easy to get many thousands of people to show up at public events in mid-January, but Trump’s election lit a match. The fire is just starting to spread.

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