Friday, April 7, 2017

Bipartisan, Democratic-Led Health Care Reform

Billy Wynne[1], writing for the Health Affairs Blog has done a wonderful job of outlining some of the essential ingredients necessary to address the national health care insurance issue. The posting on April 4, 2017, entitled, “What Now?: A Four Step Plan For Bipartisan Health Reform” is precisely what I have been saying is needed for Democrats to use in the development of an “Affordable Care Improvement Act” that could provide a sensible alternative to the GOP cobbled up, disastrous proposal known as the American Health Care Act (AHCA)[2]. See my March 27, 2017, post, “Democrats Could Lead The Bipartisan Revolution.”

I have been advocating for Democrats to take the lead now that the GOP efforts have failed and the President has declared:

“I think the losers are Nancy Pelosi and Chuck Schumer, because now they own Obamacare.  They own it -- 100 percent own it.”  And this is not a Republican healthcare, this is not anything but a Democrat healthcare. . .”

Following the GOP debacle[3], I said Democrats need to develop the "Affordable Care Improvement Act", designed to do what needs to be done to make the Affordable Care Act work better and introduce it in the House and Senate with 100% of the Democrats in both chambers supporting it. Simultaneously, they need to launch a massive public education and media campaign comparing the Republican and Democratic alternatives.

It is no wonder that the GOP is still divided on Healthcare? The House Freedom Caucus' 30+ votes will continue to block any effort that Speaker Ryan proposes. The GOP is getting so desperate to just pass something that they have now discounted rationale health care reform. The HFC's basic strategy is to reduce insurance costs for their constituents; an admirable goal, and they have found a guaranteed way to do it. Their "Plan" is don't cover anything including preexisting conditions. That should definitely reduce costs.

For example, items to be excluded under various GOP proposals in addition to preexisting conditions would include: outpatient care; emergency services; in-hospital care; pregnancy, maternity and newborn care; mental health and substance abuse disorder services; prescription drugs; rehabilitative services and habilitative services (including treatment for kids with autism or cerebral palsy); lab tests; preventive services (like vaccines, cancer screenings like mammograms and colonoscopies and, coverage of birth control); and pediatric services.

One can only imagine that eliminating coverage for these essential health care services would definitely reduce costs. Speaker Ryan said, "Instead of imposing arrogant and paternalistic mandates [like coverage for the above listed items], it [GOP plan] would increase choice and competition, creating a vibrant market where every American will have access to quality, affordable coverage."

Democrats need to step it up, lead the way, and not just be the party of “No” opposing all of the iterations of the GOP’s American Health Care Act. Instead of trying to get a few Democrats to sign on to a fatally flawed GOP proposal, why don’t Democrats turn the tables, propose a plan that makes sense and get 25-30 moderate, “Main Street” or “Tuesday Group” Republicans to sign on.

Billy Wynne has now provided the substance of what is needed in a Democratic alternative. Below is an extremely brief overview, but I highly encourage reading Mr. Wynne’s complete proposal. Some of this is fairly technical, but I am including it to illustrate the extent of Affordable Care Act (ACA) [Patient Protection and Affordable Care Act (PPACA) 2010 HR3590, or Affordable Care Act (ACA) for short] improvement ideas that exist which could be advanced.

Step 1 – Enhance The Individual Market: Wynne lays out a number of critical “mechanical options” to enhance markets and maintain the basic elements of the existing Affordable Care Act including continued funding the cost-sharing subsidies currently available to individuals in the exchange markets; actively marketing and supporting enrollment in available coverage options; and more substantial changes that would improve competition and reduce costs. Some options suggested have strong conservative support.

One major suggestion is that in lieu of the initial GOP approach of delivering tax credits of equal value to individuals at different income levels, the existing subsidy structure could be expanded to all households so that none are required to pay more than 9.5 percent of their income for coverage, which de facto phases out the subsidy at high income levels. While ensuring affordability for the middle class, this will also entice a broader array of consumers to get into the market.

Other significant suggestions include establishing default enrollment, perhaps into the lowest cost plan available with an opportunity to opt out; and ending the now four-year extension of plans that do not comply with the consumer protections enacted in the ACA.

Step 2 – Rationalize The Employer Market: The majority of Americans with health insurance acquire it via their employer -- two key changes could be enacted to improve that market’s condition. First, the so-called “family glitch,” which denies subsidies to family members if one of them has access to relatively affordable individual coverage from their employer, should be fixed to allow those family members to acquire subsidized coverage elsewhere. Second, access to the small business tax credits in the ACA could be expanded to assist more workers in this market.

Allow small business employees to be merged into the individual market completely over time and provide large employers greater opportunity to provide their employees a fixed allotment with which they can purchase insurance in a private exchange. Finally, addressing the “elephant in the room” “. . .by capping or eliminating the “around four trillion dollars over ten years” of tax exclusion for employer sponsored insurance.

Step 3 – Embrace Medicaid & Step 4 – Don’t Forget The Big Picture: Wynne says “It’s time to drop the ideological divide over Medicaid, a program that covers 74 million Americans who truly have nowhere else to turn.” He also reminds that health insurance coverage is really just a method for helping consumers address the underlying issue: their health -- we need focus on patients and the providers who take care of them.

Yes, there are problems with House leadership putting such an alternative bill up for a vote, but that's why an aggressive education & media campaign is needed. Wynne concludes:

“The bottom line is that there are a host of policies that lawmakers and regulators can embrace to start drastically improving the condition of our health care system. This will not be easy, nor will it happen quickly. Policymakers of all political stripes can come together now, though, to begin the arduous process of identifying evidence-based solutions and building the necessary consensus to enact them. It’s a winning strategy for politics and for the public.”

While I agree, I don’t think the current GOP leadership or Republican base has the desire or will to lead this effort. They are too wedded to the 7-year mantra of “Repeal & Replace Obamacare.” That’s why Democrats must take the lead.


[1] Billy Wynne, J.D., is the Managing Partner of TRP Health Policy. A division of the Washington government relations firm Thorn Run Partners, TRP Health Policy combines industry-leading, actionable analysis and insight with sophisticated, informed advocacy to help healthcare organizations solve challenges and capitalize on opportunities in the Federal policy space.
                TRP Health Policy is also home to Policy Hub, an online portal and daily digest delivering in-depth intelligence on every important regulatory and legislative development impacting healthcare.
                Previously, Billy served as Health Policy Counsel to the U.S. Senate Finance Committee. He received his B.A. from Dartmouth College and his law degree from the University of Virginia.

[2]CBO report on H.R. 1628, the American Health Care Act, incorporating manager’s amendments 4, 5, 24, and 25, March 23, 2017.

[3]List and summary of opposition to GOP AHCA from nurses, doctors, hospitals, teachers, churches, and others, from Representative Jim Cooper (D-TN)

Articles & Resources of Interest

May 25, 2017“Obviously we’re all united in opposition to Trumpcare. That’s easy. People know what we’re against, but we want to promote more what we are for.” A quote from Rep. John Conyers (D-Mich.), who has been introducing single-payer legislation (“Medicare for all.”) since 2003. House Democrats See Medicare for All as Answer to ‘Trumpcare’. H.R.676 now has 111 Democratic co-sponsors. There are 193 Democrats in the House.

"Mending Obamacare: Where Do Dems Go from Here?", The Democratic Strategist, Mar 28, 2017,  By J.P. Green

"Will GOP leadership work with Democrats? These Republicans hope so." The Christian Science Monitor, Apr 3, 2017. By Francine Kiefer.

"No ‘Death Spiral’: Insurers May Soon Profit From Obamacare Plans, Analysis Finds" The New York Times. Apr 7, 2017. By Reed Abelson.

HealthSherpa | Fast, Easy Obamacare Policy Information. Enter your zip code & find plans and prices.

Health Care Reform News Updates

Funding H.R. 676: The Expanded and Improved Medicare for All Act – How we can afford a national single-payer health plan in 2014,” by Gerald Friedman, Ph.D., Department of Economics, University of Massachusetts, Amherst.

Physicians for a National Health Program - PNHP is a non-profit research and education organization of 20,000 physicians, medical students and health professionals who support single-payer national health insurance.

Medicare for all bill reaches a record-breaking 104 [and counting] co-sponsors in Congress
Posted on Wednesday, April 26, 2017

H.R.676 - Expanded & Improved Medicare For All ActSponsor:Rep. Conyers, John, Jr. [D-MI-13] (Introduced 01/24/2017), Cosponsor statistics: 108 current

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