GOP plans to replace Obamacare with “Universal Access” pivot; much is left to the imagination

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House Republicans, responding to criticism that repealing the Affordable Care Act would leave millions without health insurance, said on Thursday that their goal in replacing President Obama’s health law was to guarantee “universal access” to health care and coverage, not necessarily to ensure that everyone actually has insurance.

@HouseGOP wants to guarantee 'universal access' to health care and coverage Click To Tweet

In defending the Affordable Care Act, the Obama administration, congressional Democrats and advocacy groups have focused on the 20 million people covered by the law, which has pushed the percentage of Americans without health insurance to record lows. The American Medical Association recently said that “any new reform proposal should not cause individuals currently covered to become uninsured,” according to The New York Times.

But House Republicans, preparing for an immediate legislative blow to the law next month, emphasize a different measure of success.

“Our goal here is to make sure that everybody can buy coverage or find coverage if they choose to,” a House leadership aide told journalists on the condition of anonymity at a healthcare briefing organized by Republican leaders.

Republicans have an “ironclad commitment” to repeal the law, the aide said, as lawmakers moved to discredit predictions that many people would lose coverage.

“There’s a lot of scare tactics out there on this,” said Representative Kevin Brady, Republican of Texas and chairman of the Ways and Means Committee. “We can reassure the American public that the plan they are in right now, the Obamacare plans, will not end on Jan. 20,” the day Donald J. Trump will be inaugurated.

The suggestion that 20 million people will lose coverage is a “big lie,” Mr. Brady said, after meeting with Republican members of his committee.

“Republicans,” Brady said, “will provide an adequate transition period to give people peace of mind that they will have those options available to them as we work through this solution.”

Having said that, Republicans still have not settled on the details or the timing of their replacement plan.

The House speaker, Paul D. Ryan of Wisconsin, portrays repeal of the law not as an ideological crusade, but as a form of urgently needed relief.

“Insurance markets are collapsing,” Mr. Ryan said last week. “Premiums are soaring. Patients’ choices are dwindling.”

The House leadership aide said that repealing major provisions of the law was a priority for the first 100 days of the Trump administration. But, he said, the date that those provisions would actually disappear would be delayed, allowing a transition period as short as two years or as long as three or four years. During that time, Republicans plan to pass one or more replacement bills.

The aide declined on Thursday to say if Republicans would seek an immediate halt to the cost-sharing subsidy payments. He did not rule out the possibility that a Republican-controlled Congress might keep the money flowing for a transition period, to stabilize the market while Republicans develop alternatives to the health law. “It’s an open question,” he said.

Republicans emphasized they were more interested in vindicating Congress’s constitutional power of the purse. But in any event, the aide said, Republicans do not intend to, “pull the rug out from people who have gained insurance under the Affordable Care Act.”

Steve’s Take:

While reading the mainstream media accounts about Republican intentions to provide “universal access” to healthcare the instant the next Congress is gaveled in, something obvious struck me. While the GOP certainly intends to repeal Obamacare first thing next month, Republicans in both chambers are completely unsettled about the details and timing of their replacement plan.

This is a perfect example of “hysteron-proteron,” a figure of speech consisting of the reversal of a natural or rational order (as in “then came the thunder and the lightning”). In other words, what should come last is put first (as in the idiom, “putting the cart before the horse”).

Let’s return from my high school Latin class and deconstruct this GOP notion of “universal access,” to get to the bottom of the political rhetoric. Remember, it’s repeal Obamacare first thing on Jan. 3, then replace it with…something else.

Republicans on Capitol Hill are fighting back against grim warnings that doing so will mean millions of people will lose their health insurance policies. A senior House leadership aide, in a briefing with reporters Thursday, conceded that the Republican plan would likely result in fewer Americans having health coverage. But that will be “because they choose not to purchase it.”

One of the key underpinnings of Obamacare and its most controversial element is the individual mandate that requires Americans to either carry health insurance or pay the penalty, notes The Fiscal Times. (The law includes large subsidies for many low and moderate-income people in order to make health insurance affordable.) The point of the mandate is to come as close as possible to universal coverage–a world in which virtually everyone is insured.

While “universal access” has a warm-and-fuzzy appeal to those who believe that health care should be available to everyone who lives in the world’s wealthiest country, it also has a powerful underlying economic rationale based on the realities of the insurance market. By requiring everyone to buy into the health insurance market, the healthy, who on average consume less health care than the sick, effectively subsidize their coverage.

Many opponents of the ACA, particularly those in the libertarian camp, see this as an unacceptable, coercive “taking” by the government, arguing that people should not be forced to purchase something they may not want.

Supporters of the law have claimed that because of the unpredictability of illness and accident, nobody can truly opt out of the health insurance market and that the mandate is the best solution to the free-rider problem–uninsured people seeking emergency care that they often cannot pay for but that hospitals are obligated to provide.

While the details of what the Republicans intend to replace the ACA with remain at best sketchy, one of the goals expressed in Thursday’s briefing, as reported by The New York Times, will be to replace the principle of universal coverage with something quite different: universal access. The idea is that having health insurance will not be a requirement, the unnamed aide said, but will be a viable option for anyone who wants it.

The details remain to be worked out, and that will be no small task if indeed it is achievable at all. The problem lies in the basic economics of the health insurance market. Without a mandate to purchase insurance, the people who see the least value in it–younger, healthier consumers–are likely to decline to buy it. The result is a pool of insured people who are older and sicker on average than the population as a whole.

…just like before the ACA.

That is a more expensive group of people to cover, and health insurers used to have two options for dealing with a pool of potential customers who were sicker than the population as a whole: raise prices or deny coverage to sick or high-risk patients.

…just like before the ACA.

Instead, the ACA removed that second option, requiring insurers selling policies through the health insurance exchanges to extend coverage to all applicants. (Indeed, the individual mandate was the trade-off that insurers accepted in exchange for dropping limitations on pre-existing conditions.) Repealing that part of the law would be wildly unpopular, and President-elect Donald Trump has said that he does not support doing so.

This leaves price increases as insurers’ only option–short of leaving the exchanges completely–for dealing with a sicker population.

…just like, well, you know.

Supporters of the ACA, myself included, argue that this is just the first step in a vicious cycle. As costs go up, healthier people start to question whether the value they receive from their insurance policy is worth the cost and more of them will drop their policies, leading to further premium increases for those who remain, and so on and so on.

How Republicans plan to address this problem is a mystery. Over the past few years, proposals for subsidized high-risk pools meant to take the sickest patients out of the general insurance pool have been floated, but whether they would be viable remains an untested theory.

Right now, Republicans are working hard to assuage the fear that they will take actions in January that will immediately throw millions of people off the health insurance rolls. Top party leaders have promised that there will be a considerable adjustment period–some have said up to four years–during which a replacement will be devised.

What isn’t immediately known is how the next Congress will handle the individual mandate. Leaving it in place during the transition period would be seen by many of the ACA’s most ardent opponents as a betrayal. But eliminating it could cause insurers operating in the healthcare exchanges to rush to the sidelines, creating a major coverage crisis for millions of Americans and resulting, at least in the near term, in the exact opposite of “universal access.”

What’s the Nitty Gritty?

Right now, while repeal of the ACA is certain, replacement is not.

As Robert Miller, MD, a Nashville physician and contributor to The Tennessean says so eloquently, “All of us have a stake in what Congress decides to do after it repeals the ACA. If repeal and replacement are not done wisely, enormous harm will result.”

Independent estimates project that repealing the ACA without a replacement could double the number of uninsured Americans to 58 million, including 4 million children.

Repealing the ACA without a replacement will affect hundreds of billions of dollars in Medicare and Medicaid funding for the healthcare delivery system, especially hospitals. Those dollars are the lifeline for rural hospitals.

The prospect of reductions in federal funding would likely prompt the closure of many rural hospitals and perhaps others. Rural communities that have lost hospitals can attest to the devastating impacts when these essential elements of local economies close. In addition to diminished access to care, hospital closures mean lost jobs and the inability to recruit and retain other industries essential to a community’s viability.

Repealing the ACA without a replacement likely will destabilize the healthcare insurance industry as well as healthcare delivery. Insurers are likely to leave the ACA market if they do not know what a replacement looks like; and it’s unimaginable that the incoming administration will fill this gap with a public insurance replacement. Employers, insurers, healthcare providers and families have a need and a right to know what comes next so that they can plan accordingly.

Steve's Take: To @HouseGOP - replace before you repeal #Obamacare Click To Tweet

I concur with Dr. Miller that, hopefully, there are a sufficient number of Republicans on Capitol who understand that the power to affect every American’s health care requires Congress to honor the medical dictum, “first, do no harm.” The message is clear: replace before you repeal. You owe that to the American people.

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