CBO Issues Devastating Report On Effects Of GOP Obamacare Replacement

The nonpartisan Congressional Budget Office has projected that twenty-four million more Americans will wind up uninsured under the Republican health care plan (which calls into question whether this should be called a health care plan at all). The plan would provide inadequate funding for Medicaid, and risks destabilizing the individual market–unless you believe Republican predictions that the free market would respond with better products. This is rather hard to believe considering the failure of the market to handle insurance for those not receiving it through employer or government programs prior to the Affordable Care Act.

To put this in perspective, studies have projected that the loss of insurance by twenty million people (which is less than is predicted under the Republican plan) will result in 24,000 more deaths per year. This backs up the statement from Bernie Sanders that “thousands of Americans will die” if the Republican plan becomes law

Remarkably, a White House analysis projected that the plan will result in an even higher number losing insurance–26 million over the next decade. This is hardly consistent with what Donald Trump promised on the campaign trail. The plan also contradicts Trump’s promises that he would not cut Medicaid and would expand payment for treatment of opiate dependence.

The Center on Budget and Priorities notes how millions would be paying more for less coverage, along with facing higher out of pocket expenses. Aaron Blake points out:

According to the CBO, 64-year olds making $26,500 per year would see their premiums increase by an estimated 750 percent by 2026. While they are on track to pay $1,700 under the current law, the CBO projects the American Health Care Act would force them to pay $14,600. Even if you grant that inflation will allow them to make slightly more money by 2026, that’s still about half of their income going to health care.

There is additional information of significance. Despite Republican claims of a death spiral, the CBO report showed that the ACA is not “imploding.” As other studies have also found, it is stabilizing as more people obtain coverage:

Under current law, most subsidized enrollees purchasing health insurance coverage in the nongroup 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. The subsidies to purchase coverage combined with the penalties paid by uninsured people stemming from the individual mandate are anticipated to cause sufficient demand for insurance by people with low health care expenditures for the market to be stable.

The Washington Post has fact checked White House press secretary Sean Spicer’s spin regarding the CBO report.

The Republican Health Care Plan Screws Many To Help Very Few

It looks like Republicans think that America has been demanding a new health care plan which will greatly reduce the number of people who are insured, increase costs for poor and older Americans, destabilize the individual insurance market, and cut taxes for the wealthy. While waiting for the CBO scoring, the Brookings Institute has made their calculations as to how terrible the Republican health care bill is, predicting that at least 15 million people will lose health care coverage:

There is significant uncertainty about exactly how CBO will model these provisions and how it will expect the various provisions to interact with one another. Nonetheless, we conclude that CBO’s analysis will likely estimate that at least 15 million people will lose coverage under the American Health Care Act (AHCA) by the end of the ten-year scoring window. Estimates could be higher, but it’s is unlikely they will be significantly lower.

 

Many will suffer from the cuts to Medicaid. Many of those who purchase private coverage on the exchanges will suffer because of how the subsidies are restructured, based on age as opposed to income and the actual costs of insurance. The Kaiser Family Foundation has posted projections regarding this.

Medical organizations and those representing the elderly including AARP, the American Medical Association and the American Hospital Association have objected to the Republican plan. AARP issued a statement opposing the “House plan that would make changes to our current health care system, such as shortening the life of Medicare, hiking costs for those who can least afford higher insurance premiums, risking seniors’ ability to live independently, and giving tax breaks to big drug companies and health insurance companies.”

The less affluent voters who backed Trump will be hurt by the changes. Of course some people do benefit. “Nearly everyone in the Top 1%, who earn more than $774,000 a year, would enjoy a hefty tax cut, averaging $33,000, according to the non-partisan Tax Policy Center. Those in the Top 0.1% would get an average tax cut of about $197,000.” Insurance companies also benefit:

Obamacare allowed insurance companies to deduct only $500,000 of their executives’ pay as a business expense. The GOP bill would repeal that limitation, starting in 2018.

Top insurers pay their leaders millions in compensation every year so this provision could mean a nice tax savings for the companies.

One excuse given by Republicans for repealing Obamacare is the increased cost of premiums. However, most people receive health care coverage through either government programs or employer programs, which have not had major increases in premiums. The individual market had frequent jumps in premiums, and that has continued, except under Obamacare most people receive subsidies to help cover this. As a consequence, only about three percent of the country is actually facing the increases in premiums which Republicans are using to justify their plan. In return, we receive more comprehensive coverage which cannot be denied based upon medical problems.

As one of the three percent who purchases health insurance without qualifying for subsidies, I certainly do not see the Republicans as doing me any favors. My premiums will be higher under the Republican plan than they are now, and the even bigger problem is that the plan may “threaten the stability of the individual market” per the Brookings report, possibly making it impossible to obtain coverage.

 

Trump Screws Up Obamacare So He Can Falsely Call It A Failure

The White House has pulled ads to promote signing up for coverage under Obamacare, including ads already paid for. If the goal is to provide more affordable coverage, this is counterproductive. Younger, healthier people tend to put off signing up, and are among the last to enroll each year. Having more healthy people sign up for coverage leads to lower insurance premiums.

Of course if the goal is to call Obamacare a failure, then this was a smart move by Trump. The higher premiums are, the easier it is to criticize the plan.

What Donald Trump might not even understand is that the Affordable Care Act did not bring about insurance with high premiums, along with high deductibles and copays. Insurance on the individual market has always been like this for those of use who purchase our own insurance, as opposed to receiving insurance through employers or government plans. The difference is that, prior to Obamacare, people could purchase expensive, high deductible plans and then lose their coverage if they got sick. If they already had preexisting medical conditions, they would often be denied coverage, or have the reasons they need health care coverage be excluded from the plan. These problems no longer exist under the Affordable Care Act.

Republicans are meeting to discuss health care, with a goal of introducing legislation by late March for an alternative program. While President Trump and Republican Congressional leaders are talking about a quick repeal of Obamacare, The Washington Post reports that, behind closed doors, many Republicans are expressing concerns:

Republican lawmakers aired sharp concerns about their party’s quick push to repeal the Affordable Care Act inside a closed-door meeting Thursday, according to a recording of the session obtained by The Washington Post.

The recording reveals a GOP that appears to be filled with doubts about how to make good on a long-standing promise to get rid of Obamacare without explicit guidance from President Trump or his administration.

Senators and House members expressed a range of concerns about the task ahead: how to prepare a replacement plan that can be ready to launch at the time of repeal; how to avoid deep damage to the health insurance market; how to keep premiums affordable for middle-class families; even how to avoid the political consequences of defunding Planned Parenthood, the women’s health-care organization, as many Republicans hope to do with the repeal of the ACA.

In a survey conducted by The New England Journal of Medicine, most primary care physicians preferred making improvements to the Affordable Care Act and opposed repeal. Improvements supported by physicians included creating a public option similar to Medicare to compete with private plans, providing tax credits to people eligible for Medicaid to purchase private plans, and increasing the use of health savings accounts. There was less support for some good ideas such as expanding Medicare coverage to those 55 to 64 years of age. There was also less support for two of the ideas promoted by Republicans, shifting even more costs to consumers and reducing regulations on insurance companies by allowing them to sell insurance over state lines. (From or dealings with insurance companies, doctors know that they cannot be trusted, and regulation is needed.) From the report:

We found that in response to the question, “What would you like to see the federal policy makers do with the Affordable Care Act?,” 15.1% of PCPs indicated that they wanted the ACA to be repealed in its entirety. Responses varied according to the physicians’ self-reported political party affiliation; no Democrats wanted to see the ACA repealed, whereas 32.4% of Republicans did. Among physicians who reported voting for Trump, only 37.9% wanted the ACA repealed in its entirety. PCPs were less likely than the general public to want the law repealed. A Kaiser Family Foundation poll conducted after the election that used a question and response options similar to those in our survey showed that 26% of the general public wants the law repealed in its entirety

When asked about aspects of the ACA as it currently exists, the physicians we surveyed almost universally supported the insurance-market regulations that prohibit insurance companies from denying coverage or charging higher prices on the basis of preexisting conditions (95.1% stated that the prohibition was “very important” or “somewhat important” for improving the health of the U.S. population). There was also strong support for other key provisions of the law, including allowing young adults to remain on their parents’ insurance plan until 26 years of age (87.6%), providing tax credits to small businesses (90.8%) and tax subsidies to individuals (75.2%), and expanding Medicaid (72.9%). A lower proportion — just under half — favored the tax penalty for individuals who do not purchase insurance (49.5%)…

Although only 15% of PCPs want the ACA repealed, nearly three quarters (73.8%) favor making changes to the law. Physicians responded most favorably to policy proposals that might increase choice for consumers, such as creating a public option resembling Medicare to compete with private plans, providing tax credits to allow people who are eligible for Medicaid to purchase private health insurance, and increasing the use of health savings accounts. PCP Survey Responses Regarding Potential Health Reform.). Physicians responded most negatively to policies that would shift more costs to consumers through high-deductible health plans. Less than half were in favor of proposals to decrease insurance-market regulations (by allowing insurance companies to sell across state lines), require states to expand Medicaid, or expand Medicare to adults 55 to 64 years of age.

Polls: Approval For Trump Falls; Rises For Obama & Obamacare

A new CNN poll shows the same finding as a recent Gallup poll which found that Donald Trump has record low approval for modern presidents:

Donald Trump will become president Friday with an approval rating of just 40%, according to a new CNN/ORC Poll, the lowest of any recent president and 44 points below that of President Barack Obama, the 44th president.

Following a tumultuous transition period, approval ratings for Trump’s handling of the transition are more than 20 points below those for any of his three most recent predecessors. Obama took the oath in 2009 with an 84% approval rating, 67% approved of Clinton’s transition as of late December 1992 and 61% approved of George W. Bush’s transition just before he took office in January 2001.

An ABC News/Washington Post poll had similar findings. Donald Trump has tweeted the polls are rigged.

In contrast, Barack Obama is leaving office with a 58 percent favorability rating. While the news has been dominated by Republican plans to repeal Obamacare, an NBC News/Wall Street Journal poll shows that the Affordable Care Act is more popular than ever. This poll was conducted before today’s report from the Congressional Budget Office showing that repeal of Obamacare would result in millions of people losing their insurance and in increase in premiums:

  • The number of people who are uninsured would increase by 18 million in the first new plan year following enactment of the bill. Later, after the elimination of the ACA’s expansion of Medicaid eligibility and of subsidies for insurance purchased through the ACA marketplaces, that number would increase to 27 million, and then to 32 million in 2026.
  • Premiums in the nongroup market (for individual policies purchased through the marketplaces or directly from insurers) would increase by 20 percent to 25 percent—relative to projections under current law—in the first new plan year following enactment. The increase would reach about 50 percent in the year following the elimination of the Medicaid expansion and the marketplace subsidies, and premiums would about double by 2026.

AMA Warns Of Risks Of Gutting Health Care Reform

With Republicans appearing to make abolishing Obamacare a top priority (following their failure to gut ethics oversight of Congress), the American Medical Association has weighed in with this letter (emphasis mine) stressing the importance of making coverage more affordable, providing greater choice, and increasing the number insured:

Dear Majority Leader McConnell, Leader Schumer, Speaker Ryan and Leader Pelosi:

On behalf of the physician and medical student members of the American Medical Association (AMA), I am writing regarding our ongoing commitment to reform of the health care system and potential legislative actions during the first months of the 115th Congress.

The AMA has long advocated for health insurance coverage for all Americans, as well as pluralism, freedom of choice, freedom of practice, and universal access for patients. These policy positions are guided by the actions of the AMA House of Delegates, composed of representatives of more than 190 state and national specialty medical associations, and they form the basis for AMA consideration of reforms to our health care system.

Health system reform is an ongoing quest for improvement. The AMA supported passage of the Affordable Care Act (ACA) because it was a significant improvement on the status quo at that time. We continue to embrace the primary goal of that law—to make high quality, affordable health care coverage accessible to all Americans. We also recognize that the ACA is imperfect and there a number of issues that need to be addressed. As such, we welcome proposals, consistent with the policies of our House of Delegates, to make coverage more affordable, provide greater choice, and increase the number of those insured.

In considering opportunities to make coverage more affordable and accessible to all Americans, it is essential that gains in the number of Americans with health insurance coverage be maintained.

Consistent with this core principle, we believe that before any action is taken through reconciliation or other means that would potentially alter coverage, policymakers should lay out for the American people, in reasonable detail, what will replace current policies. Patients and other stakeholders should be able to clearly compare current policy to new proposals so they can make informed decisions about whether it represents a step forward in the ongoing process of health reform.

We stand ready to work with you to continue the process of improving our health care system and ensuring that all Americans have access to high quality, affordable health care coverage.

Sincerely,
James L. Madara, MD

Medical groups and physicians have been conflicted regarding expected health care policy under Donald Trump. There was some early support for Tom Price to head Health and Human Services in the hope that he will work to reduce the regulatory burden, but many doctors have come out in opposition to him out of concern for reductions in coverage for many Americans.

While health care policy could likely a major impact of the all-Republican government, it received very little attention during the presidential campaign. This is partially due to the media’s preference to cover the horse race and scandal, Donald Trump making more noise on matters such as the Wall, and an extraordinarily poor campaign by Hillary Clinton which concentrated on stressing Trump’s negatives and avoiding issues. Democrats are now starting to speak out on health care. Chuck Schumer is trying to turn Trump’s slogan against him, warning that Republicans will “Make America Sick Again.” Hopefully they can provide a resistance beyond coming up with a slogan.

Democrats were successful in blocking George Bush when he attempted to partially privatize Social Security in his second term, and similarly have a chance of receiving public support in opposing Republican attempts to reduce health care coverage, including cuts in Medicare and Medicaid. Republicans are also getting jittery about health care legislation. They could safely please their constituents by voting to abolish Obamacare when Barack Obama was in office and they knew he would veto their efforts if it made it past a filibuster. Many now realize they will be held accountable for what happens, including if people lose coverage, and insurance costs continue to rise rapidly. The Committee For A Responsible Federal Budget, typically conservative on government  spending,  has outline the costs of repealing Obamacare, giving further reasons for Republicans to be cautious.

Donald Trump remains a huge wild care, having both promised to abolish Obamacare and to provide a plan to cover all Americans. So far he has given no meaningful specifics, talking primarily about health savings accounts and allowing insurance companies to sell insurance over state lines. Neither is a real plan. One point to Trump’s credit is that, while his major appointees have been from a very narrow group (primarily wealthy conservatives), he has spoken to a wider range of people. Zeke Emanuel, the architect of the Affordable Care Act, came out of a meeting with Trump expressing optimism, as reported by NPR. He believes Trump might seek to have a bipartisan bill after Republicans have complained about how Obamacare was passed by only Democrats. He also pointed out that some conservatives are pushing for “repeal and replace” as opposed to the currently discussed tactic of “repeal and delay” and discussed how legislation might be handled after an initial resolution (even if along party lines) to abolish the ACA utilizing budget reconciliation:

And so that you really do need to repeal and replace, and you need to do it in one bill. Otherwise, you’re really going to disrupt the individual insurance market in a very bad way, and you’ll be responsible for millions of people losing their coverage but also health insurance premiums going up. And I think that is not a scenario that a lot of Republicans really want…

So one possibility is that they pass a resolution saying that they will then come back and pass a bill that will repeal parts of the Affordable Care Act and at the same time have a replacement for those parts of the Affordable Care Act…

The resolution can be party lines, but the bill would then have to construct both the repeal part but simultaneously the replacement part. And I think if you do it that way, you could begin to negotiate with Democrats. If you just have a repeal and we’ll be back in three years and tell you how we’re going to fix it, then the Democrats are simply going to walk away. Chuck Schumer has made that clear.

And they should walk away because then it’s all – it’s the old pottery barn principle that Colin Powell made famous, which is, you break it; you have to fix it, and you take responsibility. And the Democrats will not want their fingerprints anywhere near the breaking of Obamacare and the disruption of the insurance industry in the United States…

The question is, what is the shape of that bill? Is it just a repeal bill, or is it a repeal with replacement? And that negotiation about that bill could take several months. My own estimate is if both sides come with good faith, they could probably hammer this out in about six months. It’s not a small item. I mean health care reform is big.

The question is, what are the gives and takes? I do think – again, one of the reasons I’m optimistic is that when you look at conservative and liberal health policy experts, there’s about 70 or 80 percent overlap between the two groups about the shape of the future and what you would need. And I think that’s, again, why I’m optimistic – because there aren’t that many ways of doing health care reform. They’re really limited.

Of course counting on the sanity of Republicans is a very risky bet.

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.

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.

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.”

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.

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.