This seems like a good time to ask about the actual impact of the vague executive order Trump issued in January, basically telling the executive branch to "waive, defer, grant exemptions from, or delay" whenever legally possible:
> To the maximum extent permitted by law, the Secretary of Health and Human Services (Secretary) and the heads of all other executive departments and agencies (agencies) with authorities and responsibilities under the Act shall exercise all authority and discretion available to them to waive, defer, grant exemptions from, or delay the implementation of any provision or requirement of the Act that would impose a fiscal burden on any State or a cost, fee, tax, penalty, or regulatory burden on individuals, families, healthcare providers, health insurers, patients, recipients of healthcare services, purchasers of health insurance, or makers of medical devices, products, or medications.
I've read both of those and neither contains much information. But I haven't seen the news mention anything more recently. Surely we've learned something about the actual impact in two months, but the news has moved on.
This legislation was a complete mess. Republicans have been warning about the Obamacare "death spiral" for years. For the life of me I can't figure out why no one is talking about the much worse, much faster death spiral embedded in this legislation: no one would be forced to buy insurance, but insurers still have to take your preexisting condition, and can only charge 30% more for one year for the extra risk. Hello adverse selection!
I'm a pretty free-market guy and can get behind healthcare reform in general, but this bill had holes big enough to drive trucks through from the right and left simultaneously with plenty of room to spare. I could believe it coming from Trump, but I have no idea what Paul Ryan was thinking... the guy is supposed to be a policy wonk.
This. As someone who's worked on the insurance side of the equation for a while, it always amazes me when people don't realize the majority of health insurance policy is a zero sum game.
If insurance companies aren't solvent and profitable, products won't be offered. And that's exactly what happens when you force unfunded / unbalanced mandates on them. Congress can easily legislate the country into a market where no one wants to offer insurance because there's no way to do so sustainably.
That said, one of the best things that ACA did was finally target some of the inefficiency in as conservative of a business as insurance. The provision capping administrative costs did a lot to jolt companies into streamlining their operations and investing in modern, more efficient technologies.
From https://www.cbo.gov/publication/52486 - "Even though the new tax credits would be structured differently from the current subsidies and would generally be less generous for those receiving subsidies under current law, the other changes would, in the agencies’ view, lower average premiums enough to attract a sufficient number of relatively healthy people to stabilize the market."
Think of the $3000 subsidy towards health insurance as a $3000 penalty if you don't buy health insurance.
Either Ryan is incompetent when it comes to writing legislation and is only good at pretending he's good at it (wouldn't surprise me), or he just wanted to kill the issue and move on the other things.
The Republicans' only position on this - one which has become religious dogma at this point, is "repeal."
They didn't prepare for a replacement because they never intended to actually replace the ACA with anything comprehensive, as comprehensive healthcare reform is philosophically anathema to them, and any language to the contrary was just lip-service to keep moderates and Democrats quiet. The Republicans probably never even expected the public backlash they got over this, but to simply strike it down and then be greeted in the streets as liberators.
The problem for the Republican leadership is that the House of Representatives is effectively a hung parliament. There's the far right House Freedom Caucus (~30 members), the moderate-right Tuesday group (~40 members), and the party doesn't have a majority without both groups. When John Boehner was speaker he kept the government mostly functioning by combining the moderates in the Republican party with the Democrats to pass bills to keep the lights on (continuing resolutions, debt ceiling increases, etc). But that doesn't work for major policy initiatives like health care.
The leadership drove the bill the wrong way. They should have hung the Freedom Caucus out to dry, moderated the bill, and tried to peel the necessary votes from Democrats in red states.
Torpedoing essential benefits without a more fundamentally comprehensive replacement was like strapping engines to a car and expecting it to turn into a plane.
There was no right way; the only way to win was not to play the game. Anything that destroyed the basic model of the ACA—except to move to a stronger public guarantee which basically no Republican members are interested in—was never going to attract significant Democrstic support; the initial version of the AHCA had substantial opposition from both hard-line conservatives and moderates in the Republican Party, and anything that did more to appeal to either of those groups expanded opposition on the other side.
Absolutely. The "big tent" the Republicans assembled started to come apart when the Tea Party insurgency began. They're now experiencing the consequences.
I wonder if the leadership suffered from the same confusion that this article shows. It's hard to call the Republicans Trump's party. Perhaps even calling Republicans a single party is going too far.
I've been a frequent critic of Obamacare. I've personally experienced some of its shortcomings: lesser coverage, more out of pocket, higher deductibles, can't see the family doctor my other family members see, and that I saw for years, etc.
But I saw nothing from the Republicans that indicated they were fixing or improving anything.
I think a number of dissenting House Republicans know that premiums are going to go up no matter what and decided they'd rather see Obamacare go down the drain with his name on it than step up and fix what needs fixing.
This is how I see a lot of the Trump presidency going. The USA isn't a dictatorship, Obama ran into similar roadblocks and I credit him for actually getting something passed rather than what was passed.
non-Americans: can you describe what dealing with your health care system is like? I want to understand: is it a supply constrained, health-care rationing, expensive bureaucracy; or is it an affordable, convenient, healthy paradise; or something in between? I see reports from people who create a portrayal of European and Asian health care systems that match their narrative of these systems either being excellent, or horrible. Can I hear from actual people who live in this systems if they are good or bad?
Can anyone explain to me why it would have been a bad idea for the Republicans to have introduced a single-player plan and then claimed to have fixed healthcare? Feels like they missed a big opportunity there. Is it purely ideology?
Because this wasn't really a "healthcare bill" it was a tax cut bill to transfer 600 billion dollars from the poor to the wealthy. It was never even about healthcare, it's about wealthy/monied interested who own the Republican party, which has somehow become the standard bearer for poor people who apparently just don't understand that their own party has it out for them.
Technically speaking, I think the nominal notion was to _prevent_ the transfer of $600 billion from the wealthy to the poor.
In actuality, because of twisted Republican orthodoxy combined with the reality of politics, at the end of the day the approach would have resulted in $600 billion in deficit spending.
Aside from the fact that Republicans don't want it, it's a surefire political loser. It'd piss off the health industry whose profits would be impacted. It'd piss off anyone who was already happy with their healthcare. It'd piss off their wealthy donors, who would have to pay more in taxes for it. It'd give a whole bunch of fuel to the activists and journalists who're already going after the Republicans, because single-payer is only workable elsewhere by refusing to pay for expensive stuff that doesn't help patients, and that stuff comes in vital-sounding guises like "essential healthcare benefits" and cancer screening and treatment. Setting it up would also be a massive, unprecedented task.
Also, I think a fundamental problem with any Republican healthcare plan is that the opposition to it doesn't have a politically coherent set of principles that they could bargain with. For example, one of the features of the ACA is that it subsidises all elderly people regardless of wealth through the 3:1 cap on age-based premium differences. This is indirectly taxpayer-funded through subsidies to buy the insurance plans that subsidise it (for people who often can't afford to use their insurance), but the trick used to hide who's being subsidised also makes insurance unaffordable for young people. So Republicans want to replace the whole mess with a straightforward taxpayer-funded, age-based subsidy. Cue press attacks about how the evil moustache-twirling Republicans want to send seniors' insurance rates skyrocketing and hand out subsidies to people regardless of wealth.
Probably some of the "preventative and wellness services" and coverage for prescription drugs, surgeries and other treatments with the worst cost-to-benefit ratios. That's how it's always worked here in the UK. For example, breast cancer screening is only offered every three years here compared to 1-2 years as required by the ACA and for a narrower age window too, some of the other screenings probably aren't offered at all, and the more expensive chemotherapy treatments aren't covered either.
Those are minor details. The political debate isn't over how often to provide breast cancer screening, but whether "preventative and wellness services" should be mandated at all.
And the _real_ dilemma in the GOP is that most Republicans don't think the government should be subsidizing any of this at all. If you gave all the Republicans a chance to pass a bill free from any kind of political consequence, they'd repeal the ACA along with all the entitlements and taxes. But that's not politically tenable for a million different reasons. This fundamental mismatch between Republican policy preferences and the reality of modern political and economic life means Republicans are incapable of governing in a sane manner. Even _if_ their various political-economic theories were correct, you can't arrange the system into a state where those theories could be applied. Reality is path dependent, and your available solutions are limited by the past.
But the thing is, when you and your constituents are convinced that the modern bureaucratic state is fundamentally irredeemable[1], there's always a convenient excuse for why things never pan out. It's like an employee who never gets anything done, always has an explanation about how somebody else is thwarting his designs, and can talk endlessly about all the changes he would make to improve things. His excuses may be individually defensible, and his ideas may be interesting, but they're irrelevant.
[1] And I don't just mean favoring small government. I've never met a person, liberal or conservative, rich or poor, who doesn't express a nominal preference for smaller government.
The House Freedom Caucus should be forced to buy their insurance on the individual markets, with no allowance for pre-existing conditions. Any thing else is absolute hypocracy.
Yes, they genuinely don't want single payer. Trump seems open to it, and certainly a lot of this debate is political posturing, but single payer is completely opposed to every stated and unstated principle of the Republican party.
It seems like most people's response to this news is either extremely happy or very upset.
I'd be interested to hear why anyone on here feels either of those emotions.
For me, it looks like I'll have to continue paying the Obamacare penalty for the foreseeable future, and it will be impossible to find an insurance plan that makes sense for my family.
I have insurance through the Washington State Health Benefit Exchange (i.e. Obamacare), and a pre-existing condition. My insurance is kind of 'meh,' but it means that I will not be bankrupted if something serious happens to me.
Had this morning's version of Trumpcare been made law, the odds of me being able to afford useful insurance would've been slim to none. So, I am ecstatic about this news.
Did Trump really think it would pass though? I figured he pushed the vote knowing it'd likely fail so he could move on to tax breaks. He then "tried", and Ryan / Freedom Caucus takes the fall in the midterms.
It doesn't really make sense to invest so much time into promoting the bill if this was the plan, though. He claimed to be personally calling hundreds of representatives, threatened those planning to vote against it, had Spicer guarantee its passage, etc. I don't know if Trump thought it would pass, but he certainly gave lots of signals that he wanted it to and was taking responsibility for it.
He absolutely had to be seen as pushing for it, even if he realized that many millions losing coverage would hurt him deeply in 2020.
Right now healthcare is shelved and the far right reps lose steam, having failed to work with their own party and a President far more popular with their constituents than they are.
Honestly I don't think he care whether it passed or not. He's not playing the game we see.
> Right now healthcare is shelved and the far right reps lose steam, having failed to work with their own party and a President far more popular with their constituents than they are.
Current polling data to support the claim that any far right Republicans are far less popular with their own constituents than Trump is would be welcome. Given his cratering approval numbers, including with Republicans, I kind of doubt that is true in general.
On one end of the spectrum, you have the 25 year old single dude who works for a big company. He pays $60 every two weeks for his PPO and doesn't understand what the big deal is. Can people really not afford $60 every two weeks? He votes Republican because he's a maker, not a taker, and he wants a tax cut. He fundamentally misunderstands the nature of his coverage: his employer pays 80% (or 100%!) of his premium.
On the other end of the spectrum, you have a family of five that makes too much money to qualify for a subsidy. They live in a red state that didn't expand Medicaid, uses the federally-managed exchange, and suffers from a lack of competition because there's only one insurer on that exchange. An HDHP for the family would cost $1,300/mo, which they can't afford, so they pay the penalty and go without insurance. They vote Republican because as they see it the government is forcing them to buy something they can't afford, and they want it to be better... or at least go back to the way it was.
A lot of people and families had plans and doctors they liked before the ACA was passed, and one of two things happened:
1. because year-over-year premium increases are regulated by the government per the ACA, insurers were forced to make their plans more efficient by reducing the size of their networks in one way or another. This meant that a lot of people lost access to their doctors and had to find another, often having to travel further and/or wait longer to see their new doctor.
2. they had terrible insurance before the ACA was passed, but didn't realize it. Perhaps they had unreasonably high deductibles, or access to few essential services, or ridiculously low lifetime limits, or punitive coinsurance rates, or... Perhaps they'd refuse to cover something because it was a "preexisting condition." Perhaps they'd drop you mid-treatment, making it impossible to get further treatment without going into severe debt. This insurance wouldn't have been much use to anyone in the event of cancer, or a heart attack, or a broken leg, but they were paying the premiums anyway, and it sure helped them feel insured. ACA made all of these practices illegal, or at least put some controls on them to ensure a baseline quality of insurance. These plans went away or became as expensive as other plans.
These people vote Republican because from their point of view ACA took away their plans and their doctors, and Obama had stupidly promised them that wouldn't happen. They had it good, or so they thought, and it was taken away from them.
Everyone else is experiencing rising deductibles and premiums with no end in sight. What most people fail to realize is that deductibles and premiums would be rising with or without ACA—as they were before the passage of ACA—at a greater rate! ACA bent the curve, so they're still increasing, but less so. Yes, your insurance cost $300/mo last year, and it costs $400/mo this year, but how much would it cost if ACA hadn't been passed seven years ago? Would you even be able to get insurance? Do you or a family member have a preexisting condition? Our minds aren't wired to think like this, though... all we see is a higher bill and want someone to blame, so we vote Republican.
I could go on. ACA did a lot, but it didn't do enough to encourage competition and control costs. Clearly. A public option and "death panels" would have helped a lot, but of course these were dropped to encourage bipartisan support for the bill... which it didn't get. Oh well.
> To the maximum extent permitted by law, the Secretary of Health and Human Services (Secretary) and the heads of all other executive departments and agencies (agencies) with authorities and responsibilities under the Act shall exercise all authority and discretion available to them to waive, defer, grant exemptions from, or delay the implementation of any provision or requirement of the Act that would impose a fiscal burden on any State or a cost, fee, tax, penalty, or regulatory burden on individuals, families, healthcare providers, health insurers, patients, recipients of healthcare services, purchasers of health insurance, or makers of medical devices, products, or medications.
https://www.whitehouse.gov/the-press-office/2017/01/2/execut...
Does anyone know what to expect when renewing insurance in 2017?