The House passed the AHCA, the American Health Care Act, in a partisan vote nearly the inverse of that which passed the ACA 8 years ago. I want to look at the bill's provisions stripped of the rhetoric about dying grandmas and impoverished children. How does it compare with the ACA? What are its provisions? Please take a look at my post of 1/13/17 for comparison with the ACA.
The ACA attempts to create universal health coverage by cobbling together expanded Medicaid with subsidized private policies for individuals. Premiums cannot be adjusted for pre-existing conditions or age. So far it has had difficulties both from its structure and its incomplete implementation (the blocking of the escalator clause). It has provided coverage for many people. The total depends on how you count it and your source, but is between 11 and 20 million. The Kaiser Family Foundation has a very nice table with data in raw numbers and percentages on medical coverage. The earliest data there is from 2013, just as the ACA was implemented. There were 41,000,000 uninsured in 2013, representing 14% of all US lives. In 2016 it was 28,00,000, or 9%. This is a significant achievement, but also limited. The absolute difference, 5% of the US population, is a small difference for such a large and messy piece of legislation, and roughly double that number remain uninsured. As I noted in my prior post, a partial success and a good first try.
The AHCA takes a very different tack. It has the following provisions-
-Ends expanded Medicaid enrollment;
-Replaces 100% ACA federal Medicaid payments with a capitated payment or a block grant to each state, allowing the states to determine how and on whom to spend the money;
-Permits rate adjustment for elderly and sick individuals. Premiums can range up to 5 times the base rate for a healthy person. Pre-existing conditions cannot be excluded but do allow for rate adjustment within that sleeve;
-The employer mandate is ended, allowing medium-sized companies to again employ without health benefits;
-Ends the tax penalty for having no health insurance;
-Creates a 115 billion dollar fund for subsidy of care for the sickest individuals, a kind of assigned risk pool;
-Allows individual state variation in strictures on insurer rating of sick individuals.
All in all, the CBO estimates 23 million fewer Americans will be covered under the bill, although it will cost 300 billion less over 10 years. This contrasts with the ACA covering 20 million more and costing 200 billion more over the same time. In essence, the bills cancel each other out, being near-opposites in effect.
If we take 20 million people insured and a cost of 250 billion over 10 years, this works out to a cost of 1250.00 per covered life per year. That's a hell of a low cost for medical coverage.
At issue here is not just the laws but the underlying philosophical assumptions which shape them. The Democrats tried to create something as close to universal coverage as our society could tolerate. The Republicans are trying to create a system that insofar as possible removes the federal government from healthcare and returns it to states and individuals. Below this level of intent lies further divergent assumptions on the role of government in healthcare and society. Broadly speaking, Democrats see healthcare as a federal, societal level problem, and Republicans as an individual problem. Both sides of this philosophical divide are trying to work through existing social construct, which itself reflects the philosophical divide of the parties. We have a private insurance system onto which has been grafted a federal guaranteed system for the elderly and the poor.
I believe both legal efforts are a mistake. Without the cost escalator, the ACA is going to fail. Many private insurers have and will pull out, and rates will soar as insurers are forced to raise premiums to cover their costs (as opposed to getting the federal escalator money). The Republican effort is a back-handed return to the status quo ante, a clearly undesirable situation.
The entire Western World considers healthcare a societal problem. Society as a whole benefits when any of its members is healthier, and the cost is thus borne by society, not the individual. This is paid for by taxes, which fall differentially on the wealthy. That healthcare costs fall differentially on the wealthy in the US now is conveniently elided in the entire discussion. We're already paying for our healthcare 'system' in its failures as much as its direct costs.
I continue to believe the best combination is universal basic healthcare for everyone, including maternity benefits, abortion, and contraception. The most expensive care, and certain major care for the elderly, could be paid for by private wrap-arounds. I continue to see Germany's system as the best model for this.
Looked at mathematically, covering all 40 million uninsured at the 1250.00 per year rate would cost 50 billion yearly. This is......1.25% of the current federal budget of 4 trillion. I have a very hard time saying that universal healthcare is not worth this amount of money yearly. I continue to support that goal, as I have my entire professional career. Even if we cover all 310,000.000 Americans at an average cost of 1250.00 yearly, that is 387 billion yearly. Of course that total cost would be paid for in taxes but offset by s dramatic fall in health insurance premiums. Even for me, a state worker, I would get an additional 6,000 yearly in salary as opposed to insurance premium payments on my behalf.
The ACA is a flawed and failing bill. The AHCA is a terrible bill, and a regression not simply in execution but in concept.
Ted
The ACA attempts to create universal health coverage by cobbling together expanded Medicaid with subsidized private policies for individuals. Premiums cannot be adjusted for pre-existing conditions or age. So far it has had difficulties both from its structure and its incomplete implementation (the blocking of the escalator clause). It has provided coverage for many people. The total depends on how you count it and your source, but is between 11 and 20 million. The Kaiser Family Foundation has a very nice table with data in raw numbers and percentages on medical coverage. The earliest data there is from 2013, just as the ACA was implemented. There were 41,000,000 uninsured in 2013, representing 14% of all US lives. In 2016 it was 28,00,000, or 9%. This is a significant achievement, but also limited. The absolute difference, 5% of the US population, is a small difference for such a large and messy piece of legislation, and roughly double that number remain uninsured. As I noted in my prior post, a partial success and a good first try.
The AHCA takes a very different tack. It has the following provisions-
-Ends expanded Medicaid enrollment;
-Replaces 100% ACA federal Medicaid payments with a capitated payment or a block grant to each state, allowing the states to determine how and on whom to spend the money;
-Permits rate adjustment for elderly and sick individuals. Premiums can range up to 5 times the base rate for a healthy person. Pre-existing conditions cannot be excluded but do allow for rate adjustment within that sleeve;
-The employer mandate is ended, allowing medium-sized companies to again employ without health benefits;
-Ends the tax penalty for having no health insurance;
-Creates a 115 billion dollar fund for subsidy of care for the sickest individuals, a kind of assigned risk pool;
-Allows individual state variation in strictures on insurer rating of sick individuals.
All in all, the CBO estimates 23 million fewer Americans will be covered under the bill, although it will cost 300 billion less over 10 years. This contrasts with the ACA covering 20 million more and costing 200 billion more over the same time. In essence, the bills cancel each other out, being near-opposites in effect.
If we take 20 million people insured and a cost of 250 billion over 10 years, this works out to a cost of 1250.00 per covered life per year. That's a hell of a low cost for medical coverage.
At issue here is not just the laws but the underlying philosophical assumptions which shape them. The Democrats tried to create something as close to universal coverage as our society could tolerate. The Republicans are trying to create a system that insofar as possible removes the federal government from healthcare and returns it to states and individuals. Below this level of intent lies further divergent assumptions on the role of government in healthcare and society. Broadly speaking, Democrats see healthcare as a federal, societal level problem, and Republicans as an individual problem. Both sides of this philosophical divide are trying to work through existing social construct, which itself reflects the philosophical divide of the parties. We have a private insurance system onto which has been grafted a federal guaranteed system for the elderly and the poor.
I believe both legal efforts are a mistake. Without the cost escalator, the ACA is going to fail. Many private insurers have and will pull out, and rates will soar as insurers are forced to raise premiums to cover their costs (as opposed to getting the federal escalator money). The Republican effort is a back-handed return to the status quo ante, a clearly undesirable situation.
The entire Western World considers healthcare a societal problem. Society as a whole benefits when any of its members is healthier, and the cost is thus borne by society, not the individual. This is paid for by taxes, which fall differentially on the wealthy. That healthcare costs fall differentially on the wealthy in the US now is conveniently elided in the entire discussion. We're already paying for our healthcare 'system' in its failures as much as its direct costs.
I continue to believe the best combination is universal basic healthcare for everyone, including maternity benefits, abortion, and contraception. The most expensive care, and certain major care for the elderly, could be paid for by private wrap-arounds. I continue to see Germany's system as the best model for this.
Looked at mathematically, covering all 40 million uninsured at the 1250.00 per year rate would cost 50 billion yearly. This is......1.25% of the current federal budget of 4 trillion. I have a very hard time saying that universal healthcare is not worth this amount of money yearly. I continue to support that goal, as I have my entire professional career. Even if we cover all 310,000.000 Americans at an average cost of 1250.00 yearly, that is 387 billion yearly. Of course that total cost would be paid for in taxes but offset by s dramatic fall in health insurance premiums. Even for me, a state worker, I would get an additional 6,000 yearly in salary as opposed to insurance premium payments on my behalf.
The ACA is a flawed and failing bill. The AHCA is a terrible bill, and a regression not simply in execution but in concept.
Ted
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