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The Dem plans for health care and the ACA

Greenbeard

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We already know the House Dems' first vote in the new Congress will be to defend the ACA against the GOP lawsuit to end pre-existing condition protections. But what then?

The package of reforms with the most support in the Dem caucus in the current Congress (H.R.5155 - Undo Sabotage and Expand Affordability of Health Insurance Act of 2018) is the obvious starting point.

What are those reforms?

Premium relief through more generous premium subsidies

How it works now: The ACA provides subsidies to people under 400% of the federal poverty line for their premiums: once they've put a certain percentage of their income toward a benchmark silver plan, the subsidy pays the rest of the cost of the plan.

How it would change: The Dem reforms would make the premium subsidies more generous by (1) lowering the percentage of income an individual or family has to contribute, and (2) making premium subsidies available to people over 400% FPL, eliminating the "cliff" some have criticized.

Household incomeMax % of income put toward premiums (ACA)Max % of income put toward premiums (H.R. 5155)
100%-133% FPL2.0%1.0%
133%-200% FPL4.0%2.0%
150%-200% FPL6.3%4.0%
200%-250% FPL8.05%6.0%
250%-300% FPL9.5%7.0%
300%-400% FPL9.58.5%
400% FPL and up-8.5%

To put this in concrete terms, let's imagine the example of a family of four (two 40-year-olds with two young kids) buying the national average 2018 benchmark plan.

If that family makes $30K, its monthly premium falls from $50 under the ACA to $25 under the proposed reforms.

If it makes $50K, its monthly premium falls from $263 to $167.

If it makes $75K, its monthly premium falls from $595 to $438.

And if it makes $105K, its monthly premium falls from $1,494 to $744.

Out-of-pocket spending relief through more generous cost-sharing reductions

How it works now: The ACA requires insurers to reduce out-of-pocket limits and spending (e.g., deductibles, copays, etc) for low-income people, effectively making their coverage more generous. This is referred to as cost-sharing reduction (CSR).

While silver plans normally have 70% actuarial values (actuarial value being a measure of plan generosity that indicates how much the insurer shells out vs. how much enrollees have to pay out of pocket when people get services), under the ACA people with lower incomes get silver plans of 73% actuarial values, 87%, or even 94%.

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These reductions are the reason that, despite all the hoopla about high deductibles in the exchanges, the median deductible actually faced by consumers in the marketplaces in 2016 was $850.

How it would change: The Dems would make the CSRs both more generous and more widely available. The CSR94 plans are currently reserved for only the poorest segment of marketplace shoppers; the Dem bill would make them available to everyone currently eligible to buy a CSR plan (i.e., those at or below 250% FPL). And while shoppers above 250% FPL currently aren't eligible for CSR plans at all, the Dems would make CSR87 plans available to those above that income level but below 400% FPL.

Household incomePlan Generosity for CSR Plans (ACA)Plan Generosity for CSR Plans (H.R. 5155)
100%-150% FPL94%94%
150%-200% FPL87%94%
200%-250% FPL73%94%
250%-400% FPL-87%

Oh, and they permanently make appropriations available to reimburse insurers for those cost-sharing reductions. The GOP has refused to appropriate funds to fulfill the government's obligation to make insurers whole for the CSRs, which led to large premium hikes in 2018 to make up for the lost revenue.
 

Greenbeard

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Continuing on:

Premium relief through reinsurance

How it works today: The ACA had built-in mechanisms to stabilize the risk profile of marketplace shoppers and promote competition between insurers on performance (not on their prowess at cherry-picking healthy customers), some designed to be permanent and some designed to be temporary (through 2016) to help the exchanges get on their feet. The temporary programs in particular were disrupted by GOP attempts to sabotage them.

How it would change: The Dems would create a permanent reinsurance program for the marketplaces, providing some financial backstop against particularly high-cost individuals and thus removing some of those expenses from other customers’ premiums.

Several states have already moved to implement reinsurance at the state level and the results have been good. Some examples:


Fix the ‘family glitch’

How it works today: Premium subsidies in the marketplaces are only available to individuals and families who don’t get affordable coverage at work. That is, those who either don’t get health insurance through their jobs at all and those who are offered coverage at work that’s simply too expensive. However, employer insurance is deemed to be affordable if individual coverage meets the law’s affordability thresholds. But employer family plans themselves might not meet those thresholds even if an individual plan from that employer does—yet it doesn’t matter, a family in that circumstance can’t get a premium subsidy in the marketplaces.

How it would change: The affordability threshold for employer plans would be applied to both individual and family coverage. If that family coverage is unaffordable, the family can opt out and go out to shop in the exchanges with the appropriate premium tax credit.

Halt Trump Administration Actions to Drive Up Premiums for Those With Pre-Existing Conditions

These pieces would halt recent regulatory actions, preventing HHS from changing the rules around Association Health plans, disallowing the reintroduction of junk insurance plans, and preserving the requirement that insurance cover the essential health benefits.

To encourage competition, the Dem bill would require HHS to develop a standard benefit plan design to be sold alongside other plans. Several state-based exchanges already do this.

To reverse the attempts by certain GOP states and the current administration to discourage enrollment, the bill would reinvigorate the navigator program and support other outreach and educational activities regarding health insurance enrollment.

Supporting State Innovations

This would make funds available to states for activities to support and increase insurance enrollment, from exploring auto-enrollment (with opt-out) in the marketplaces to implementing state-level individual mandates, etc.

It would also open the door to states, if they so choose, taking back administration of their exchanges from the federally facilitated exchange most states now use.
 

Chomsky

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Thanks for taking the time & effort to post this. :thumbs:

Well, I'm all for it. As long as there's no mandate, I'm good. I have no idea how the insurers will manage without the mandate, but since I prefer single-payer anyway I'm fine with subsidizing American's healthcare for a start. But only for a start along the road to single-payer.

Honestly though, means tested benefits are all wrong in my opinion. If a benefit is deemed worthy, it should be made universal. Means tested benefits lead to fraud & disincentive. So I say, "Roll-out Medicaid For All, and be done with it!"
 

Mycroft

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Who's going to pay for this premium relief?

Yep. The taxpayers.

Don't care about that deficit anymore, do we?

Anyway, this won't get past the Senate...let alone the President.

Why are the Dems wasting their time?
 

Bullseye

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Continuing on:

Premium relief through reinsurance

How it works today: The ACA had built-in mechanisms to stabilize the risk profile of marketplace shoppers and promote competition between insurers on performance (not on their prowess at cherry-picking healthy customers), some designed to be permanent and some designed to be temporary (through 2016) to help the exchanges get on their feet. The temporary programs in particular were disrupted by GOP attempts to sabotage them.

How it would change: The Dems would create a permanent reinsurance program for the marketplaces, providing some financial backstop against particularly high-cost individuals and thus removing some of those expenses from other customers’ premiums.

Several states have already moved to implement reinsurance at the state level and the results have been good. Some examples:


Fix the ‘family glitch’

How it works today: Premium subsidies in the marketplaces are only available to individuals and families who don’t get affordable coverage at work. That is, those who either don’t get health insurance through their jobs at all and those who are offered coverage at work that’s simply too expensive. However, employer insurance is deemed to be affordable if individual coverage meets the law’s affordability thresholds. But employer family plans themselves might not meet those thresholds even if an individual plan from that employer does—yet it doesn’t matter, a family in that circumstance can’t get a premium subsidy in the marketplaces.

How it would change: The affordability threshold for employer plans would be applied to both individual and family coverage. If that family coverage is unaffordable, the family can opt out and go out to shop in the exchanges with the appropriate premium tax credit.

Halt Trump Administration Actions to Drive Up Premiums for Those With Pre-Existing Conditions

These pieces would halt recent regulatory actions, preventing HHS from changing the rules around Association Health plans, disallowing the reintroduction of junk insurance plans, and preserving the requirement that insurance cover the essential health benefits.

To encourage competition, the Dem bill would require HHS to develop a standard benefit plan design to be sold alongside other plans. Several state-based exchanges already do this.

To reverse the attempts by certain GOP states and the current administration to discourage enrollment, the bill would reinvigorate the navigator program and support other outreach and educational activities regarding health insurance enrollment.

Supporting State Innovations

This would make funds available to states for activities to support and increase insurance enrollment, from exploring auto-enrollment (with opt-out) in the marketplaces to implementing state-level individual mandates, etc.

It would also open the door to states, if they so choose, taking back administration of their exchanges from the federally facilitated exchange most states now use.
Great idea, more government messing around, more spending, more "free" stuff. Only one problem, or actually two - all this has to go through a GOP controlled Senate and get Trump's signature. What's Pelosi going to offer in return?
 

ttwtt78640

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How do the demorats propose to pay for these additional PPACA subsidy benefits?
 

vesper

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How do the demorats propose to pay for these additional PPACA subsidy benefits?

They never worried about it before why would you ask how they would pay for it now? :) These people live on Rock Candy Mountain. Bottom line they can vote away in the House on any old thing they want but it isn't going anywhere accept sit on a shelf and collect dust.
 

ttwtt78640

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They never worried about it before why would you ask how they would pay for it now? :) These people live on Rock Candy Mountain. Bottom line they can vote away in the House on any old thing they want but it isn't going anywhere accept sit on a shelf and collect dust.

They made such a stink over the tax rate cuts not being paid for - I just expected that some additional revenue would be proposed to fund this give away.
 

Dittohead not!

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Winston

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Great idea, more government messing around, more spending, more "free" stuff. Only one problem, or actually two - all this has to go through a GOP controlled Senate and get Trump's signature. What's Pelosi going to offer in return?

Who's going to pay for this premium relief?

Yep. The taxpayers.

Don't care about that deficit anymore, do we?

Anyway, this won't get past the Senate...let alone the President.

Why are the Dems wasting their time?

Too late. The new tax law gutted Obamacare, thank God, and anything the House passes is dead on arrival in the Senate, thank God again.

IMO, a good strategy for Dems would be to force Republicans to vote 'No', on popular Democratic bills, so they can use their votes against them in 2020.
 

TrumpTrain

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IMO, a good strategy for Dems would be to force Republicans to vote 'No', on popular Democratic bills, so they can use their votes against them in 2020.

What popular bills would those be?
 

Greenbeard

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So I say, "Roll-out Medicaid For All, and be done with it!"

Weirdly enough, that appears to be the de facto GOP position as well. They increasingly like the Medicaid expansion, they just hate markets. I would not have guessed a decade ago that this is how it would shake out.

Why are the Dems wasting their time?

Because people want lower premiums.

And they're tired of GOP sabotage driving up premiums for no reason.

They never worried about it before why would you ask how they would pay for it now? :)

The ACA was already more than paid for. It raised more revenue than the projected cost, which is why it was a deficit-reducing bill. As it turned out, the actual costs of the coverage expansions were hundreds of billions of dollars below projections and the actual savings achieved in the Medicare program were hundreds of billions of dollars above projections. Given that reality, there's no reason not make the coverage more generous within the financial envelop of the original package--or beyond it, for that matter.

Great idea, more government messing around, more spending, more "free" stuff. Only one problem, or actually two - all this has to go through a GOP controlled Senate and get Trump's signature. What's Pelosi going to offer in return?

What ransom will the GOP demand for more affordable plans and lower deductibles?
 

Blue Dog

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The GOP had Congress for two years and did not pass their own viable alternative. There is no excuse for that. Doing nothing but dismantling and excoriating PPACA is not cutting it. Congress needs to demonstrate that they can legislate. The HoR should pass these bills and if the GOP Senate objects than the American people should use their vote in 2020 to see which side they agree with.

Jmo
 

TrumpTrain

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Obamacare was a horrible horrible law that threw people off their plans, and made other people accept plans with features they did not want. Obama LIED when he said you could keep your doctor. Why anybody would want to save that foul law is beyond me.
 

TrumpTrain

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The GOP had Congress for two years and did not pass their own viable alternative..........

Congress was filled with a fair number of never-Trumper Republicans. Those idiots stalled much of Trump's agenda.
 

1751Texan

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Who's going to pay for this premium relief?

Yep. The taxpayers.

Don't care about that deficit anymore, do we?

Anyway, this won't get past the Senate...let alone the President.

Why are the Dems wasting their time?

Lets be clear those paying via taxes were those making 200K+ individual. Is that your tax bracket?
 

TrumpTrain

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Who's going to pay for this premium relief?

Yep. The taxpayers.

Don't care about that deficit anymore, do we?

Anyway, this won't get past the Senate...let alone the President.

Why are the Dems wasting their time?

Thats all Obamacare is, subsidies to insurance companies. Thats all it is, along with some destructive regulations.
 

1751Texan

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Obamacare was a horrible horrible law that threw people off their plans, and made other people accept plans with features they did not want. Obama LIED when he said you could keep your doctor. Why anybody would want to save that foul law is beyond me.

Obama care ....like every other large program needed maintence legislation to fix problems.

The GOP held Congress for 8 years after ACA was passed. Fixes were not going to pass themselves. the GOP did what they were voted in for.

Now the Democrats will slowly be voted in to fix ACA. We were voted in to stop Trump and the GOP from killing it.

Now its time to fix what can be.

but Trump lost. There will be no Trump repeal and replace.
 

Helix

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during the next Democratic majority, priority one should be Medicaid for all. push it through, and then let Trumpists try to take it away. should have done that in 2010 rather than the ACA Romneycare half measure. the Democrats need to learn that Trumpists will never support them in any way no matter what they do.
 

Greenbeard

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Obamacare was a horrible horrible law that threw people off their plans, and made other people accept plans with features they did not want. Obama LIED when he said you could keep your doctor. Why anybody would want to save that foul law is beyond me.

Yes, very hard to see why it's become so popular.

Medicare’s cost surprise: It’s going down
During the Obama era, Medicare’s per-person spending barely budged, inching up only about 1 percent per year. That’s less than the rate of inflation, meaning that per-person Medicare costs, when adjusted for inflation, have been going down.

Health Spending Growth Slowing, More on Pace with Economic Growth | Employers’ Health Care Cost Growth Has Plateaued

Baby Survival Rates Improved in States With Affordable Care Act, Data Show
Published in the American Journal of Public Health, new data shows that infant mortality rates decreased in states that expanded Medicaid.

Out-of-hospital cardiac arrests fell under the Affordable Care Act
In Oregon, the rate of cardiac arrests happening outside of hospitals fell significantly after implementation of the Affordable Care Act and its expansion of health insurance coverage, researchers report.

Medical care, health have improved for low-income adults under ACA
Boston, MA - The Affordable Care Act's health coverage expansions have produced major improvements in medical care and health for low-income adults, including reduced out-of-pocket spending, better access to primary care and preventive services, improved self-reported health, and improved care for those with chronic conditions, according to a new study from Harvard T.H. Chan School of Public Health.

Affordable Care Act Increased Rate of Early Cancer Diagnoses
The implementation of the Affordable Care Act (ACA) in 2014 and subsequent Medicaid expansion correlate with earlier diagnosis of breast, colorectal, and lung cancer, according to a study being presented at the 2017 American Society of Clinical Oncology (ASCO) Annual Meeting in Chicago.

Uninsured cancer patients saw increased coverage for care following Medicaid expansion
A new study finds that Medicaid expansion enacted as part of the Patient Protection and Affordable Care Act (ACA) improved coverage for care for cancer patients receiving radiation therapy and potentially decreased health care disparities. Analysis of more than 197,000 patient records from one of the nation’s largest cancer registries, which found that the uninsured rate for these vulnerable patients dropped by half in states that fully expanded their Medicaid programs, will be presented today at the American Society for Radiation Oncology’s (ASTRO’s) 59th Annual Meeting.

ACA credited with earlier diagnosis of gynecologic cancers in young women
The gains in insurance coverage with the Patient Protection and Affordable Care Act (ACA) have already translated into improved health for young women with gynecologic cancers, who are getting diagnosed at earlier stages of their disease because of ACA benefits. That's the conclusion of a new study by researchers at Johns Hopkins Medicine, who looked at nationwide trends in gynecologic cancer diagnosis in a large population of women before and after the ACA's implementation in 2010.

Fewer Patients Have Been Dying From Hospital Errors Since Obamacare Started
Hospitals have cut down on deadly medical errors, saving around 87,000 lives since 2010, according to a new government report.
 

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Thanks for taking the time & effort to post this. :thumbs:

Well, I'm all for it. As long as there's no mandate, I'm good. I have no idea how the insurers will manage without the mandate, but since I prefer single-payer anyway I'm fine with subsidizing American's healthcare for a start. But only for a start along the road to single-payer.

Honestly though, means tested benefits are all wrong in my opinion. If a benefit is deemed worthy, it should be made universal. Means tested benefits lead to fraud & disincentive. So I say, "Roll-out Medicaid For All, and be done with it!"

You understand of course that this is just a cheap political stunt with no hope of passage. Notice your buddy forgot to mention cost. Insurance companies won't pick up the tab, you DID notice the word subsidized didn't you?

I have from the beginning of this joke called ACA said single payer is the true answer. However you have to get through two hurdles. One, who pays. Currently most private insurance is paid for largely by corporations. So whomever changes that will be attacked as a corporate stooge. That is why Warren Buffett wanted this over tax cuts. Next is accessibility. When something is free clearly usage goes up. Where will the increased supply of doctors come from.

Most hard questions have a thousand easy answers. Sadly they are almost always wrong. Wish I had the silver bullet to fix this problem. Alas I do not.

Yes HC is a hard problem to fix.
 

Helix

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A message from the local Communist Party.

i'm not a communist or even a socialist. i don't support giving the means of production to the workers. you should probably learn the definitions of these political systems before pretending that you understand them.
 
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