Fox Republican Debate Dominated By The Donald

Fox Debate August 2015

Fox brought in a record 24 million viewers for the first Republican debate on Thursday night , and nobody doubts it was because of Donald Trump. CNN explained what this number means:

For perspective, the first GOP primary debate four years ago, also on Fox, attracted 3.2 million viewers.

The most-watched primary debate that year, broadcast by ABC, reached 7.6 million.

Thursday’s debate audience more than tripled that one.

The audience easily exceeded pretty much everything that’s been on American television this year, from the finale of “The Walking Dead” to the final episode of David Letterman’s “Late Show.”

The debate was bigger than all of this year’s NBA Finals and MLB World Series games, and most of the year’s NFL match-ups.

It also trumped Jon Stewart’s Thursday night’s sign-off from “The Daily Show,” which averaged 3.5 million viewers.

Trump is a known ratings magnet. His reality show “The Celebrity Apprentice” used to reach 20 million viewers a week. But it has slipped over the years, averaging 6 to 8 million viewers for recent seasons.

The debate, as well as most of the talk afterwards, was about Donald Trump. They might as well have named it Presidential Apprentice. By the end, many viewers might have been expecting to go to the boardroom to see who Trump would fire. Hint–it might not have been one of the candidates considering what he has been saying about Megyn Kelley and the other Fox correspondents. Among the most crude:

Trump was the center of attention from the start when the very first question was a show of hands  as to “who is unwilling tonight to pledge your support to the eventual nominee of the Republican party and pledge to not run an independent campaign against that person.” Only Donald Trump raised his hand. (Full transcript of the debate can be found here).

Donald Trump did make a great case for campaign finance reform:

I will tell you that our system is broken. I gave to many people, before this, before two months ago, I was a businessman. I give to everybody. When they call, I give.

And do you know what?

When I need something from them two years later, three years later, I call them, they are there for me.

QUESTION: So what did you get?

TRUMP: And that’s a broken system.

QUESTION: What did you get from Hillary Clinton and Nancy Pelosi?

TRUMP: Well, I’ll tell you what, with Hillary Clinton, I said be at my wedding and she came to my wedding.

You know why?

She didn’t have a choice because I gave. I gave to a foundation that, frankly, that foundation is supposed to do good. I didn’t know her money would be used on private jets going all over the world. It was.

Trump also restated his opposition to the Iraq war but flip-flopped on his previous support for a single payer system. Trump could have been the best candidate in the room if he hadn’t turned into a Tea Party clown.

There were some other moments when Republican candidates deserved credit. This includes Rand Paul criticizing both his fellow Republican candidates and Hillary Clinton for their policies which on sending more arms to middle east:

I’ve been fighting amidst a lot of opposition from both Hillary Clinton, as well as some Republicans who wanted to send arms to the allies of ISIS. ISIS rides around in a billion dollars worth of U.S. Humvees. It’s a disgrace. We’ve got to stop — we shouldn’t fund our enemies, for goodness sakes.

This was followed by John Kasich defending taking funds for the Medicaid expansion under Obamacare:

First of all, Megyn, you should know that — that President Reagan expanded Medicaid three or four times.

Secondly, I had an opportunity to bring resources back to Ohio to do what?

To treat the mentally ill. Ten thousand of them sit in our prisons. It costs $22,500 a year to keep them in prison. I’d rather get them their medication so they could lead a decent life.

Rand Paul made a another good point when he argued with Chris Christie over NSA surveillance:

The Fourth Amendment was what we fought the Revolution over! John Adams said it was the spark that led to our war for independence, and I’m proud of standing for the Bill of Rights, and I will continue to stand for the Bill of Rights.

Beyond this, we primarily learned from the debates that Republicans hate Barack Obama, Hillary Clinton, Obamacare, and Planned Parenthood.

I am looking forward to seeing Bernie Sanders debate Hillary Clinton on foreign military intervention and suppression of civil liberties. Clinton’s record on these topics does fit well in the GOP mainstream.

I am hesitant to write about winners because we have learned that the winner of a debate is not based upon the debate itself, but the perception of the candidates after people have listened to the talking heads in the days following the debate. This is further complicated with the Republican Party as most of their voters receive their thoughts from Fox. Criticism from the Fox commentators could make Donald Trump look like a loser, but so far he has managed to survive better than the pundits have predicted, and it is not looking like Fox will be successful against him.

From my perspective, which could be quite different from that of Fox, the winners were John Kasich and Marco Rubio. Kasich barely squeaked into the prime time debate, and the two debates did show that Kasich really did deserve to be there more than Rick Perry, who was excluded, possibly by fudging the results of the polls. Kasich and Jeb Bush looked the most stable in the group. Bush already has his position as top contender after Trump, but now Kasich might replace Scott Walker as the leading challenger to Bush and move into the top tier.

I also downgraded Bush for his discussion of his brother’s policies. It wasn’t faulty intelligence which got us in Iraq as he claimed, but his brother twisting the intelligence to justify the war he wanted to start. Jeb! also seemed oblivious to the fact that ISIS and the other problems now occurring in Iraq are due to his brother destabilizing the region. They all seemed oblivious, when talking about the deficit, to the fact that the deficit is a consequence of George W. Bush both fighting the war on credit and cutting taxes on the wealthy.

The other Republican who looked good, if you ignore his actual views, was Marco Rubio. He could make a good candidate in a television-based campaign. The entry of Trump into the race made it hard for candidates like Rubio to get attention, but he did get a shot at being noticed Thursday.

On the other hand, it seemed a battle throughout the evening between Mike Huckabee and Ted Cruz to be the most bat-shit candidate on stage, which was impressive considering that Donald Trump was on the same stage. I was edging towards awarding this to Huckabee, with lines such as, “The purpose of the military is kill people and break things,” until Cruz gave his closing statement, and clinched the title:

If I’m elected president, let me tell you about my first day in office. The first thing I intend to do is to rescind every illegal and unconstitutional executive action taken by Barack Obama.

The next thing I intend to do is instruct the Department of Justice to open an investigation into these videos and to prosecute Planned Parenthood for any criminal violations.

The next thing I intend to do is instruct the Department of Justice and the IRS to start (sic) persecuting religious liberty, and then intend to cancel the Iran deal, and finally move the U.S. embassy in Israel to Jerusalem.

I will keep my word. My father fled Cuba, and I will fight to defend liberty because my family knows what it’s like to lose it.

In contrast, Huckabee went for the laugh as opposed to Cruz’s tirade:

It seems like this election has been a whole lot about a person who’s very high in the polls, that doesn’t have a clue about how to govern.

A person who has been filled with scandals, and who could not lead, and, of course, I’m talking about Hillary Clinton.

So, in conclusion, Trump wins for continuing to totally dominate the discussion, Kasich and Rubio had smaller victories which might improve their position if the race should return to be about the more conventional candidates, and Cruz edged Huckabee for the scariest Republican in the room. Hillary Clinton and Bernie Sanders must really have felt happy seeing this debate and the caliber of candidate they might come up against in the general election.

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CBO Shows ObamaCare Costing Less Than Projected–Ignore Conservative Attempts To Distort The Data

There was more good news from the Congressional Budget Office today regarding the Affordable Care Act. The latest’s estimates significantly reduce the costs of expanding medical care under the law:

 The Congressional Budget Office on Monday significantly lowered its estimate of the cost of providing health insurance coverage to millions of Americans under the Affordable Care Act.

Douglas W. Elmendorf, the director of the budget office, said the changes resulted from many factors, including a general “slowdown in the growth of health care costs” and lower projections of insurance premiums that are subsidized by the federal government.

In March 2010, when President Obama signed the health care law, the Congressional Budget Office estimated that the expansion of coverage would cost the federal government $710 billion in the fiscal years 2015 through 2019, Mr. Elmendorf said.

“The newest projections indicate that those provisions will cost $571 billion over that same period, a reduction of 20 percent,” he said. The Affordable Care Act not only subsidized the purchase of private insurance, but also authorized a major expansion of Medicaid, the federal-state program for low-income people.

As usual, conservatives are cherry picking and distorting the numbers to portray this as a negative. Among other distortions of the facts, they fail to take into account the fact that having a substantial portion of the country be uninsured results in higher costs for both government programs, as well as costs which are passed on to those who do pay for insurance. The bottom line is that, even before these more favorable numbers, the CBO found that the Affordable Care Act results in a reduction in the deficit. Strange that conservatives who place such a high priority on reducing the deficit (which was run up by Republicans during the Bush years) oppose a program which will help reduce the deficit.

Of course if conservatives are unhappy with the cost of the Affordable Care Act, they should keep in mind the fact that costs are much higher due than they otherwise might be due to providing coverage through private insurance companies rather than through a single-payer system modeled on Medicare. Somehow I doubt many conservatives would go for the far more cost effective single-payer model.

Conservatives are also attacking the law because, while reducing the number of uninsured by 27 million people, there will still be 31 million uninsured in 2025. However, when looking at who will remain uninsured, I wonder which group conservatives are complaining about. Of this 31 million, 30 percent are illegal aliens and conservatives would sure protest if health care coverage were extended to them. Another 1o percent are ineligible for coverage because of living in states which did not expand Medicaid–a decision which conservatives support. The remainder are people who will qualify for coverage but choose not to purchase it.

The number of uninsured might fall as more red states go along with the expanded Medicaid program. It was just announced that Indiana is the latest to offer the expanded Medicaid program.

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Ideological Republican Legislatures Blocking Attempts At Expanding Medicaid By More Pragmatic GOP Governors

Governors are often more pragmatic than other politicians, having to actually run the state government and consider fiscal realities. Accepting Medicaid expansion is an obvious decision for governors, as long as they consider economic factors rather than Republican ideology, as the federal government picks up most of the cost. The federal government pays 100 percent of the cost of Medicaid expansion for the first three years with this gradually dropping to 90 percent in 2020. In contrast, the federal government pays approximately half the cost of the original Medicaid program,with state governments responsible for the rest.

So far some Republican-run state governments have accepted and others have rejected Medicaid expansion. Additional Republican governors would like to participate in the expanded Medicaid system but this is being blocked by more ideological members of the state legislature. AP reports:

Partisan politics have driven states’ Medicaid decisions ever since the Supreme Court ruled in 2012 that expansion was optional, not mandatory, under the new law. Within months, every Democratic governor agreed to expand Medicaid (although Republican legislatures blocked a few of those efforts).

Only nine states with Republican governors accepted the offer…

The law expanded Medicaid eligibility to adults with annual incomes up to 138 percent of the federal poverty level. That will qualify an individual making less than $16,105, and a family of four earning less than $32,913.

So far, 27 states have agreed to expand Medicaid. But several more, including some with Republican governors, now want in. These governors note that their residents pay the federal taxes that fund expansions, so declining to participate amounts to subsidizing other states without receiving benefits.

Several Republican governors and one independent are meeting Republican legislative resistance to their expansion proposals. Some have tried to woo conservatives by adding “free enterprise” provisions, which require federal approval.

Perhaps the most aggressive GOP governor is Bill Haslam of Tennessee, who won re-election in November. Meeting with newspapers and others, Haslam now says Medicaid expansion is “morally and fiscally the right thing to do.”

The full article also reports on Republican legislatures blocking Medicaid expansion in Wyoming and Alaska, as well as reporting that “Arkansas could become the first state to rescind a decision to expand Medicaid.”

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End Of Temporary Increase In Medicaid Payments May Impact Treatment In 2015

The Affordable Care Act has been a tremendous benefit to those who purchase insurance on the individual market, but success has been mixed for the working poor who receive coverage from an expansion of Medicaid as opposed to obtaining private plans. While reimbursement varies by state, it is significantly lower than what Medicare and private insurance plans pay, and often insufficient to meet overhead expenses of private physicians. Many people who might benefit from the expanded Medicaid plan were denied coverage in Republican-controlled states which refused to allow the program, despite the vast majority of the costs being paid by the federal government, following a Supreme Court decision allowing them to opt out of the program. There are also concerns as to whether those covered by Medicaid will be able to obtain sufficient coverage.

In order to increase the number of physicians who accept Medicaid patients, the Affordable Care Act provided for an increase in payment to Medicare levels for primary care services for two years. As The New York Times reports, this period ends at the end of 2014, raising questions as to whether as many private physicians will continue to see Medicaid patients. President Obama has recommended an extension of this increased pay but it is unlikely to be approved by a Republican Congress which is more likely to continue to talk about repealing Obamacare as opposed to work to improve upon it.

It is difficult to predict exactly what the impact of the end of the increased Medicaid payment will be. The article does quote one physician of complaining that this was a “bait and switch” tactic. In reality, the federal government was quite open about the two year time frame for the plan, but it is possible that not all physicians paid adequate attention to information available. Private physicians have historically limited the number of Medicaid patients they accept due to the poor reimbursement, among other problems with Medicaid programs, and I doubt that many have taken a significantly larger number in the past two years in response to a temporary plan.

Much of the Medicaid population is treated by clinics and hospital facilities which are paid different from private physicians, with  Medicaid reimbursement representing an improvement over providing free care as in the past. Contrary to claims frequently made at conservative sites, expanding Medicaid does provide significant benefits for many people, but this will not be an ideal situation as long as Medicaid reimbursement is often less than overhead costs for private physicians. Most likely Medicaid patients will continue to be treated by a combination of clinics and by private doctors who take limited numbers of Medicaid patients.

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Americans Generally Satisfied With Healthcare Costs But Those On Medicare Are Happier Than Those With Private Insurance

A Friday afternoon news dump is not always bad news. Gallup released a poll under this headline on Friday: As ACA Takes Effect, Majority OK With Personal Health Costs. Gallup reported, “Nearly six in 10 Americans (57%) say they are satisfied with the total cost they pay for healthcare, on par with other readings over the last five years. So far, there is little indication that the Affordable Care Act (ACA), also known as ‘Obamacare,’ has affected the way Americans view their healthcare costs, either positively or negatively.”

Gallup Insurance Satisfaction

Note that the graph above shows very little change over time, with the current numbers very close to when Obama took office. Satisfaction did increase slightly in 2014, presumably because of more people having coverage thanks to the Affordable Care Act.

Satisfaction increased by age, essentially correlating with reaching age 65 and having Medicare. The assumption that those who are older are more satisfied because they have Medicare is verified when the results are broken down by type of insurance. Satisfaction with costs  is at 74 percent among those with Medicare or Medicaid, compared to 58 percent with those on private insurance. Note that another recent study did show that overall satisfaction was much closer than this poll on satisfaction with costs. Out of pocket payments for those on Medicare are typically significantly lower than those covered by private insurance, except for those with the most generous employer-paid plans.

Gallup Insurance Satisfaction by Age

Other findings were that people were generally satisfied with the quality of health care but less satisfied with healthcare coverage as a whole in the United States compared to other countries. Gallup concluded:

U.S. adults holding health insurance via a private insurance plan are about as likely to rate their coverage positively (77%) as Americans holding either Medicare or Medicaid (75%), suggesting both groups are about equally happy with their plans. But, as noted earlier, Medicare and Medicaid holders are far more satisfied with the cost of their plan.

As Gallup has found in the past, Americans are far less effusive with their praise for healthcare coverage in the U.S. as a whole. This year is not an exception: Fewer than four in 10 Americans now rate healthcare coverage in the U.S. as excellent or good.

Before passing the ACA, the large majority of Americans who had health insurance were broadly satisfied with their medical care and coverage and their healthcare costs. Thus, a major test of the ACA will be whether it succeeds in expanding affordable healthcare to the previously uninsured while doing “no harm” to the large majority of Americans who are already highly satisfied with their healthcare coverage. So far, the verdict is positive. Gallup finds no decrease in insured Americans’ satisfaction with their healthcare services and their costs. At the same time, the uninsured are as negative as ever, but their numbers have dwindled. Gallup’s annual November updates of these trends will monitor whether this positive outcome persists as implementation of the ACA progresses.

Republicans have backed high deductible plans as a way to restrain health care costs for quite a long time. Now that they got what they want with plans sold on the exchanges (like plans previously sold in the individual market) generally having high deductibles, they have been using this as a line to attack Obamacare. If this is the main objection, rather than cowering in the face of attacks on the ACA, Democrats might be better off taking advantage of this as a reason to push for the type of single payer plan that most liberals supported before Obama compromised and promoted what was previously a Republican health care plan.

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Four More Studies On The Benefits Of Obamacare

Over the past year I receive reports from various medical journals and medical practice publications with what feels like a constant flow of studies showing the success of the Affordable Care Act, many of which I have written about in previous posts. Jonathan Chait has an article in New York Magazine on 4 New Studies Show Obamacare Is Working Incredibly Well which gives a representative sample of the studies now being published. While there are more, for the moment I’ll just stick to briefly mentioning the four studies described by Chait, partially in response to Chuck Schumer’s recent comments questioning whether the Democrats should have passed the Affordable Care Act for political reasons .

He started with one of the main goals of the law, expanding the number people who have medical coverage, while also pointing out that the number would be significantly higher if the Supreme Court hadn’t blocked Medicaid expansion:

Every serious method of measuring has shown the law effecting significant reductions in the uninsured rate. The latest, a report by the Urban Institute yesterday, shows that the uninsured rate has fallen nationally by 30 percent…

That rate is 36 percent in states participating in the Medicaid expansion. The states whose Republican governors or legislators have boycotted the expansion have seen their uninsured rates fall by just 24 percent, dragging down the average.

See his full article for more information along with charts demonstrating these benefits.

He next looked at health care costs:

When the law passed, conservatives insisted it would increase rather than decrease health-insurance costs. (Esteemed conservative intellectual Yuval Levin, in 2010, insisted it “completely fails” to reduce overall health-care spending.) Since the law passed, health-care inflation has fallen to historically low levels. Conservatives have repeatedly insisted this was a blip that would soon be reversed, and seized upon any apparent evidence for this case. When health-care spending spiked in the first quarter of 2014, Megan McArdle announced vindication: “After all the speculation that Obamacare might be bending the cost curve, we now know that so far, it isn’t.” (It turned out the first-quarter spike in health-care spending was a preliminary miscount that has since been corrected.)

Also yesterday, the Centers for Medicare and Medicaid reported that health inflation in 2013 not only remained in, it fell to the lowest level since the federal government began keeping track…

His third  study was on medical errors:

Obamacare has a wide variety of reforms designed to bend the cost curve. One of them is a new payment system that encourages hospitals to avoid readmissions. The old Medicare system reimbursed hospitals for every procedure. This meant they had a perverse incentive to do a bad job taking care of their patients — a patient who developed an infection, or needed readmission, would produce a second stream of revenue for the hospital. Obamcare’s payment reforms changed that incentive. A new report finds that hospital-acquired medical conditions has fallen by 17 percent since 2010. (This has not only saved huge amounts of money, it has also saved 50,000 lives.)

He concluded by quoting from a Kaiser Health News analysis  on the benefits of increased competition:

A surge in health insurer competition appears to be helping restrain premium increases in hundreds of counties next year, with prices dropping in many places where newcomers are offering the least expensive plans … In counties that are adding at least one insurer next year, premiums for the least expensive silver plan are rising 1 percent on average. Where the number of insurers is not changing, premiums are growing 7 percent on average.

The downside is that the lower prices require consumers to actively shop on the exchanges. Customers who automatically renew their existing plan without comparison shopping will miss out.

That is an important point at the end. Failing to shop around can lead to paying much higher premiums than is necessary. The Obama administration is considering a plan in which people can choose to be automatically be placed in the least expensive plan available in a tier as opposed to automatically having the current plan renewed. This has the downside (as in recognized in the proposal) that people would then be at greater risk of winding up in a plan which their doctor doesn’t accept. It is far safer to shop around for the best plan on your own, taking into consideration factors such as which doctors are in a plan.

Now, if only more Democrats would talk about the benefits of the plan they passed, as opposed to cowering in terror when attacked by Republicans, the party, and the country, would be far better off.

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California Study Debunks Claims That Medicaid Expansion Will Increase ER Utilization Long Term And Excessively Increase Costs

Opponents of the Affordable Care Act and Medicaid expansion have often twisted the results of a study in Oregon showing an increase in Emergency Room utilization after their expansion of Medicaid. Subsequent studies have debunked claims that Medicaid patients are abusing Emergency Rooms and studies of the Medicaid expansion in Ohio showed that better management of the Medicaid patients can lead to better control of chronic disease while limiting Emergency Room use. A new analysis from the UCLA Center for Health Policy Research released Wednesday also specifically debunks claims made based upon the Oregon study, showing that the increase in Medicaid utilization is short-lived. From Kaiser Health News:

While the Medicaid expansion may lead to a dramatic rise in emergency room use and hospitalizations for previously uninsured people, that increase is largely temporary and should not lead to a dramatic impact on state budgets, according to an analysis from the UCLA Center for Health Policy Research released Wednesday.

Researchers reviewed two years of claims data from nearly 200,000 Californians, including a group  who had enrolled in public programs well in advance of the expansion of Medi-Cal,the state’s version of Medicaid, in January. These programs were designed to ease the expansion of Medicaid by providing insurance to low-income adults who were not eligible for Medi-Cal at that point but would be when the health law’s expansion went into effect earlier this year. The researchers  divided the group into four categories, based on the researchers’ assessment of each group’s pent-up demand for health care.

In July 2011, after being enrolled in California’s Low Income Health Program, the so-called “bridge to reform,” the group with the highest pent-up demand had a rate of costly emergency room visits triple — or more — that of the other groups. But from 2011 to 2013, that high rate dropped by more than two-thirds and has remained “relatively constant,” according to the analysis.

“We were hoping that this would be the case,” said lead author Jerry Kominski, director of the UCLA Center for Health Policy Research, “because we think that that’s what access to care does for low-income individuals … that there’s an additional increase in demand for services and that that demand, or utilization, drops off pretty rapidly.”

Rates of hospitalization for the “highest pent-up demand” group also started high and dropped by almost 80 percent over the two-year period. Curiously, if ER and hospitalization rates were dropping, it’s reasonable that outpatient visits might rise. But that wasn’t the case; the rate of outpatient visits was largely unchanged during the two-year period.

Kominski said that one of the fears of the Medicaid expansion was the potential high cost of low-income patients. He argued that this analysis should ease those fears: “What our findings say to the country is (that) concerns about Medicaid expansion being financially unsustainable into the future are unfounded.” Under the Affordable Care Act, the federal government provides 100 percent of the cost of the newly eligible under the Medicaid expansion, but in 2017 that contribution will phase down until it reaches 90 percent in 2020.

As was the case in Ohio, a key factor in keeping costs down was better coordination of patient care:

One factor in helping drive down the higher rates of use, Kominski said, is better efforts at coordination for Medi-Cal beneficiaries. For example, virtually all Medi-Cal beneficiaries are now enrolled into a Medi-Cal managed care plan. “To the extent that other states don’t have adequate coordinated care mechanisms in place for their Medicaid populations, then the kinds of drop off that we observed in California may not occur there,” Kominski said.

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Health Care Advocates File Suit Against California For Lag In Enrollments In Expanded Medicaid Program

By most measures the Affordable Care Act has been a success, increasing the number insured without the problems predicted by Republicans. However not everything has worked out perfectly to date. The biggest problems have been with the expansion of Medicaid. The worst problem has been seen in the Republican controlled states which have blocked Medicaid expansion, but there are also problems in some states which are attempting to participate in the program. Last May, Joe Gandelman reported at The Moderate Voice on a case in which someone he knew who was in need of immediate medical attention had difficulty obtaining coverage. It turned out that the problem was that he qualified for the expanded Medicaid program in California. As he qualified for this, he could not receive subsidies in the exchanges, but he did not receive timely coverage due to a backlog of around 600,000 people who qualified but were not processed for the program.

Since then I have looked at this backlog periodically as data came out and while the number has decreased, hundreds of thousands of people have still not received coverage. A coalition of health care advocates has now filed a suit against the state in response to this backlog. Kaiser Health News reports:

California’s lingering backlog of Medi-Cal applications has left hundreds of thousands of people unable to access the health care they are entitled to receive, according to a lawsuit filed Wednesday by a coalition of health advocates and legal services groups.

The lawsuit, filed in Alameda County Superior Court, says the state is failing to process applications within 45 days as required by law. Some applicants have been waiting to receive their Medi-Cal cards since the end of last year, according to the suit. The applicants include children, pregnant women and adults with life-threatening health conditions, who advocates say are either postponing treatment or paying cash to see doctors.

Medi-Cal is the state’s version of Medicaid, the publicly funded health insurance program for low-income Americans. About 11 million people receive Medi-Cal benefits in California, including 2.2 million who applied since January. Roughly 350,000 applications are still pending.

The lawsuit cites several cases, including that of Tulare County resident Robert Rivera, who applied for Medi-Cal in January but died of a pulmonary embolism while the state was determining if he was eligible for the insurance. Two months after his death, Rivera’s mother received a letter saying that the benefits had been approved.

Los Angeles County resident Mark Mullin submitted an application in February 2014, but wasn’t approved until four months later — after he sought legal help. During the time his application was stuck in the backlog, Mullin had to undergo an emergency appendectomy.

The suit is asking the state to process cases within 45 days and to grant people Medi-Cal benefits while officials verify applicants’ incomes. The coalition is also asking the state to send notices to Medi-Cal applicants who have been waiting for 45 days notifying them of their right to go before an administrative law judge.

The long wait is “unacceptable,” said Katie Murphy, managing attorney at Neighborhood Legal Services of Los Angeles County. Murphy said she is concerned that the problems will get worse as more people apply for Medi-Cal. “If they are not fixed, more people will continue to wait and more will continue to suffer medical emergencies,” she said.

California Department of Health Care Services officials said they have been working closely with the counties and have reduced the backlog by 250,000 since early July. Many of the cases are still pending because of incorrect or incomplete information.

Department spokesman Tony Cava said people who need immediate care can get in-person assistance with their application at a county social services agency. They also can get their medical bills covered for care received while their applications were pending, he said.

The lawsuit was filed by several organizations throughout California, including Neighborhood Legal Services of Los Angeles County, the National Health Law Program and Bay Area Legal Aid.

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Hundreds of Thousands More People To Obtain Health Care Coverage Under Obamacare With Pennsylvania Joining Expanded Medicaid Program

Pennsylvania has become the 27th state, and 9th with a Republican governor, to accept the expanded Medicaid program. This significantly increases the number of people to receive health care coverage under the Affordable Care Act starting with about 300,000 and increasing to over a half million over the next two years. Some Republican governors are vulnerable for failing to join the program, especially considering that the federal government will pay 100% of the expense for expanding health care coverage through 2016, and afterwards it will gradually fall to 90 percent. Corbett is in danger of losing his reelection bid in Pennsylvania but it does not appear that his late adoption of the program will be enough to save him.

Currently three additional states, Indiana, Missouri, and Utah, are considering expansion and twenty states are not  considering Medicaid expansion at this time.

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Biggest Lies About Obamacare Debunked Once Again

Michael Tomasky described how, despite all the predictions and lies from opponents, the Affordable Care Act is working and the dire predictions are all failing to come true. He suggested why all the predictions of doom have failed to come true:

…maybe it’s not just dumb luck that the law seems to be working, especially in the states that took the Medicaid money and set up well-run exchanges. Maybe it’s working because bureaucrats (!) anticipated all the potential problems and planned for them in the writing of the law. Nancy-Ann DeParle, one of the administration’s chief architects of Obamacare, put it this way: “When President Obama took office, there were 42 million uninsured Americans, premiums that were unaffordable for families and businesses, a delivery system with the wrong incentives, and unsustainable cost growth. The Affordable Care Act was the product of nearly two decades of bipartisan analysis and discussions among health policy experts and economists to address these problems, and most–indeed, virtually all–of the policies in the law had widespread agreement from these experts.” In other words, writing this law wasn’t guesswork.

He then listed what he considered to be the five biggest lies about Obamacare and why they are not true:

1. Healthy People Won’t Sign Up

Or call this “Death Spiral Part I.” The idea here, spread lustily by many conservatives since 2010 but especially during last fall’s disastrous roll out, was that healthy people simply wouldn’t buy insurance. Senator Orrin Hatch said last November that “at this pace, the Obama administration will never be able to meet their enrollment goals.” Speaker John Boehner at the time groused that “the idea that the federal government should come in and create a one size fits all for the entire country never was going to work.”

Their hope was that only really sick people would sign up, which would lead rates to spike—the much-feared death spiral (more on that later). But lo and behold it turned out that millions of healthy people did want health insurance. As noted above, the precise numbers are hard to come by. But Gallup’s estimate is that the country has roughly 10 million newly insured citizens under Obamacare. And insurance companies report that around 80 to 85 percent of them are paying their premiums (this was another canard spread on the right, that people would sign up but never pay).

In sum, the law’s advocates were right, and its critics wrong, that health insurance was something normal Americans did in fact want. “There never was any realistic prospect of a death spiral,” says Jon Gruber of MIT, one of the country’s top health-care economists.

2. You Won’t Be Able to Choose/Keep Your Doctor/Plan

It’s true that this happened in a limited number of cases—maybe six or seven million people who bought policies on the individual market got cancellation letters from insurers telling them that their plans didn’t meet the minimum requirements under the new law, as NBC News explosively reported last fall.

It harmed the administration’s credibility, and rightly so. But it didn’t represent much of a change from the past — the “churn-rate” in the individual market has always been high. More importantly, no one seems to have followed up with this population to try to figure out what percentage did, in fact, lose coverage and/or have to pay considerably more for a new plan, so we don’t actually know how many of those six or seven million walked away satisfied or dissatisfied.

But more broadly, in a country where some 260 million people have health insurance, no one has adduced any proof that the ACA has resulted in anything remotely like the cataclysm opponents predicted. In fact, last fall, rated such claims as outright falsehoods. And Gruber noted to me that if some people are “losing” their doctors, it’s often by their own choice, because now that they have so many different coverage options, many are choosing less expensive or so-called “limited network” plans. “No one is making people buy these plans,” Gruber says. “They’re cheaper alternatives. This is capitalism at its finest. For the right to criticize that is just ludicrous.”

3. Obamacare Will Explode the Federal Deficit

You heard this one a jillion times back when the law was being debated. Still today, Republicans and conservatives are deft at cherry-picking numbers out of official reports that can convey the misleading impression that fiscal watchdogs think the law will be a disaster.

The truth is that the Congressional Budget Office said in 2010 and reaffirmed this summer that the Affordable Care Act’s budget impact would be positive. The 2010 estimate was that the ACA would cut deficits by $124 billion over its first decade. And in June, CBO head Douglas Elmendorf reported that his experts “have no reason to think that their initial assessment that the ACA would reduce budget deficits was incorrect.”

Now, he throws in a number of caveats, as any bureaucrat should, having to do with the fact that many provisions of the act will kick in later. But Elmendorf sees no hard evidence to suggest that initial estimates were wrong. In fact, says Paul Van de Water of the Center on Budget and Policy Priorities, “The CBO has estimated that the law will especially reduce the deficit in its second decade, and there’s every reason to believe that those estimates are on course.”

4. Okay, Then, It Will Bust States’ Budgets

Texas’ Rick Perry, Florida’s Rick Scott, and numerous other Republican governors have said that Obamacare will bust their budgets. They’re basing that on the fact that the federal government will pay 100 percent of the costs of Medicaid expansion through 2016, but a little less than that thereafter (although never less than 90 percent). So states are going to have to start shelling out (that is, states that take the money in the first place, which Texas and Florida did not).

That’s true as far as it goes. But here’s the part Perry and Scott leave out. All states have, of course, an existing relationship with the Medicaid program in which states pay for some portion of the program’s implementation. And a number of studies estimate that in that pool of funds, states will save significant amounts of money that will offset most of the new expenses incurred under Obamacare. For example, Massachusetts found that after implementation of Romneycare, its costs for “uncompensated care”—charity work, basically—decreased considerably. And one study released in June found that uncompensated care costs are already dropping dramatically under the ACA—but only in the states that have taken the Medicaid money.

Thus, Perry, Scott, et alia are perhaps agents of a self-fulfilling prophecy: Yes, the ACA might bust the budgets of their states—the states trying to kill off Obamacare. But in the states trying to make it work, the budgetary impact, say most nonpartisan experts, will be a little bit negative, but pretty small.

5. Premium Rates Will Shoot Through the Roof

This is the big enchilada, and the culmination of the alleged death spiral. The charge here is that the lack of healthy enrollees will force insurers to jack rates up to the heavens, because they’ll have all these sick and dying people on their hands. Premium hikes for this year were all over the map, because they were based on guesswork by the insurance companies about who was enrolled. But now, the companies have hard data. So just watch, critics say, as the rates go boom.

To be sure, you can go to your Google machine and enter “insurance premium increases 2015” and find a lot of scary headlines from earlier this year. But you can ignore them all, because no one really knows yet.

Here’s how it works. By roughly this past Memorial Day, insurance companies submitted their 2015 rate requests to the states. These could range from tiny to huge—but they’re just requests. State insurance commissioners are now reviewing the requests. Final, approved rates will be made public in November (before November 15, when Obamacare’s second enrollment period begins). By the way, the ACA, for the first time ever, rationalized this “rate season,” so that everything happens in almost every state at the same time and in more or less the same way. Before, there was no national logic to the process at all.

Again, to echo back to what DeParle said: The people writing the law knew all this was coming, and understood very well that rate shock would be a risk. As a result there are numerous provisions in the law designed to guard against it. The most notable one carries an obvious name: “rate review.” Under rate review, any request for an increase of 10 percent or more has to be approved by a board, to which the insurer has to offer copious documentation proving that such a hike is necessary. Prior to the ACA, there was no such review.

Before we go any further, let’s step back. What’s a typical, pre-ACA rate increase? Good question. In 2008 it was 9.9 percent; 2009, 10.8 percent; 2010, 11.7 percent. Within those broad averages, numbers were all over the map: In 2010, rates went up in Kentucky by just 5.5 percent, but in Nebraska by 21.8 percent.

The numbers released in November will similarly be all over the map. There are just too many variables to say otherwise—how much competition there is among insurers in any given state (in general, it’s increased); what the risk pool looks like in a state (how old, how sick); and other factors. So undoubtedly, there will be some isolated hair-raising increases.

We don’t know, but we do have some early indications and studies, and they are pretty hopeful. The Health Research Institute at PricewaterhouseCoopers looked at rate requests from insurers that have been filed across 29 states and the District of Columbia and found that the average increase is 8.2 percent, which is impressively low and definitely not “sticker shock.” And remember, these are mostly just requests (in Rhode Island and Oregon, the rates are final), which aggressive state insurance commissioners might seek to make still lower.  “So far, the filings suggest modest increases for 2015, well below the double digit hikes many feared,” says Ceci Connolly, the managing director of the institute.

All the above is about the individual market—people buying insurance on their own, either through state exchanges or the federal marketplace. For a host of reasons, that’s the best barometer by which to measure the law’s success. But there are other markets, too, notably the small-business market, where employers with fewer than 50 employees buy for their workers. There has been some grumbling among conservatives that this “small-group” market will take an especially hard hit, but that seems not to be the case either.

Again, there will be great variance in the small-group market, according to Jon Kingsdale, of the Wakely Consulting Group in Boston. He says the biggest impact will be that, because of some technical changes made by the law, employers with older employees and larger families will likely see rates increase, while employers with younger workers and smaller families may see rates decrease.  But overall, says Kingsdale, “I do not believe there will be a significant jump in rate in the small-group market, because the underlying body of people being insured is not so different from the prior year.”

One last point on rates: This is another area where Republican saboteurs of the law can, if they choose to, make it not work. That is, Republican state insurance commissioners can approve big premium hikes just to make the law look bad. Says Sally McCarty, the former Indiana state insurance commissioner, now at the Georgetown Center on Health Insurance Reforms: “States that are in earnest about implementing the law will likely see lower increases, and states not so concerned about seeing the law succeed will see higher increases.”



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