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Tuesday, January 10, 2017

Sounding the Alarm on "Obamacare" Repeal

It is certainly no secret that Donald Trump and the ultra-conservative Republican Congress are gearing up for the repeal of the Affordable Care Act – “Obamacare” as they like to call it.  It is also clear to many of us that they have an unbridled ideological obsession about this which is hopefully going to result in a wide-spread negative reaction (and perhaps torrents of protest) because they have no alternative measures with which to replace the health coverage of over 20 million enrolled in the ACA (not counting perhaps 10 million more who were able to enroll in Medicaid under expanded income eligibility guidelines).

As you must know by now, the repeal process is underway. A Resolution was passed last week that instructed two relevant committees in the House and two in the Senate to draft legislation within their particular purview that “would cut at least $1 billion from the deficit over 10 years.” (NY Times).  Their legislation is due by Jan. 27th and will be in the form of a reconciliation bill which can be adopted under fast-track procedures, and which will require no more than 51 votes to pass the Senate because, in the Senate, the filibuster rule will be curtailed.

The seemingly innocuous language of the resolution will allow the four committees to propose budget cuts that will affect the functioning of the Affordable Care Act, something with which the House already has some familiarity, having voted more than 60 times to repeal “Obamacare.”  Some parts of the ACA law may remain intact, such as the prohibition on insurers denying coverage to those with pre-existing conditions, and those under age 26 being able to remain on their parents’ insurance. Since Senate rules require that reconciliation bills must have provisions that have some effect upon spending or revenue, the committee bills will address those issues in perhaps the following ways:

·         Eliminate the tax penalties imposed on people who do not have coverage and on larger employers who do not offer coverage to employees
·         Eliminate the billions of dollars that go to states each year to cover expanded eligibility under Medicaid
·         Repeal the subsidies for those obtaining coverage under the marketplace exchange plans
·         Could possibly repeal some of the taxes and fees on certain high-income people, on health insurers, and on certain drug and medical device manufacturers

    Republicans have taken every opportunity to indicate that the effective date of repeal will be delayed for two to four years to avoid disruption and to provide time to craft replacement legislation.  But, make no mistake:  There are some thorny problems left to address.

  1. If the Republican Congress has failed to produce a credible alternative health care bill over the last 6 years, is it plausible that they can do so over the next 2-4 years?  Rep. Sander Levin of Michigan, Chairman of the Ways and Means Committee when the ACA was signed into law, has said that “the American Academy of Actuaries has highlighted concerns about premium rate hikes” under the GOP non-Plan.  In a letter to Speaker Ryan, the Academy made clear that: “Delaying the effective date of repeal while a replacement is worked out likely won’t be enough to assure the stability and sustainability of the individual market.”  Health Plans, hospitals and researchers have all echoed the same worry, says Mr. Levin.
  2. Since Trump expects to issue Executive Orders to undo some of the ACA provisions and policies, what will be the effect on an alternative plan, and how will the newly insured under ACA be affected?  According to some reports, Trump is more concerned about shoring up the stability of the insurers than of addressing the devastation of the about-to-be uninsured.        
  3. According to a NY Times article at, Mike Pence indicated last Wednesday that the replacement would “probably encourage greater use of personal health savings accounts and make it easier for carriers to sell insurance plans across state lines.  Also, it would encourage small businesses to band together and buy insurance through ‘association health plans’ sponsored by business and professional organizations.” Trump has endorsed some kind of state-run “high-risk pools” for people with pre-existing conditions. None of which answers the question of how millions of people unable to afford these before they got ACA coverage will be able to afford these measures after repeal!
  4. The thorniest question, of course, comes down to affordability and mandated coverage. The latter can perhaps be put off, but the former is going to determine what the millions of former ACA-covered clients are going to be able to afford during the interim period and beyond it.  Without adequate subsidies, millions of people will again simply not be covered.  And by the way, guess where many Republicans want to put that money they will save on no more subsidies?  According to the Tax Policy Center, the primary recipients will be those earning over one million dollars annually.  Another use will be to shore up large insurance companies that lost money during the first few years of operation in the ACA exchanges (because of their own miscalculations, by the way!).
  5. Another tremendously important dilemma is the fact that certain provisions of the ACA depend on other provisions in the law to work effectively.  This is one more reason why many health care professionals are warning against repeal.  Doctors, hospitals and even some insurance companies are warning against repeal because of what the absence of certain provisions will do to them and their livelihoods.  Medicare and Medicaid will be affected by the ACA repeal and that could affect payments to hospitals and doctors.
  6. Not only are there provisions within the law that work with other provisions, but repeal would likely affect the entire healthcare system and professional groups like the American Medical Association are sounding the alarm. For example, repeal could have an effect on Medicare recipients who could lose access to free preventative care and more affordable prescription drugs.  
  7. No one has taken the time or made the effort to address the one thing in the law that was included to protect consumers and to advocate for reasonable changes and adjustments in the law.  That is the section on consumer advocacy and protection.  (Please see my posting of 9/29/2013 for details).  Republicans despise consumer advocacy and oversight boards, but they don’t want you to realize that so they keep quiet on that matter while they surreptitiously try to eliminate every such entity they can find!  Soon, you will have zero such groups to advocate for your needs, while the favored 1% of wealthiest citizens will continue to reap every possible government dole-out that becomes available.
  8. Another thorny issue that repeal of the law portends is that its successes will be thrown away with repeal, which is something that Republicans cover-up by telling the Big Lie that the ACA is falling apart from the inside out.  Not so.  In fact:
·         enrollment for coverage is at a higher pace than last year at this time or in any other year; the navigator provision has been of great help in this enrollment
·         the percent of Americans without insurance coverage is at an all-time low and so is the rate of rise in premiums
·         over 20 million depend on the law for health care coverage (and about 10 million more signed up for Medicaid under enhanced eligibility rates)
·         there is also increased access to primary healthcare and a reduced reliance on emergency unit care
·         Seniors on Medicare are experiencing the disappearance of the “doughnut-hole” and a reduction in their cost for prescribed medications
·         Large numbers of young adults up to age 26 are being covered on their parent’s policies
·         Women are experiencing more equality in rates and treatment, and benefiting tremendously from ACA provisions directed at their circumstances

I want to conclude today with something unusual.  I want to conclude with sort of an exercise; perhaps a way to look outside one’s own situation.  Picture, if you will, a person who has multiple health problems, in this case, let’s say heart disease, Parkinson’s disease and skin cancer.  Any one of these, allowed to go untreated, could result in a fatal conclusion - death. 

Just think of the expense involved in treating this person who would require a primary physician versed in watching for the worsening of any of the three conditions.  A cardiologist would be very important, as would a cardiac surgeon, a neurologist, and a plastic surgeon.  Of course, numerous lab tests would be required to monitor the effect of medications, the complications of these diseases such as blood thinning, edema, loss of balance, loss of fine motor coordination, removal of some skin cancers, and even some mechanical equipment such as stents, a valve replacement in the heart perhaps, a pacemaker and/or defibrillator, and perhaps an operation on the face to remove what were becoming  worrisome growths.  Then there would be the therapies: physical mostly, but perhaps speech as well for complications from Parkinson’s.  Of course, one cannot forget the expense of hospital stays and perhaps a few ambulance rides. Have I forgotten anything major?  How about a gastroenterologist needed to monitor the effects of certain drugs on digestive system, liver, kidneys, etc.? Oh yes - how about all those necessary medications -- as many as 15-20 separate pills. I’m sure there must be more items involved, but let this serve as a broad overview of this (real) person’s health picture, and his/her overwhelming need for a very adequate health insurance plan. 

For many such people dealing with multiple diseases or conditions, Medicare, a very good Medicare supplement, and perhaps extra coverage for dental, vision and hearing treatments and devices is a necessity.  It is not an exaggeration that some kind of insurance – perhaps Medicaid – will also be needed at the end stage of this person’s life as nursing home or hospice care may be inevitable but personal resources will have been gradually exhausted.

Now please do what many people are failing to do - switch from your vision of this person with multiple diseases and with adequate health insurance coverage to meet the demands of these conditions to a vision of a person who has no health insurance coverage and can't afford it – and has no help to manage these conditions and their resulting side effects.  Millions of such people exist in this country, with more about to be forced back into that reality.  They could not afford the medical insurance coverage, they could not even get adequate coverage because of insurance company restrictions on pre-existing conditions and long-term pay-outs.  Some who got very basic cheaper coverage also got a lifetime cap on expenses, and higher costs for co-pays and limits on certain treatments.  If they were eligible for Medicare, they also got stuck in an expensive “doughnut hole” which affected their treatment because they could not afford the expensive drug costs. 

What did they do?  They overloaded our emergency rooms, community health clinics and public health services trying to get treatment to save their lives – all of which services were not equipped to handle the onslaught of chronically ill people.  Rates of medical insurance climbed every year for all those who were covered in order to pay for those public services for those who weren’t covered.  That was before the passage of the much-derided “Obamacare” that was set-up to cover the uncovered or inadequately-covered persons so that their right to adequate health care would not be compromised, and so that the rest of us could reasonably expect to be free of the out-of-control rising rates we were being forced to bear by insurance companies in order to balance their costs and maintain their rather lucrative profit-margins.  And now, radical Republicans are determined to repeal the ACA so that we can go backwards to allowing insurance companies their large profits made possible by their undue and unfair restrictions, unreasonable rates and unwarranted caps.  Unwitting proponents of repeal are about to get what they have been asking for – along with the rest of us -- health bills that we can’t afford and bankruptcies we didn’t expect and cannot endure.

 As usual, unscrupulous politicians in the Congress have bamboozled you.  They directed blame for initial flaws and hiccups in the ACA to one person – Barack Obama – when it was Republican inattention, delay and outright opposition to providing adequate health care coverage for an uninsured segment of our population that played a key role in rising health care costs, rising deficit-spending and rising difficulties for small hospitals and for folks who are sick, often with multiple diseases.

Repeal of the ACA is not only irresponsible; it is immoral because care of the sick and vulnerable is an integral part of the ethical code inherited and embraced by this nation.  Congress is about to bring real harm upon millions of individuals -- including children, women and Senior Citizens -- who have gained health care coverage, and assistance for medication costs, under “Obamacare.”  Those who vote to repeal should be declared ineligible to hold public office because they will have violated their oath of office by bringing direct harm to real people, and abandoned their fiduciary obligations by directly abrogating the constitutional principle of the General Welfare of the People and the obligation in Article 1, Section 8, to do all in their power to execute the responsibilities named therein. 

Stop these anarchists.  Go on or to and join the anti-repeal movement in a meaningful (and well-guided) manner.  As our President said in his farewell address last night: we weaken democracy when we write-off certain people and our responsibilities toward them and toward all.  We must constantly work - for a lifetime - to improve our great nation and its ideals. Being an involved Citizen is the most important Office in a democracy, because self-government is the underpinning of our democracy. In a phrase that I shall ever remember, he declared that the Constitution - a piece of parchment with writing - has no power or meaning unless We the People give it force and meaning.

So, he concluded: "Dive in.  Stay at it.  Have faith in America and in fellow Americans.  It is in the power of ordinary citizens to bring about change with our hearts, our ideals, and our enthusiasm. Believe in your ability, and in the Creed at our Core: "Yes, WE CAN!"  

Thank you, Mr. President, for your grace, your determination, your capacity to focus on the good, and your undiminished commitment to the fundamental values that have nourished, sustained and inspired us for centuries.  I am committed to grass roots activism to bring about meaningful change in our democracy and will continue that quest in the spirit you have manifested throughout your Presidency.  I am also committed to preserving your distinct legacy in any way I can because the successes and the achievements of your terms must be preserved for the edification of future generations. May many blessings be yours in the next phase of your life of service.