Monday, April 01, 2019

Trump healthcare reruns: Graham-Cassidy and the Sundowning Kid

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April Fool! Trump is once again promising an ACA replacement with low premiums and low out-of-pocket costs.
It's coming along great:
The president brought up healthcare again on Friday, claiming he would have a “much better” plan than Obamacare. “The health care’s going very well,” he told reporters in Florida.
Takes a person back...to, say, Jan. 15, 2017
President-elect Donald Trump said in a weekend interview that he is nearing completion of a plan to replace President Obama’s signature health-care law with the goal of “insurance for everybody"...

Trump said his plan for replacing most aspects of Obama’s health-care law is all but finished. Although he was coy about its details — “lower numbers, much lower deductibles” — he said he is ready to unveil it alongside Ryan and Senate Majority Leader Mitch McConnell (R-Ky.).

“It’s very much formulated down to the final strokes. We haven’t put it in quite yet but we’re going to be doing it soon,” Trump said.
He noted that he is waiting for his nominee for secretary of health and human services, Rep. Tom Price (R-Ga.), to be confirmed....

“We’re going to have insurance for everybody,” Trump said. “There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.” People covered under the law “can expect to have great health care. It will be in a much simplified form. Much less expensive and much better.”
The finishing strokes -- along with the first strokes -- were unveiled by Paul Ryan and House Republicans in March 2017 as the American Health Care Act (the executive branch never had a plan). The AHCA would have repealed federal funding for the ACA Medicaid expansion, ultimately pushing 15 million people out of Medicaid, and replaced the ACA's income-adjusted subsidies with flat subsidies, also eliminating the Cost Sharing Reduction subsidies that reduce deductibles for about 5 million low-income ACA enrollees to the $0--$1000 range. The flat premiums subsidies would have left any 64 year-old with an income below $75,000 paying $14,600 for a plan with a deductible topping $4,000, according to CBO and Kaiser Family Foundation estimates*; a 52 year-old would pay about $8,500 per year for the same plan. Premiums would be especially steep for older enrollees, as the AHCA allowed insurers to charge the oldest enrollees five times as much the youngest adults, expanded from the ACA's 3-to-1 ratio.

When the AHCA passed the House, Trump lauded it as a "great plan" -- though a few weeks later he told Republican senators it was "mean" and urged them to do better.

Republican senators' answer: the Better Care Reconciliation Act. The BCRA did adjust subsidies by income, and age as well -- but set the benchmark plan at an actuarial value of  58%, which according to CBO estimates would have translated to $13,000 deductibles by 2026.  As the BCRA also repealed the ACA Medicaid expansion, that would have been the subsidized plan on offer at the lowest income levels as well as the highest -- putting the low deductible coverage available at incomes up to 200% FPL far out of reach. CBO forecast that both plans -- the AHCA as passed and the BCRA as it came to vote -- would have uninsured more than 20 million people.

Trump's reaction to the final version BCRA? On the eve of the marathon Senate session that ultimately voted down three ACA repeal bills (the others being repeal without replacement and a so-called "skinny repeal" focused on the individual mandate):
Standing in front of people he called “Obamacare victims,” President Donald Trump gave yet another plea against the Affordable Care Act (ACA) on Monday. He called on the Senate to act now and replace current health care law with the  Better Care Act Reconciliation (BCRA).

“The question for every senator, Democrat or Republican, is whether they will side with Obamacare’s architect, which have been so destructive to our country, or with its forgotten victims,” said Trump. “Any senator who votes against  starting debate is telling America that you are fine with the Obamacare nightmare which is what it is.
Last of all was the Graham-Cassidy ACA repeal bill, the most wantonly destructive of all, which would have replaced both the ACA marketplace and the ACA Medicaid expansion with block grants to states, leaving them to come up with their own schemes to replace those programs. The block grants were to be unevenly apportioned, with a formula favoring those that had refused the ACA Medicaid expansion.  CBO forecast that Graham-Cassidy too would uninsure millions -- though it could not venture a firm estimate, as the bill created such open-ended chaos with states left to their own devices.

Graham-Cassidy never made it to a vote -- but Trump endorsed it in his signature nuanced manner:
To the extent that the Trump administration's current planning for a new ACA replacement is not a complete fabrication, its embryonic plan is reported to be a variant of Graham-Cassidy, which vaporized the ACA's mandatory Essential Health Benefits and protections for people with pre-existing conditions, along with gutting Medicaid spending across all programs (as the AHCA and BCRA did as well).

I trust that readers of this blog won't feel deprived if I spare myself the effort to find some freshly piercing way to memorialize the infinite scope of Trump's lying. The only consolation is that this time the threats are as empty as the promises -- unless and until Republicans regain control of Congress (along with the presidency) in 2020.

Postscript: Trump's healthcare strategy is simple:
1. Promise what sounds like Medicare for all (heavily subsidized premium w/ tight coverage rules)
2. Deliver Graham-Cassidy (massively under-subsidized private offerings, barely regulated)


Update, 4/2: From Trump: Never mind! No new plan till 2021. But the threat from Texas vs. U.S. lingers. After all, Trump is keeping Ruth Bader Ginsburg's seat warm for a right-wing ideologue.
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*CBO estimated that plans in the AHCA marketplace would have an average actuarial value of 65%. The Kaiser Family Foundation estimated that that would translate to an average deductible of $4,100.  In 2019, 70% AV plans in the ACA marketplace deductibles average $4,033. The average AV in the ACA marketplace in the 39 states using HealthCare.gov was 78% in 2018

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