Those uninsured by the BCRA "not losing, but choosing"? Get ready to hear it more.

Bloomberg reporter Steve Dennis flags a Republican talking point in favor of their latest travesty of a 'healthcare" bill that we're likely to hear more of in the next two weeks:

Frequent GOP talking point in Senate hallways: +22M won't be "losing" health insurance, they'll be "choosing" to go without. https://t.co/o4Anh6DY5i

— Steven Dennis (@StevenTDennis) July 6, 2017

That's in response to:

Not lose, choose. Apparently you believe freedom is optional https://t.co/WIUJz2Mxv7

— JohnCornyn (@JohnCornyn) July 6, 2017

This argument was first voiced byPaul Ryan, defending the first iteration of the House bill, and later by Tom MacArthur*, whose amendment undermining protections for people with pre-existing conditions secured that bill's House passage. As Cornyn, the Senate majority whip, has emerged as gaslighter-in-chief defending the Senate bill (the so-called Better Care Reconciliation Act, or BCRA), we should regard it as a kind of front-line defense. If the cabal now redrafting the BCRA in secret manages to improve the CBO score by throwing a couple hundred billion dollars back in the coverage pot -- reducing the forecast increase in the uninsured to, say, 15 or 12 million --expect to hear a lot more of it.

There is a ghost of truth in the allegation, which can be made to look more substantial by gaslight. so let's shine some stronger light,. A few points:

Senate exterminators gear up to expel Medicaid expansion beneficiaries

Earlier this spring, we had a squirrel in our eaves. An exterminator installed a one-way door, leaving the squirrel free to rattle about until circumstances drove her outside. Which of course they did, after a few days -- maybe three, maybe seven.

Way back in mid-January, when the AHCA was just an exhalation from Paul Ryan's college memories, this promise from Texas Senator John Cornyn seemed startling and impressive:

When Cornyn was asked if he was concerned about people who’ve benefited from Medicaid expansion losing coverage, he said it was a shared concern.

“Were all concerned, but it ain’t going to happen,” Cornyn said. “Will you write that down… It ain’t gonna happen.”

What's next for Democrats in the healthcare wars?

While the ACA appears to have escaped repeal for the time being, the ACA marketplace remains under apparent and threatened assault from the Trump administration -- which, after all, has to administer it.

The avowals of Trump and other Republican leaders, including Ryan and McConnell, that the marketplace will implode or is in a death spiral; the withdrawal of advertising for the marketplace in the closing weeks of open enrollment last January; the threat not to enforce the individual mandate; the possibility of destroying the marketplace immediately by stopping federal payments to insurers for Cost Sharing Reduction subsidies; and, most recently, the walk-back of avowals that Ryan's repeal bill is dead -- all these factors have left insurers and therefore the marketplace in a shaky position. Insurers may withdraw, and premiums are likely to spike, as they did last year.

Even if Hillary Clinton had won the presidential election, the marketplace would be in need of fixes. The risk pool is sicker, older and smaller than originally envisioned. The subsidies are smaller than they should be. Millions whose employers offer nominally "affordable" individual insurance but unaffordable family insurance are denied marketplace subsidies through the family glitch. The trio of risk control programs designed to smooth insurers' losses in a new kind of market expired too quickly, and one -- the risk corridor program -- was sabotaged by Republicans.

Given the need for fixes, and the at least momentary acknowledgment by Republican leadership that "we're going to be living with Obamacare for the foreseeable future," as Paul Ryan rather astonishingly put it last Friday, a number of progressives have started to scope out possible means by which Democrats in Congress could win Republican support for legislation that would improve competition, participation and affordability in the marketplace. If such a deal were possible, it would entail agreeing to provisions that would reshape the marketplace more to Republicans' liking. These might include:

Progressives, don't forget: The Freedom Caucus killed the AHCA

Defenders of the ACA are right to take some satisfaction and pride in the failure of Paul Ryan's repeal bill, the American Health Care Act.  All those packed Town Halls, jammed phone lines and floods of mail had their effect. Dozens of Republican reps and senators, moderate and not so moderate, expressed qualms about un-insuring tens or hundreds of thousands of their constituents -- and tens of millions of Americans.

As we consider next steps, though, it's important to take full measure of the rather mind-bending fact that it's the Freedom Caucus that really sank the bill. They reportedly killed it partly because Trump managed somehow to trivialize their concerns even as he caved to most of them -- but more fundamentally, because it left some ghost of the ACA tax credits and consumer protections intact for those seeking insurance in the individual market.

For these zealots (and their right-wing think tank backers), the AHCA wasn't harsh enough.  It didn't cut the taxes that fund Obamacare benefits fast enough. It didn't uninsure beneficiaries of the Medicaid expansion fast enough. It didn't kill the concept of subsidized private insurance dead enough. It didn't take us back to the future of medical underwriting and health "insurance" that would render unaffordable coverage for such incidentals as childbirth and mental health treatment.

What exactly is the Medicare guarantee?

As Paul Ryan revs up Republican engines for Medicare privatization, Nancy Pelosi vows to Greg Sargent that Democrats will fight it to the death:

Pelosi adamantly stated that Democrats would not give any ground on the core ideological dispute here, which is over whether to maintain a government coverage guarantee. “We are not going to a casino — this is a guarantee,” Pelosi said. “This is a value system for us, and we will fight for it. Is it a guarantee, or not?”

This raises a question: what precisely is the Medicare guarantee?

At present, there's a pretty specific answer: for 95% of seniors, the federal government will pay about 85% of the premiums for insurance that covers a bit more than 80% of the average user's medical costs. That's what traditional Medicare does right now, via Parts A, B and D, for those whose incomes are below $85,000 for a single person or $170,000 for a couple.

Put another way, the federal government pays a bit more than two thirds of the average senior's total medical costs. Low income beneficiaries have all or part of their premiums and out-of-pocket costs paid by Medicaid, though a variety of programs. High income seniors pay higher shares of their premiums, with the percentage stepped up through several income brackets.

What Ryan wants to do to Medicare

Last week, Paul Ryan indicated that he wants to move fast not only to repeal the ACA but to privatize Medicare to a premium support structure, as he's been proposing since 2011.

Of course, Medicare is already almost 1/3 privatized, in that 31% of enrollees have chosen Medicare Advantage plans rather than traditional fee-for-service Medicare. And MA's market share is growing year by year.  So why is Ryan so compelled to accelerate the process?

I have a post up at medicareresources.org, sister publication to healthinsurance.org, that aims to answer that question. Democrats generally assume that Ryan wants to shift the costs of Medicare away from the federal government and onto seniors, and I think that's right, but he has not explicitly called for doing so since 2011. His plan is studiously vague, and therefore hard to pin down. But what it would do, I think, along with de-emphasizing traditional Medicare by making it one choice among many on an exchange, is cut the cord that currently binds the rates that MA plans pay to providers to the rates paid by traditional Medicare.  That would accelerate cost growth in MA, which would in turn probably trigger a shift of costs to seniors.

I hope you'll read the post.

In which "strategic advisor" Howard Dean attacks IPAB

Why would Howard Dean -- physician, former governor, former meteoric presidential candidate and current "strategic advisor" to healthcare clients at a lobbying firm, stick a knife in IPAB, the Independent Payment Advisory Board created by the Affordable Care Act to rein in the federal government's Medicare spending?

In a Wall Street Journal op-ed published this morning, Dean first pays lip service to core aspects of the ACA before launching into a perfunctory, mail-it-in attack on  IPAB:

Ryancare hits the workplace

The voucherization of American health insurance may already be upon us.

No, Paul Ryan has not gotten his proposed "premium support" system for Medicare enacted.  But increasing numbers of employers are adopting or considering a shift from "defined benefit" to "defined contribution" insurance plans -- a shift that mirrors the transformation of pension benefits over the past twenty years (as Peter Orzag pointed out in a Dec. 2011 column).

Under a defined contribution model, as described in a recent Booz & Co. report, "instead of designing and offering defined health benefits, companies make cash contributions to savings accounts that employees use to purchase insurance products of their choice. This model allows the company to cap its healthcare cost at a desired threshold" (p. 4).

To meet the nascent and anticipated demand for this model, health insurers and benefits consultants are rolling out private healthcare exchanges enabling employers to outsource the benefits management. these exchanges provide a menu of health insurance options to the employees of companies that buy in. Such exchanges have been a feature of health plans for retirees for some time; companies are now beginning to offer them to current employees.

Adoption of this system may be accelerated by the coverage mandates the ACA imposes on employers that provide health insurance -- e.g., the ban on annual and lifetime benefit caps, the requirement to offer coverage to employees' children up to age 26, the free provision of preventive care, and other mandates.

Question: given the ACA requirement that employer plans cover a minimum 60% of participants' average medical costs, and cap participants' annual out-of-pocket expenses at $6250 per individual/$12500 per family, and meet the minimum essential benefit requirements that govern the ACA exchanges or potentially pay a penalty,* how can an employer control its costs by capping its "defined contribution"?

Medicare for all, or Obamacare for seniors? Or both?

Many have noted that the Medicare reform plan included in Paul Ryan's 2012 budget, though sketchy in detail, looked a lot like Obamacare for seniors plus a public option -- the public option being traditional Medicare, which would compete with private plans on an ACA-like exchange.  Throughout the presidential campaign, Ryan emphasized that his plan would not affect current seniors, only kicking in for those under 55 when the plan was enacted.

This year, to meet the GOP target of balancing the federal budget within ten years, Ryan is reportedly planning to move the migration age up.

That possibility has led Avik Roy, the most vocal spox for conservative health reform ideas, to stop worrying, love the ACA, and envision its fusion with Ryancare:

There has been an important development since last year’s House budget: the reelection of President Obama. Obama’s victory means that Obamacare will be implemented, warts and all, making it politically impossible to repeal, even if Republicans are fortunate enough to retake Washington in 2017.

The paradox of power, immigration reform edition

It's pretty amusing that Republicans are lambasting Obama for daring to stick his oar into the immigration reform process:

...Republicans quickly condemned the reports of a new administration plan, calling it “dead on arrival” and “very counterproductive”...

On Sunday, Representative Paul D. Ryan of Wisconsin, another Republican calling for immigration changes, said on “This Week” that the president’s efforts to develop his own legislation would undermine efforts on Capitol Hill and were taking “things in the wrong direction.” 

No one is more aware than Obama that he, as president "remains a polarizing figure," as the Times' Michael Shear and Julia Preston put it.  The last time Congress was huffing and puffing in the early stages of a Grand Bargain, almost exactly two years ago (2/15/11), over deficit reduction,  Obama explained why he had not unveiled a detailed plan:

Fever breaking?

In meetings with donors and editorial boards during the 2012 campaign, Obama suggested that his reelection would "break the fever" of fanatic GOP opposition to everything he proposed. The fiscal cliff brinksmanship at the turn of the year did nothing to suggest any such "break"-through, as Obama acknowledged in a New Republic interview conducted in mid-January and published just yesterday:

Chris Hughes: You spoke last summer about your election potentially breaking the fever of the Republicans. The hope being that, once you were reelected, they would seek to do more than just block your presidency. Do you feel that you've made headway on that?

Not yet, obviously.

CH: How do you imagine it happening?

I never expected that it would happen overnight. I think it will be a process. And the Republican Party is undergoing a still-early effort at reexamining what their agenda is and what they care about. I think there is still shock on the part of some in the party that I won reelection. There's been a little bit of self-examination among some in the party, but that hasn't gone to the party as a whole yet.

Now, just a day after that interview appeared, the doctor may be looking up and offering some cautious optimism.  For a day at least, the stonewall seems to be cracking at three points:

The real budget battle: voucherize Medicare, or IPABize it?

Noting that the emerging Republican budget strategy seems to be stalemate -- refuse to approve any new taxes, consequently give up on entitlement reform, and blame Obama, Jonathan Chait notes that this strategy makes a kind of sense. That is, it locates the long-term budget battle where it belongs, on the means of controlling healthcare costs:

This may sound like a cynical strategy. And it is. But it’s not a purely cynical strategy. It reflects an important intellectual development on the right. Capretta is advocating not just the classic no-taxes-ever approach that has defined the party for years, but also its newer (or newly fervent) belief in privatizing health-care services.

The main driver here is Paul Ryan, whom Capretta advises. (Yuval Levin, another Ryan favorite, makes a similar, though less openly cynical, no-deal argument for the Weekly Standard.) Ryan has accepted the argument, traditionally pushed by Democrats, that the main driver of long-term budget deficits is not the aging population but skyrocketing health-care costs. Ryan has decided that the only possible answer to the problem is to turn Medicare into a system of subsidized private insurance, and that the wonders of competition between insurance firms will dramatically suppress cost inflation (“the way it always works when the consumer is in charge,” he says).

What's truly cynical is not Ryan's ideological faith in the competition fairy, but his demonization, in the illustrious McCaughey-Bachmann-Palin tradition that is now general GOP dogma, of other more proven means of controlling healthcare costs. Chait continues:

In which Henry Aaron talks himself into supporting a raised Medicare eligibility age

Henry Aaron of Brookings, one of the nation's top healthcare economists, has a rather odd perspective on the current brewing battle over so-called "entitlement reform." On the one hand, he focuses his concern on the older elderly, with their ever-dwindling purchasing power, which leaves him less hostile to raising the Medicare eligibility age than other left-of-center economists who acknowledge a need to trim benefits. He is more distressed by proposals to trim cost-of-living increases, e.g. the so-called chained CPU, which seem to strike most observers as a milder, more gradual mode of trimming benefits. Indeed, in the fullness of time, when the ACA is fully up and running and providing affordable care to the uninsured, Aaron favors raising the Medicare eligibility age to expand the ratio of working to retired adults.

On another front, Aaron at once provides historical and comparative data to demonstrate that U.S. senior health and pension benefits are unduly skimpy, and effectively concedes that given our political culture, we need to plan how best to make them skimpier still. He suggests that only by agreeing to benefit cuts can Democrats forestall more radical proposals to shred the safety net, e.g. via private accounts for social security or voucherization of Medicare. At the same time, he argues for benefits that increase with age, with offsets for lower-income younger elderly for whom raised retirement ages are a burden, and for a variety of formulas to shift costs onto the wealthier elderly (his Medicare reforms look something like those proposed by Senators Lieberman and Coburn: providing catastrophic insurance but ending Medigap as we know it, and making the wealthy elderly pay a much higher percentage of the actuarial value of their coverage).

I find it odd that Aaron argues, in effect, for preemptive concessions -- proposing policy choices he regards as less than optimal as a means of forestalling more radical, Paul Ryanesque attacks on safety net programs: 

NRO's Jim Geraghty: Romney lost - tis all for the best

I'm not familiar with the thinking of NRO's Jim Geraghty. But this bit of self-contradicting self-consolation, from the NRO "Morning Jolt" email*, struck me as curious:

One other thought, and before I go further, I want to emphasize I wish Romney had won. But I felt a strange sense of relief upon hearing our nominee's post-election remarks:

Maybe I shouldn't do debate assessment

I begin to think I'm not a good reader of debates. While not looking at commentary, I was afraid that Biden would be laughed off the national stage. He shouted nonstop until his voice gave out; he grimaced far too much and failed to look at Ryan when confronting him (though I may have been misled in that by the C-Span split screen; when I switched to PBS he seemed more natural in this regard), he interrupted incessantly, and I thought he was often incoherent on domestic policy (though generally effective on foreign), failing to answer Ryan's allegations systematically and jumbling a bunch of not-fully-articulated assertions together. Ryan, on the other hand, struck me as methodical, systematic, unruffled and precise -- never mind that his characterizations of Obama administration policies -- and Romney's -- were wildly misleading.

Giving Ryan undue credit for Wyden-Ryan

I had a faint expression of interest in response to a letter I sent the Times a week-plus ago, responding to Steven Rattner's call for some form of healthcare rationing. Frankly I can see now why they didn't run it, as I concerned myself with a tangential point, while several letters the Times did publish went for the heart of Rattner's argument (and are well worth reading). Still, mine had some political relevance, as it took Rattner to task for giving Ryan credit for cost control mechanisms he dropped from his 2013 budget.  Here it is:

Obama corrects an expired talking point

As Republicans have doubled and trebled down on their post-truth campaign -- asserting falsely that Obama is gutting welfare reform, gutting Medicare benefits, denigrating business owners, etc. -- Obama has persisted in one misleading talking point: that Paul Ryan proposes a Medicare voucher system that, according to a CBO estimate, could raise seniors' healthcare costs by an average of over $6000 by 2030.

From Palin to Ryan: a short history of demonizing IPAB

The battle between the parties over Medicare reform is a battle about how best to control costs.  Ryan and Romney rely exclusively on the Competition Fairy, -- the notion that if private insurers are induced to compete for Medicare policyholders, they will find ways to hold down costs.  If that fails, Ryan/Romney would most likely shift costs to seniors, with some ostensible protections for low-income beneficiaries.  The Obama administration, via the Affordable Care Act, seeks to use the government's market clout to change the rules of the payment game for providers, creating new incentives to reduce unnecessary care and new rewards and penalties focused on patient outcomes.

One big happy future family: Romneycare, Obamacare, Ryancare

On a second read of the Medicare reform plan outlined in Paul Ryan's 2013 budget, I was whipsawed by crosscurrents of irony.

I was going to lambaste the plan for its touching faith in the Competition Fairy, believed to shower her low cost/high quality beneficence on private insurance plans competing in a government-run and -financed marketplace. Then it occurred to me that the ode I was reading was virtually identical to the praises sung by Democrats for the prospective healthcare exchanges to be established by the Affordable Care Act. Indeed, the ode may have been composed in large part by a Democrat -- Ron Wyden, who coauthored a proposal with Ryan in December 2011 that Ryan's more recent plan resembles more than it departs from (notwithstanding important differences).  Here's part of the opening movement  of Ryan's Song -- emphasis (and repetition) in the original:

How Ryan duped Wyden, cont.

In my last post, I noted that

1. Senator Ron Wyden, by partnering with Paul Ryan last December in a proposal to convert Medicare to a premium-support program, seriously blurred Democrats' line of attack on Ryan/Romney Medicare reform proposals.
2. Wyden himself is having difficulty articulating the differences between that joint proposal and the Medicare reform plan included in Ryan's 2013 budget ("Ryan 2013").
3. Those differences are real, pertaining to the ways in which costs are controlled and the degree to which increased costs are passed on to seniors.

The key differences are that 1) Wyden-Ryan caps overall Medicare cost growth at GDP +1%, vs. GDP +.5% under Ryan 2013; 2) Wyden-Ryan does not abolish the ACA's Independent Payment Advisory Board, which is mandated to furnish Congress with proposals to keep costs under the cap, mainly by reducing payments to providers in various ways; and 3) Wyden-Ryan caps seniors' yearly  out-of-pocket costs while Ryan 2013 does not.

That comparison was based on a report by Kaiser Family Foundation.  I have since compared the texts of the Wyden-Ryan proposal and the Medicare reform section of Ryan's 2013 budget.  The latter comparison shows that while the differences inferred by Kaiser are real, the earlier report -- surely at Ryan's impetus -- fudges the key distinction, which is whether cost increases in excess of yearly targets can be passed on to seniors. In fact, while Wyden-Ryan emphasizes controls on payments to providers as a means to keep costs below its GDP +1% cap, it leaves the door open to increases in premiums for higher income seniors as a way to cover cost increases in excess of the cap.  Moreover, while Wyden-Ryan does not demonize the Independent Payment Advisory Board (as Ryan 2013 does at length), it does not mention IPAB at all -- and dances around IPAB's function when laying out the means of keeping costs under the cap. Wyden-Ryan also takes one Ryanesque slap at IPAB-in-absence, listing as one the authors' principles,  "Build a strengthened program around the needs of patients, not bureaucrats" (p.8 )