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Thursday, March 30, 2017

Fixing whatever is wrong with Obamacare isn't that complicated

by digby

This piece by Henry Aaron lays it all out:
Republicans insist that Obamacare is failing. Facts refute the charge. The law set out to expand health insurance coverage, and it has done so — by more than 20 million people. Overall health care spending since enactment of Obamacare has been well below historical trends. Commonly reported measures of health care quality have been improving.

To be sure, the law has its problems. Obamacare leaves some people with burdensome health insurance costs. Too few insurers offer plans in some areas.

The AHCA would have made the first problem worse and done little to solve the second. It would have ended Medicaid for millions of poor people, and raised premiums for individuals and small groups by as much as 20%. It would have slashed help for people in their 50s and 60s.

It would have used the savings from these cuts to finance tax reductions for the well-to-do and to pay for premium subsidies for people with incomes as high as $200,000 a year, most of whom can afford to buy health insurance on their own if they are not covered through work.

The problems of insurers are more complicated. Through inexperience or the desire to attract customers, some insurers initially set premiums so low that they lost money. Unsurprisingly, they then either raised prices or stopped selling in the Obamacare marketplaces.

Those drafting Obamacare foresaw such difficulties and authorized payments to insurers that enrolled sicker-than-average customers. The Republican-controlled Congress reneged on that commitment.

Unwilling to take responsibility for problems they helped create, Republican critics now allege that insurance prices are excessive and that marketplaces are collapsing.

Both charges are false. Premiums are lower, not higher, than projected before Obamacare passed. And independent analysts now agree that after the price adjustments, insurance markets will be stable and that insurers will make money.

Trump and Republicans should devote themselves to correcting acknowledged flaws in Obamacare, not to sabotaging it. Many of these improvements would advance Republican objectives and help politically red states: 
• The Obamacare mandate that large-and medium-sized employers provide insurance to workers applies only to workers employed 30 or more hours a week. Republicans correctly criticized the design of this mandate. It should be improved or repealed. 
• Some Republicans have proposed replacing the 40% excise tax on high-cost health plans, the so-called Cadillac tax, with a requirement that people include the cost of employer-financed health insurance above certain thresholds in their personal taxable income. Democrats should welcome that shift. 
• Nineteen states have been unwilling to extend Medicaid coverage, partly from a fear that the federal government will cut payments and leave states holding the bag. Congress should reassure states on this score. It would help all states, most of which are Republican-controlled. 
• Republicans and some Democrats have decried the provision of Obamacare authorizing the creation of the Independent Payment Advisory Board, an unelected group empowered to hold down growth of Medicare spending by proposing cost-reducing changes that would take effect unless both houses of Congress mustered majorities to block them. So, change it.

Should the GOP move ahead on these repairs, Democrats would want something in return. For instance, they would seek to raise, rather than lower, assistance for those who currently face high out-of-pocket medical costs. But that’s the kind of tradeoff Donald Trump, supposed dealmaker, should proudly strike — isn’t it?

There is a deep irony here. Medicaid, which Republicans now seek to roll back, was originally a Republican proposal. The Obamacare marketplaces, the requirement that individuals carry insurance, and subsidies to help them afford it were originally Republican ideas.

Republicans now fail to acknowledge clear-cut evidence that these ideas are working and refuse to consider changes that would make them work even better. So sad.

Aaron thinks that this could be the basis for a compromise with Republicans but I really, really doubt it. If Democrats had a majority in the congress and a Democratic White House they could do this and yet it wouldn't be a slam dunk. And as our politics are currently constructed, they would have to do it all without GOP buy-in and would have to appease red state Democrats who would be facing the Koch brothers and swarms of wingnut activists.

That's the reality. But it's important to put this out there so that people know that whatever problems exist with the ACA, they are fixable. There may be more problems in the future that need to be fixed too. That's how this stuff works. In the old days you could get bipartisan co-operation to fix such problems in existing programs. But those days are gone.

Right now we have a president who has said that he wants the program to blow up so he can blame the Democrats. And frankly, I think the rest of the Republicans probably secretly agree with him.  Their opposition has always simply been a weapon with which to bash Democrats. It's clear by now that they don't have the slightest idea of how to successfully replace it without killing people.

Right now the best hope is that the program toddles along for a couple of years until the Democrats can take back the congress, pass these fixes, let the lunatic in the White House run against them in 2020 and beat him.