Selasa, 07 Maret 2017

The American Health Care Act debut

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(C) cmfu via Flickr Creative Common License 
Today's Managing Health Care Costs Number is 0

We're 24 hours out from the unveiling of the American Health Care Act (AHCA), the Republican bill seeking to end Obamacare as we know it.   The zero above is how much analysis has been completed by the Congressional Budget Office. Nonetheless, Committee hearings start tomorrow.

The House Energy and Commerce Committee  has put out a summary document, and there are good summaries available from:

This bill is substantially less conservative than the leaked draft of a few weeks ago.  Specifically

  • The tax credits to fund exchange plans for the poor and near poor are refundable (so they can be obtained even by those who pay no federal income tax)
  • Rich people will not be eligible for these tax credits, meaning the amount available for the poor and near poor is higher.  The credits start phasing out at income of $75,000 (individual) and $150,000 (family)
  • Medicaid expansion will remain relatively untouched until 2020
  • Essential benefits will remain a requirement
  • The employer sponsored health insurance tax deduction has not been changed

Still, the plan remains deeply regressive and likely to hurt public health and lead to more uninsured and worse health outcomes.

  • The amount of tax credit offered will not be adequate for the poor and near poor to afford premiums
  • The Cost Sharing Reduction (CSR) for those earning less than 250% of the federal poverty limit (FPL) is gone as of 2020 - meaning that those of very modest incomes won't be shielded from high deductible health plans. 
  • Would change Medicaid to a per capita grant to states as of 2020
  • Offers huge tax savings to the rich through eliminating most taxes associated with the ACA in 2018, even though the programs continue unchanged until 2020. That will blow a huge hole in the deficit.
  • The amount of relief available for middle income Americans goes up a bit, and for poor Americans goes down a lot.
  • The AHCA eliminates public health funding (12% of the CDC budget)
  • Lowers the eligibility for children from 133% to 100% of the FPL
  • Removes federal funding for state expansions of Medicaid to above 133% of FPL as of 2019
  • The age band increases from 3:1 to 5:1 - so young (healthy) people could shave a few hundred dollars from their premium, but older Americans who are more likely to suffer from a serious illness will have to pay more.   Even if the bill does not decrease the number insured, it could decrease the number of high risk people insured
  • There is plenty of language about requiring proof of citizenship for Medicaid coverage, and rechecking eligibility every 6 months.  Medicaid rolls could shrink just because of hassles, which are harder for the poor to overcome.
  • Required actuarial values will go away, making it harder for consumers to shop
  • The AHCA seeks to eliminate all Medicaid coverage for any service obtained at a Planned Parenthood office. Plan Parenthood is the largest provider of women's health services in the country. 

There's plenty of reporting about the basic details of the plan - which is not as bad as I expected but still likely to cause an enormous amount of pain and harm.  Here are two of the more arcane elements, which have not yet been fully reported on.


Section 113 – Elimination of DSH Cuts
Repeals the Medicaid Disproportionate Share Hospital (DSH) cuts for non-expansion States in
2018. States that expanded Medicaid would have their DSH cuts repealed in 2020.

This is a surprise. Safety net hospitals have been devastated by the loss of DSH funds in states that did not expand Medicaid.  This could be a lifeline for them.

Section 114 (b)
• Would limit the effective date for retroactive coverage of Medicaid benefits to the
month in which the applicant applied. This provision would apply to Medicaid
applications made (or deemed to be made) on or after October 1, 2017.

This is awful for the sick who are poor - and also poison for hospitals.  It often takes weeks or months to prove eligibility, and now only future medical expenses will be covered.

There are also some open questions.

Bob Kocher and others have tweeted that mental health parity is gone.  I can't find this in the bill - or in any coverage.   MHPAEA (Mental Health Parity and Addiction Equity Act) was separate legislation passed in 2008, although the ACA included some additional enforcement

Republicans have been angry about some efforts to reform provider payment - and the Centers for Medicare and Medicaid Innovation has been threatened. It appears to have escaped the axe in the AHCA


It is difficult to say what question, or set of questions, would lead to this bill as an answer. Were voters clamoring for a bill that cut taxes on the rich, raised premiums on the old, and cut subsidies for the poor? Will Americans be happy when 15 million people lose their health insurance and many of those remaining face higher deductibles?



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