How could Patty Murray "thread the needle" with Lamar Alexander?

Ever since the Cassidy-Collins bill was introduced in January, I've thought that Democrats should engage with Republicans in Congress who were willing to leave the ACA's taxes and core benefits intact. Cassidy-Collins didn't do that, but I thought it came close enough to be a basis for talks.

Triage was the byword. If a handful of the dozen-odd Republican senators who were then expressing qualms about repeal of the Medicaid expansion in particular could be engaged in compromise negotiations, I thought, that would lessen the chances of passage for a bill that would uninsure tens of millions -- as would the AHCA, the BCRA, and now Cassidy-Graham.

Events have almost proved me wrong. The prevailing Democratic strategy -- we'll talk about fixes when they give up on repeal -- has almost worked. Three repeal bills failed in the Senate. Lamar Alexander, HELP Committee chaired, has held hearings on a bipartisan bill to stabilize the individual market.  And on the other end of the equation, Cassidy -- who seemed like a possible partner since he wanted to preserve ACA taxes and so something like its scale of benefits -- is now a driving force behind a bill that would zero out ACA benefits and lay waste to Medicaid.

Still, ironically, we're at a point again where I'm tempted by similar logic: if Patty Murray and other Democrats engage with Alexander and come up with a compromise stabilization bill, that could blunt the drive toward Cassidy-Collins passage. Would co-sponsors of a stabilization bill, led by Alexander, turn around and vote for Graham-Cassidy?

AHCA Reduces Federal Spending on Private Health Insurance by....4%

[originally posted May 30]  The Republican bill rejiggers subsidies for the individual market but barely reduces them on net. Almost all the real cuts are in Medicaid     

Hours before House Republicans introduced the American Health Care Act, their ACA partial repeal/replace bill, on March 6, former CMS director Andy Slavitt tweeted:

When #ACA replacement bill is out, don't get distracted by exchanges.

The big issue is dramatic cuts in Medicaid to pay for huge tax cuts.

— Andy Slavitt (@ASlavitt) March 6, 2017

That remains true. In fact, it's truer than has been fully recognized.

The basic math of the AHCA, according to the Congressional Budget Office (CBO), is a $992 billion* reduction in federal revenue over ten years, offset by a $1.1 trillion reduction in spending on health insurance benefits. Most of that spending cut is in Medicaid, reduced by $834 billion over ten years, according to the updated CBO analysis released on May 24.

The rest of the spending reduction ostensibly comes from cuts in subsidies to private insurance. But that reduction is largely illusory -- - because two of the major tax cuts included in the AHCA subsidize privately purchased health insurance and medical care.

The pre-existing condition smokescreen

In a snappy summary by Axios's David Nather of  the latest AHCA stall-out, this caught my eye:

The holdouts are mainly worried about weakening coverage for sick people. Rep. Ryan Costello of Pennsylvania: "Protections for those with pre-existing conditions without contingency and affordable access to coverage for every American remain my priorities for advancing healthcare reform, and this bill does not satisfy those benchmarks for me."

What this tells me is that the moderates will ultimately go along with ending the ACA Medicaid expansion and girdling all federal Medicaid spending with per capita caps.  I have long worried that Republican relative moderates will go squish on Medicaid if AHCA damage to the individual market is moderated past a certain threshold.

Now more than ever, the bottom line remains what Andy Slavitt said it was two months ago:

If ACA is repealed, how many will max out on restored lifetime coverage caps?

In the waning days of his noble tenure as acting CMS director -- perhaps the last era in which CMS and HHS will function as fact-based agencies dedicated to improving healthcare delivery -- Andy Slavitt became a forceful Twitter advocate for the ACA, the payment reforms initiated under the ACA and MACRA, and other programs that require money, effort and commitment.

Among those tweets was one that listed 19 benefits that would be lost under ACA repeal, most of them little-known, including this:

That set me wondering: how many people would hit the coverage caps? And lo, an estimate exists. In our till-now-at-least-partially-fact-based-society, it sometimes seems that someone (or some interest group) has looked into almost any question that can be posed.

What's a healthcare article without a touch of Levitty?

It is a fact universally acknowledged among healthcare reporters that there are two ways to structure an article.

The first is to give Kaiser's Larry Levitt the lead quote to articulate or validate an asserted trend.

The second is to use other authorities to assert said trend -- and deploy Levitt about two-thirds down to inject a note of skepticism or a reality check. Today offers a perfect specimen of plan b: Gaming Obamacare, by Politico's Paul Demko.  The thesis is brought to you by the nation's insurers:

Obamacare customers are gaming the system, buying coverage only after they find out they’re ill and need expensive care — a trend insurers warn is destabilizing the fledgling health law marketplaces and spiking premiums for everyone.

700 words in, we're well prepped for the Levitt Reality Check:

What I wanted to ask Kevin Counihan

At a press briefing held yesterday, ACA marketplace CEO Kevin Counihan urged current ACA private plan holders to shop for a new plan, as "more than seven in ten of our customers can find lower prices by shopping."  Good -- the marketplace has gone all-in recently to try to convince existing customers not to renew their current plans without price-checking.

The next part of his message, however, betrays a skewed focus in my view. It's this: “Roughly eight in ten of our customers can get coverage for less than $100 a month after tax credits." That puts the focus unduly on premium, which is tantamount to dangling high-deductible bronze plans in front of low-income buyers.

The fact is, if you have access to a plan with a subsidized premium under $100, you are likely to be eligible for Cost Sharing Reduction (CSR) subsidies that will reduce deductibles and copays. CSR will cut out-of-pocket costs dramatically if your income is under $23,340 for a single person (200% of the Federal Poverty Level), and more modestly if your income is above that but below $29,175 (250% FPL).* But those secondary subsidies are available only with silver level plans, which have higher premiums than bronze.

Using Healthcare.gov's shop-around feature, I spot-checked the highest income that would enable a 44 year-old solo buyer to get the cheapest bronze plan in her zip code for under $100, give or take a dollar or two. In Chicago, it's $25,500. In Miami, it's $26,000. In Dallas, $27,500. In Biloxi, MS, $28,800; in Missoula, Montana, $25,500; in Newark, NJ, $27,700.  All of them are under the CSR threshold.

Older buyers with somewhat higher incomes can get bronze plans for under $100, since  the price spread between bronze silver increases with age.** In the six towns mentioned above, a 64 year-old could slip under the mark with an income ranging from $29,000 (barely CSR-eligible) to $33,500. Still, it's fair to say that the vast majority of buyers who can get a plan for under $100 are CSR-eligible.