As Republican moderates cave on Medicaid cuts, what can Dems do?

As I feared back in March, the "moderate" Republicans in the Senate who profess concern about plans to repeal the ACA Medicaid expansion and impose per capita caps on federal funding for Medicaid are going squish. They'll settle for slowing repeal of the expansion rather than stopping it, and perhaps for some partial easing of the per capita caps, such as exempting coverage for the disabled.

Now as in March, Republican senators in states that have benefited from the expansion speak as if repeal of the expansion and a steady erosion in federal funding for all Medicaid programs is a natural disaster that they must help their constituents cope with, rather than their own free choice to inflict suffering on vulnerable people to fund tax cuts for the wealthy.

Here's Bill Cassidy of Louisiana, until now the strongest defender among Republican senators of maintaining ACA-level funding, speaking to Matt Fuller and Sam Stein of the Huffington Post. Over 300,000 Louisianians have gained Medicaid coverage since incoming governor John Bel Edwards implemented the expansion, beginning July 1, 2016.

CBO flips off the Upton Amendment to the AHCA

The CBO report on the amended AHCA that passed the House expends considerable ink on the malign effects of the MacArthur amendments that won over the Freedom Caucus. Those amendments allowed states to opt out of ACA regulations banning medical underwriting and mandating that all qualified health plans cover ten Essential Health Benefits.   CBO forecast that states encompassing one sixth of the U.S. population would  fully embrace the opt-out -- and that in those states, guaranteed issue would effectively end, and services removed from EHBs such as maternity care would become prohibitively expensive. The individual market in these states would  thus become unstable, according to CBO.

When the MacArthur amendment became part of the AHCA, many Republican moderates anticipated such results and announced that they could not support the legislation because it did not adequately protect people with pre-existing conditions. A critical mass flipped back, however, when Fred Upton -- one of those who said he could not support the bill with the MacArthur amendment -- introduced an amendment allocating a mere $8 billion over 10 years for states to use to lower premiums for those harmed by the return of medical underwriting.  While that amendment was widely derided as a band-aid on a gunshot wound, Upton issued a statement declaring it sufficient:

“This week, I expressed my deep concerns with the AHCA as it was written to both President Trump and our leadership. We immediately got to work on a responsible fix.

In December 2008, support for ACA linchpins was broad and shallow

As the Affordable Care Act's first open enrollment season wraps up with a major surge, the law's implementation remains as polarized as public opinion and party rhetoric. States that ran their own exchanges and accepted the Medicaid expansion reduced their uninsured populations by three times as much as states that abstained on both counts, according to Gallup polling. California and Connecticut reached 175% of the CBO's projection for first-year private plan signups; Oklahoma, just 28%, according to Charles Gaba's spreadsheet. Meanwhile, as Obama declared, "the repeal debate is and should be over” and “the Affordable Care Act is working," Republicans geared up once again to make repeal and denigration of the law the centerpiece of their election strategy.

At this juncture, after five years of political mortal combat, it's instructive to look back at Americans' reactions when first confronted with the proposed core provisions of the ACA. The Kaiser Family Foundation probed opinions about those measures back in December 2008, polling over 1600 adults (thanks, Larry Levitt). By that point, the prospective law's outlines were clear, as all three Democratic candidates had proposed similar healthcare reform plans.

At first blush, respondents were enthusiastic about the mechanisms for expanding private-market health insurance: requiring employers to cover employees, and requiring individuals to buy affordable coverage. When asked to consider potential consequences of those mandates, however, respondents turned ambivalent.  The poll results might have been read to provide cover to Democrats to move forward. But they also pointed to multiple entry points for Republicans to exploit the pending legislation's tough tradeoffs.

Tell me your ACA-shopping story

Always fair-minded, Jonathan Cohn pauses in his celebration of lower-than-forecast ACA premiums (as highlighted by the latest CBO update) to acknowledge:

In the transition from the old system, in which insurers could charge higher prices to the sick or avoid them altogether, to a new system, in which everybody pays the same price regardless of pre-existing condition, some young and healthy people must now pay more for their individual policies

The "and" in "young and healthy" is interesting, because, as the conjunction suggests if you look twice, it's not just the young who are paying more under ACA rules. Some if not most healthy older buyers who were in the individual market in 2013 are now paying more -- that is, if no one sharing the insurance has a preexisting condition.*

If you're in the individual market and you're paying more for your insurance in 2014 than you did in 2013, I'd like to speak to you (or, for that matter, if you're unsubsidized and paying less or about the same).  I'd like some detail about what your prior policy covered vs. what your current one does -- what were the tradeoffs. (I wrote up two such stories last month, and I'd like to do more.)

In which Ezra Klein makes Avik Roy acknowledge why U.S. healthcare costs are so high

Avik Roy and Ezra Klein had a long --very long -- conversation about Roy's beefs with the Affordable Care Act. They covered "rate shock,"  minimum coverage standards, and Roy's dreams of a more fundamental system overhaul that would push everyone onto healthcare exchanges by privatizing Medicaid and Medicare and ending the employer tax deduction for health care benefit provision. 

Roy has been a relentless critic of the ACA. Having read some of his writings about it but by no means all, I was surprised to learn, as Klein probed his reaction to feature after feature, that he "do[esn't] have* a problem with standardizing benefits" and that "guaranteed issue [no refusals or cost bumps for preexisting conditions]is fine." His objections really boiled down to three: 1) he objects strenuously to "community rating," i.e., the ACA's limiting of the price differential between the youngest and oldest age cohorts to 3-to-1, as opposed to the roughly 6-to-1 ratio that Roy says the market would dictate.  2) He would like the exchanges to offer plans that cover even less than the lowest cost plans in the current design -- plans covering, say, 40% of a member's average yearly costs rather than the 60% that the exchange's lowest-run "bronze" plans are designed to cover. 3) As mentioned above, he would like more radical reform -- health exchanges for everyone.

As Klein eventually made Roy implicitly acknowledge, though, none of his favored solutions get at the root of the United States' disproportionate healthcare inflation.

Does the Affordable Care Act "soak the young"?

Avik Roy revives the complaint that formed the emotional core of the legal case against the Affordable Care Act: that the act shafts young adults by forcing them to buy coverage that effectively subsidizes insurance for older adults. Here's the basis of his complaint:

Under free-market conditions—what insurance pros call experience rating—the typical 18-year-old costs one-sixth what it costs to insure the typical 64-year-old.

But Obamacare, in a sop to the AARP, requires that insurers only charge three times as much to their costliest beneficiaries what they charge to their least-costly ones. As the illustration below shows, this increases the cost of insurance for the young by 75 percent, while offering only a modest 13 percent subsidy to older Americans.

Before moving on to the core alleged problem, let's note a couple of sleights of hand at the outset: