Seven years ago today, President Obama signed the Affordable Care Act into law, ushering in a host of reforms for the U.S. health care system. And today, House Republicans are planning to vote on the American Health Care Act (AHCA), which would repeal many of the ACA’s spending-related provisions and implement replacements for some aspects of the ACA. The bill was still undergoing changes as of last night, and it’s still unclear whether it has the votes to pass in the House. To say it’s been an eventful few week (and year) in the health wonk world would be an understatement. So welcome to the Health Wonk Review, where we make sense of all the goings-on!
We have a variety of posts this week that focus on the AHCA, but there are also several that tackle other subjects. Without further ado however, a shout out to David Williams, who has been writing at Health Business Blog for a dozen years! David’s blog turned 12 earlier this month, and David celebrated with a roundup of his favorite posts from the past year. Cheers, David, and here’s to a dozen more!
I want to start off with an outstanding article by Harold Pollack, at healthinsurance.org. Harold digs into the story of Tamara Estes, a 59-year-old Texas woman who earns $24,000/year driving a school bus in Texas, and who has $118.72 in her checking account with four days left until payday. Estes is uninsured, although she would qualify for a significant tax credit under the ACA if she purchased coverage (if the AHCA were to be enacted, her premiums would be higher thanks to the AHCA’s 5:1 ratio for older versus younger enrollees, and her tax credit would be smaller, since the AHCA doesn’t provide larger tax credits for low-income people). Her primary concern, however, is deporting undocumented immigrants. Harold’s article is full of empathy and understanding, with a good dose of reality. I highly recommend it.
Non-AHCA Health Wonkiness
Dr. Roy Poses shines a light on some fundamental flaws in our health care system in Whose Costs? Who Benefits? — A Close Reading of a Hospital System CEO’s Prescription for Controlling Health Care Costs. The CEO notes that hospitals are in the health care business, and advocates for increased “efficiency.” But will that lead to better health outcomes and lower health care costs for patients and society? Or just better bottom lines for the hospital system and its CEO? Poses added this commentary: “IMHO, as long as we continue to regard the market as being always right (and assuming somehow we have, or at least could have a free market in health care), that health care is a business not a calling, and that business management dogma is the best way to run health care organizations, we will not succeed in improving any aspect of health care dysfunction.” I agree.
Anthony Wright, writing at Health Access, explains that since Trump has backed off his promises to take on the pharmaceutical industry, states have to take the lead in regulatory action to protect consumers with regards to pharmaceutical pricing. California is stepping up, reintroducing transparency legislation that has gained new momentum in the wake of recent spikes in drug prices. California is already among the states that limit out-of-pocket costs for covered drugs, but S.B.17, the recently re-introduced legislation, would greatly increase the transparency of prescription drug pricing in the state. Limiting consumers’ out-of-pocket costs doesn’t target the underlying costs, which are ultimately passed along to consumers and taxpayers in the form of higher premiums (and premium tax credits). S.B.17 would be a good compliment to the existing consumer protections that California has implemented.
At Workers’ Comp Insider, Julie Ferguson explains that although Trump might have promised to “make American great again,” his proposal to cut funding for the Chemical Safety Board is only going to make us less safe. Julie notes that the Chemical Safety Board has a very small budget and only 40 employees, but is the “only independent government agency that investigates industrial chemical disasters.” Cutting funding for this small, but crucial, government agency is a perfect example of penny wise and pound foolish. Without the investigations and recommendations from the Chemical Safety Board, disastrous chemical accidents end up repeating themselves. People who work with hazardous chemicals, and the people who live in communities near those worksites, deserve better.
At Health System Ed, Peggy Salvator digs into the difference between providing health insurance coverage to everyone versus providing medical care to everyone. They are certainly not the same thing, and the concept of “underinsured” has become more commonplace over the last decade, as deductibles and out-of-pocket costs have risen steadily to keep premium somewhat affordable. Peggy suggests that it might be time to start over with a new system, and build it from the ground up, with a focus on universal medical care rather than medical insurance.
The American Health Care Act
Joe Paduda’s article, Three-legged horses can’t run, sums up some of the reasons Democrats aren’t particularly eager to help Republicans implement their health care reform plan. I would also add that I really think Democrats would be happy to work with Republicans if the latter were trying to make changes to the ACA that extend benefits to more people (as opposed to increasing the uninsured population by 24 million over the next decade). If Republicans were trying to fix the family glitch, or provide subsidies to people in the coverage gap, or extend subsidies to people making a bit more than 400 percent of the poverty level (without taking them away from lower-income folks), Democrats would probably lend a hand. But to roll out a bill that’s going to reduce taxes on the ultra wealthy and extend tax credits to the upper middle-class at the expense of old people and poor people? Republicans are on their own with that one.
With the House vote on the AHCA scheduled for today, Charles Gaba‘s latest analysis at ACA Signups is required reading. Charles has combined his own data with data from the Center for American Progress to create a comparison of how many more uninsured people there would be if the ACA were repealed and not replaced, versus if the AHCA were to be enacted. His comparisons are broken down by state, and within each state, he’s got data for every congressional district. In my own district (Colorado, 2) there would be about 95,000 additional uninsured residents with full ACA repeal and no replacement, versus about 39,000 additional uninsured residents under the AHCA (note that in both cases, keeping the ACA would be 
a better option, as is the case everywhere). But in some districts — like the entire state of Alaska — there would be more uninsured people with the AHCA than with full ACA repeal without replacement.
At Balloon Juice, David Anderson summarizes what might be going on with the AHCA, as of Wednesday evening. Everything is very much up in the air with the legislation, and House leadership was still planning a March 23 vote, even with last-minute scrambling on March 22 to rewrite portions of the bill to appease the House Freedom Caucus.
At InsureBlog, Patrick Paule is not a fan of the AHCA. Democrats are universally united against the AHCA, but the law has also had plenty of critics on the Republican side of the aisle. Many of them — like Patrick — would rather see a full repeal of the ACA. That needs 60 senators, which isn’t going to happen with the current makeup of the Senate. But the House Freedom Caucus, along with Senators like Rand Paul (R, Kentucky) have railed against the AHCA for being “Obamacare-Lite”
At xpostfactoid, Andrew Sprung has created a helpful way of looking at insurance benefits by multiplying the percentage of premium that’s subsidized (by the government or by an employer) with the actuarial value (AV) of the health plan. He then compares how ACA plans fare at different income levels versus AHCA plans for people earning up to $75,000 (where AHCA tax credits start to phase out). If House Republicans end up including repeal of the ACA’s essential health benefits requirement in their final version of the AHCA, actuarial value would go down and the numbers would come in even worse for AHCA plans.
My own entry this week explains how my own family would be impacted by the AHCA, and my thoughts on the bill (spoiler: it would be great for us, but there are other families that need help far more than we do, and the bill would take away from them to give to me). I wrote this piece before the amendments to the bill were introduced this week, so it’s not entirely up to date at this point. The amendments would result in larger tax credits for people over the age of 50, but the increase isn’t enough to offset the premium hikes that would hit older people if the ACHA’s 5:1 premium ratio (for older versus younger enrollees) were to be implemented.
That does it for this edition! Thanks for reading, and please share your favorite articles. The next Health Wonk Review will be hosted at InsureBlog on April 6.
