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The Best Bipartisan Answer To Repeal And Replace The Affordable Care Act

If this is Congress wants their brand of health insurance to be more affordable for the average American tax payer, they must restore the leverage of insurance and the law of large numbers into the equation. They must be willing to negotiate with insurance carriers, not just dictate terms to them. The carriers will do whatever the federal government wants them to do, but they are going to want the government to pay for it. And, this time around, they are also going to want to actually get paid. ACA is NOT insurance, and that is one of the foremost reasons it is falling apart. The BEST Answer to the Repeal and Replacement of the Affordable Care Act is to move entirely away from the failed Obamacare model and start fresh. Too much of the ACA muddy water has gone under the Broken legislative bridge. In 2017, under Reconciliation, the best that the U.S. House and Senate and the Trump Administration could do was propose modifications to the ACA (ACA Light and ACA Dark). And, right now the Democrats and some Republicans, and their staffs are thinking, " We have put so much effort into ACA and created so much super-structure at this point, why don't we just modify it?" Since the insurance companies are threatening and delivering radical rate increases, I hear that opinion a lot from the people that do not understand the nature of these programs. All the insurance carriers have designed and loaded these benefit plans into their systems and the Market Place Exchanges have learned about, and the actuaries have priced them, and the computers have been programmed to deliver them and guess what; the people participating have all gotten too familiar with them. In this situation, our elected Representatives have recently failed in their attempt to spend tens of billions of Dollars in the omnibus bill to temporarily shore up Obamacare’s failing system by taking the easy way out throwing more money at the insurance carriers. Taking the easy way out will enshrine the vestiges of ACA, the very elements that caused it to fail. If we continue down this road of musical chairs, the only one left without a working chair when the music stops will be the American people. Human nature will naturally cause the ACA to fail. At some point, you have to realize that in order to save ourselves, we have to abandon ship!

Washington Monument

Medicare Part C - Medicare Advantage is a very similar program to the ACA. It is tremendously popular with seniors, covering now over 35% of our elderly and disabled (19 Million) citizens. Despite the concern that ACA would lead to reductions in Medicare Advantage plan enrollment since the ACA was enacted, Medicare Part C members increased substantially, which is a testament to the Program’s affordability and popularity. Today, Medicare Advantage (MA) has evolved into a powerhouse program expected to cover to over 21 Million enrollees in 2018. MA currently garners about 50% of the new enrollees within their first year of Medicare eligibility.

Compare this to the declining 8 - 9 Million ACA enrollees. Medicare Advantage Plans are running like a top, right now, under the Centers for Medicare and Medicaid (CMS), HHS and Secretary Alex M. Azar II. All the insurance carriers understand the program. The government knows the cost of the various Plans by geographic area. And, there is an administration and infrastructure in place to handle the expansion of the program. The insurers are pulling out of Obamacare. The health care providers at large, including the American Medical Association (AMA) and the American Hospital Association (AHA) were all against AHCA repeal Bill and they defeated it by a narrow vote. In sum, the key players of the health care system, including all the Democrats and even the President of the United States do NOT whole heartedly support AHCA. So, the $64 Dollar question is why isn’t Congress willing to look at the Medicare Advantage (Part C) Program, which they created back in the early 80’s? The Medicare Part C Program is almost ready and certainly able to fill the gap for Obamacare people and probably also many of the Twenty-eight (28) million uninsured citizens would join.

The answer to that question is as complex as it is unfortunate. The Reconciliation process requires cooperation between the parties and nothing in 2018 (and for the foreseeable future) that one party likes will be considered acceptable and supported by the other party. And, now we have two new huge plays have been called on the playing field. The new wrinkle the democrats is the support for single-payer. The Center for American Progress, a Bastian of the Democratic establishment produced a plan for a single-payer health care system. Senator Bernie Sanders and others also introduced Medicare for All bills to which a majority of the conference, 120 Democrats have signed on. All the hopeful Democratic party Presidential candidates in 2020, including Bernie Sanders, Cory Booker, and Elizabeth Warren have endorsed single-payer, and Senator Warren has urged democratic candidates running in 2018 to advocate the single-payer position, which many are doing.

A recent Kaiser Family Foundation poll showed only a modest increase in the public support for single-payer with 53% of the public, up from 46% in 2009, supporting the concept of all Americans getting coverage through a single government plan. Admittedly, the number of the people answering this poll affirmatively is a reflection of all the problems with the ACA, coverage for pre-existing conditions, exasperating rate increases, runaway inflation and the failure of the federal government to deal effectively with the need to extend coverage to our most vulnerable citizens. Again, most people think that Medicare is a single-payer system and it is not!

The Republicans are going full steam in the opposite direction. The RNC has been running Anti-Single-Payer Facebook ads in active electoral districts considered up for grabs in 2018 midterms. These ads point out studies that have concluded that “Medicare for All” could cost Americans as much as 32 Trillion Dollars over a 10-year period. In addition, the Republicans had the colossal failure the so-called Graham-Cassidy Reform Bill, which generated heated debate in Congress as well as other public and televised forums. This Bill dropped the whole health care budget problem onto the states in the form of block grants, the concept of which, a few states favor. The Bill also attempted to cap the way the federal government shared expenses on the state Medicaid programs by re-introducing capitation financing, similar to that proposed by AHCA and referenced herein on the Medicaid web page. The latest versions full (official) name isn’t just Graham- Cassidy. It is the Graham-Cassidy-Heller-Johnson Bill. It, fortunately, turned out to be political suicide for its sponsors due to opposition from virtually everybody in the industry. It was ill-conceived, hastily prepared and poorly packaged and sold as a risky 40-yard punt attempting to get a few points on the board because a touch down was impossible. 

What caught everybody by surprise, including the White House, is that not only are the ACA subsidies popular (as any good give away usually is) with constituents but the Medicaid Expansion also had much stronger political support than anticipated. A host of Republican Governors across the country clearly saw that this legislation would potentially drive up premiums, further destabilize markets and potentially throw millions of their constituents off the insured rolls while at the same time sticking their states with costly changes and opening their fragile state budgets to additional unintended expenses down the line. To make matters worse, all 50 state Medicaid Program Directors went on record criticizing the cost and the procedures required to revamp each states healthcare system. These Directors unanimously agreed that it was almost impossible to accomplish the required administrative changes in the two-year time frame allowed by the legislation, especially given NO allocation of federal money or additional resources to accomplish their task.

Unfortunately, instead of this Bill being soundly defeated on the facts, the Republican leadership withdrew the legislation and postponed the vote. Based on the associated criticism of the Democrats, Charles Pierce of Esquire magazine (Reference – www.esquire.com/news-politics/a12477944/why-graham-cassidy-failed/ ) harshly asserts that the Republicans will not support any bipartisan plan to fix problems with the ACA. “The simple fact is that the ACA places in the federal government powers that most Republicans do not believe (it) should have, and that it helps people that most Republicans do not believe deserve help, either through their own sloth, or through some inscrutable divine selection to be found between the lines of the Book of Deuteronomy.” Republicans also believe that single-payer will kill the vibrant health care system that will grow to become 20% of the nation’s GDP by 2025. 

Senator Graham boldly asserted that his Bill would eventually pass. This appears to be more true than fiction, irrespective of the fact that our government presides over successful health insurance plans that satisfy almost one-third of our citizens, Republicans apparently fear that the Democrats are going to be persuasive with their single-payer ambitions. In order to prevent that catastrophe from further wrecking the American health care system, the Republican consensus appears to be a drop-dead drag out effort to get the remaining healthcare money out of Washington DC.

To that end, former PA Senator Rick Santorum is heading up a coalition of conservative leaders, being hosted and coordinated by the Heritage Foundation and the Galen Institute and charged with the responsibility to come up with a New health reform plan for state block grant funding. In the group's Open letter to the American public, their stated goals  are:

1. Lower costs and improve patient choices.
2. Give states flexibility and resources to achieve these goals.
3. Set federal guardrails so people can choose private coverage options if they don’t like the options their state provides.

This plan may or may not include more palatable Medicaid reforms and include bells and whistles that may help the states develop their own unique programs. Everyone likes the idea of state “incubator” programs, like Governor Scott advocates for Florida. The only problem with this idea is; each state will be doing something different and there is no need for successful graduation, integration or interaction with any other state. We can do better than that. The one succinctly stated objective is to have all of the health care dollars, including all the ACA money, flow directly through the block grants to the states and NOT to the insurance companies. This plan would replace Obamacare payments to insurers while basically leaving everything else up to the states. In our humble opinion this is as misguided and ludicrous an approach as it was when the Affordable Care Act directed all of the insurance carriers, as to who they would cover, how they were to rate, who they would enroll and how the government was going to pay them, or not pay for them, as the case may be. Basically, the governement is at fault for what has happened to the ACA, not the insurance companies!

Fortunately, the Republicans can’t make any “REAL” changes in the ACA without the Democrats. Our goal is to show our representatives on both sides of the aisle, the error of their ways. And, convince you to forcefully recommend a “REAL” solution that is not lost on the Senators and Representatives of our greatest and most powerful houses of Government. “We the People” want to spend the rest of our healthy lives giving our Congress an approval rating that is equal to our patriotism and our love for our Country. That will not happen until and unless our Congress earns it by adopting Medicare Advantage as the final piece of legislation, and the last Part of Medicare necessary to complete the greatest health care system the World has ever known.

Medicare Part C is a “REAL” insurance program. There are currently no exclusions or waiting periods for coverage for anybody with a pre-existing condition. As previously mentioned, the design and funding of Medicare Advantage Plans is a collaborative process between the insurance companies and The Centers for Medicare and Medicaid Services (CMS). If Congress would authorize the necessary changes to make it work for under age 65 citizens, like it does for over age 65 retirees, we would have a solvent and affordable health insurance contract and a system that will work day in and day out for everybody. 

CMS can translate any legislative funding goals into regulations, and the health insurance carriers can develop the programs accordingly, with certain adjustments for the benefit of the participants. The rates for Bronze, Silver, Gold (and we would add Cooper) benefit plans should be self-supporting, and subsidies, tax credits and sliding scale premiums and other financial assistance can be whatever we are willing to spend on it. More on that on our web page, “100 Billion Dollar Savings.” There will be financial rewards to the carriers for better healthcare management. But, there WILL NOT BE any loss recovery, no payments to stabilize markets, no adjustments for unanticipated market conditions and hopefully no law suits. If Congress agrees to design a program to effectively extend Medicare Advantage Plans to the uninsured under age 65, the federal government would know in advance exactly how much the Program is going to cost and accurately be able to determine how much “We the People”, and the participants in the program are ultimately going to have to pay for it. The federal government would allow insurance carriers the necessary latitudes to do whatever is necessary to prevent adverse selection and make the program work. Managing the program, keeping the risk pools vibrant, reaching the maximum possible number of uninsured and creating the necessary incentives to adapt the program to changing market conditions will be required. This is critical. A national program is the ONLY way we, as a nation, are ever going to have the ability to positively impact on the escalating cost of health care by effecting changes in both consumer behavior and provider negotiations.

President Trump told Senators that, the more money they are willing to put into their plan, the greater the number of Americans that can take advantage of it. He wants it to be a fantastic program. He “gets” it! And, I hope “his desires” are not lost on the Senators and Congressional representatives as we review their plans and help them with their responsibility to fix these problems with our health and our health care system.