New Health Care Bill

[samclem]

Right, so here's the glaring discrepancy that highlights the problem with whatever the CBO is doing to generate these numbers:

The latest ACA replacement now being considered by the Senate, spends $616 billion on subsidies and Medicaid plus-ups (beyond the baseline Medicaid spending). And what result does this produce by 2026 according to the CBO? As you note:

In later years, other changes in the legislation—lower spending on Medicaid and substantially smaller average subsidies for coverage in the nongroup market—would also lead to increases in the number of people without health insurance. By 2026, among people under age 65, enrollment in Medicaid would fall by about 16 percent and an estimated 49 million people would be uninsured, compared with 28 million who would lack insurance that year under current law.

So, they predict an increased in the number of uninsured of 49M - 28M = 21 million. Okay.

But, in 2015, the same CBO scored the "Restoring America's Healthcare Freedom Act" (H.R. 3762). (President Obama vetoed this bill.) The version scored by the CBO had >zero< dollars for premium subsidies and zero dollars for Medicaid expansion. If that law were implemented and various insurance market reforms were also repealed, how many additional uninsured did the CBO predict it would produce by 2026 beyond the predicted ACA baseline? 23 million. Bold added below:

By CBO and JCT’s estimates, enacting H.R. 3762 would increase the number
of people without health insurance coverage by about 27 million in the year following the elimination of the Medicaid expansion and marketplace subsidies and by 32 million in 2026, relative to the number of uninsured
people expected under current law. (The number of people without health insurance would be smaller if, in addition to the changes in H.R. 3762, the insurance market reforms mentioned above were also repealed. In that case,the increase in the number of uninsured people would be
about 21 million in the year following the elimination of

the Medicaid expansion and marketplace subsidies; that
figure would rise to about 23 million in 2026.)

So, compared to the expected 2026 ACA numbers, the CBO says that a program (described in H.R 3762) that spends zero on Medicaid expansion and zero on Marketplace subsidies produces +23 million uninsured by 2026. And the CBO later says that the present Senate bill, which spends $616 billion over that same 10 years on subsidies, mostly for the poor, gets almost identical results: +21 million uninsured in 2026.

In what world does that make sense? There's something very wrong with the CBO methodology, and those who want to defend the CBO could start by explaining this craziness.

 

[Gumby]

But how does that affect you or anyone else on this forum? That's what we most want to know.

 

[samclem]

But how does that affect you or anyone else on this forum? That's what we most want to know.

I didn't realize "we" had this burning question.

Virtually everyone who is an American citizen and not on Medicare is affected by these policy decisions. The discussion, I think, is intended to help me and all participants better understand the policy proposals/laws that are being proposed. The CBO estimates have been cited here and elsewhere as being a unique/especially valuable means of comparing these health insurance options. My intent is to explain that the CBO estimates may in fact not be much value in discerning differences in the proposals if:
a) they predict results that don't match common sense experience when comparing plans of wildly different characteristics (e.g a plan offering $616B in subsidies/aid over 10 years has virtually the same number of uninsured as a plan that offers zero aid)
b) we know they have, in fact, been quite inaccurate in prediciting some very important aspects of health insurance (e.g. the number of people who would buy marketplace plans in 2016 under the ACA. They said 25 million, the real number was 9.5 million)

If people are going to cite the CBO analysis as something meaningful, it seems cricket to allow others to offer posts that dispute that. Since the CBO is nonpartisan, I'd assume this gores no oxen.

 

[W2R]

Any strategies for individuals to use in preparing for or dealing with any known aspects of the new bill?

 

[samclem]

Any strategies for individuals to use in preparing for or dealing with any known aspects of the new bill?

A few items people can start considering/crunching numbers on:

-Medicaid expansion: The Senate bill pares back federal money for this starting in 2020. If an ER is in a state with expanded Medicaid and using that benefit now (i.e. household income between 100% and 133% of the federal poverty level) , then it might get scaled back after 2020. Not a big deal if a person will soon be under Medicare, but otherwise it will be worth tracking what is happening in your state capital as they decide whether to keep funding it after 2020. Similarly, those between 100% and 133% of the FPL now might find it beneficial to look for ways to decrease their MAGI to below 100% of the FPL (to get on Medicaid) or consider how this might affect their quality of life.

- Employer Mandate: Under the Senate plan this is eliminated. If your employer was only offering insurance because of the mandate (a small %age of employers), then it could go away and you may be shopping for insurance elsewhere. On the plus side: Possible wage increases (compensation stays constant if labor demand doesn't change) and likely expanded options on the individual market as more folks go looking for policies.
If you were keeping the job just for the insurance benefit--the time for ER might come sooner than you thought, so it might be best to be read to make preparations if the bill (or something like it) becomes law (shift AA to a less volatile mix to avoid a sequence-of-return failure in the early years, etc)

 

[NomDeER]

Right, so here's the glaring discrepancy that highlights the problem with whatever the CBO is doing to generate these numbers:

The latest ACA replacement now being considered by the Senate, spends $616 billion on subsidies and Medicaid plus-ups (beyond the baseline Medicaid spending). And what result does this produce by 2026 according to the CBO? As you note:
So, they predict an increased in the number of uninsured of 49M - 28M = 21 million. Okay.

But, in 2015, the same CBO scored the "Restoring America's Healthcare Freedom Act" (H.R. 3762). (President Obama vetoed this bill.) The version scored by the CBO had >zero< dollars for premium subsidies and zero dollars for Medicaid expansion. If that law were implemented and various insurance market reforms were also repealed, how many additional uninsured did the CBO predict it would produce by 2026 beyond the predicted ACA baseline? 23 million. Bold added below:
So, compared to the expected 2026 ACA numbers, the CBO says that a program (described in H.R 3762) that spends zero on Medicaid expansion and zero on Marketplace subsidies produces +23 million uninsured by 2026. And the CBO later says that the present Senate bill, which spends $616 billion over that same 10 years on subsidies, mostly for the poor, gets almost identical results: +21 million uninsured in 2026.

In what world does that make sense? There's something very wrong with the CBO methodology, and those who want to defend the CBO could start by explaining this craziness.

It seems like you're comparing apples to oranges (and maybe some kumquats and grapefruit ). The two reports used different baseline estimates. Also, unlike in 2015, the new bill does not completely eliminate all the regulations and it attempts to provide at least some substitute for the mandate and has some cap on age discrimination even though it is significantly higher than the ACA cap. Plus, my understanding is that the 2015 bill repeals the Medicaid expansion, but the new bill goes further and reduces spending for even traditional Medicaid. That's one of the reasons there's concern for the disabled and the elderly in nursing homes --two groups that are primarily in traditional Medicaid, not expanded Medicaid.

I don't think the subsidies under the Senate bill will go primarily to people who were on expanded Medicaid. Those people won't be able to afford to pay for insurance even with the subsidies or won't be willing to buy it if they're not getting basic medical care from that insurance.

So, the difference between the two bills is much more than providing some money for subsidies in the Senate bill. And, frankly, I don't think a two million person difference is trivial. Especially if you're one of those two million people.

I'm not saying that the CBO is perfect at estimating the number of insured. I'm just saying I wouldn't think that they are crazy just because of the bottom line uninsured estimates in two different bills.

But, I don't think we really need the CBO to realize that reducing Medicaid spending and reducing subsidies is likely to result in more people being uninsured and paying more out of pocket. And allowing higher premiums for older people while also allowing for insurance companies to provide fewer essential health benefits would disproportionately affect people who have retired early or wish to do so.

Until we see a final bill signed into law, though, it's really hard to make any decisions.

 

[SecondCor521]

Any strategies for individuals to use in preparing for or dealing with any known aspects of the new bill?

I believe the first version of the Senate bill reduces the upper limit for subsidies from 400% of the FPL to 350% of the FPL. If one is currently receiving subsidies and it matters in your budget, you could do some multi-year tax planning around that. For example, if one has expenses of 375% of FPL, one might try to aim for 400% of FPL in 2018 and 350% of FPL in 2019.

 

[scrabbler1]

I believe the first version of the Senate bill reduces the upper limit for subsidies from 400% of the FPL to 350% of the FPL. If one is currently receiving subsidies and it matters in your budget, you could do some multi-year tax planning around that. For example, if one has expenses of 375% of FPL, one might try to aim for 400% of FPL in 2018 and 350% of FPL in 2019.

It's not expenses which determine subsidies, it is income (MAGI). My MAGI is about 375% of FPL, so I am in that small range who would lose the subsidy, albeit a small one, based on the proposal.

 

[MBSC]

-Medicaid expansion: ...it will be worth tracking what is happening in your state capital as they decide whether to keep funding it after 2020. Similarly, those between 100% and 133% of the FPL now might find it beneficial to look for ways to decrease their MAGI to below 100% of the FPL (to get on Medicaid)...

If an expansion state decides not to continue the expansion funding on their own, they will revert to pre-ACA (non-expansion) rules where a person usually had to either be disabled, age 65+, or have a dependent child to qualify for Medicaid.

A non-disabled adult without dependent children earning under 100% FPL would be eligible for premium subsidies since the criteria to receive subsidies changes to 0%-350% FPL from the current 100%-400% FPL under the current proposal.

Historically, Medi-Cal (California Medicaid) eligibility for adults has been limited to parents with very low income. Adults without dependent children were not eligible for Medi-Cal. Medi-Cal also covered individuals with disabilities and provided wrap-around coverage for many elderly in the state.

Source: http://www.kff.org/health-reform/fact-sheet/the-california-health-care-landscape/

There are more than 2.6 million people in the coverage gap across the 19 states that have not yet expanded their Medicaid programs, and more than a quarter of them are in Texas.

Who is currently eligible for Texas (non-expansion) Medicaid?

In addition to the aged, blind, and disabled, the following populations are eligible:

- Adults without dependent children are not eligible at all (this is generally the case in states that have not expanded Medicaid) unless they’re disabled.
- Adults with dependent children are only eligible if their household income doesn’t exceed 18 percent of poverty level. This amounts to about $3,600 a year for a family of three.

Source: https://www.healthinsurance.org/texas-medicaid/

 

[ShokWaveRider]

But how does that affect you or anyone else on this forum? That's what we most want to know.

I am not sure if anyone here uses Medicaid. I still worry about it as the Hospitals will have to take up the slack, so when we REALLY need the ER, it will be saturated or over capacity. I also feel for those who Really need it, but it does not affect me directly.

I, like most in the 400% of FPL range AM worried about subsidies going away till I reach Medicare age. Giving me a tax credit for taxes I do not pay in the first place, does not work as it happens after the fact. Currently my Subsidy goes straight to the Insurance company. Where would someone like me get and extra $1500pm to pay up front? And others for that matter, living off a fixed income.

In FLA if they used a 5:1 ratio, as we have a very high population of 55 - 64 year olds, would IMHO affect the balance of things. I confess I do not really know what it is now.

 

[MBSC]

Giving me a tax credit for taxes I do not pay in the first place, does not work as it happens after the fact. Currently my Subsidy goes straight to the Insurance company. Where would someone like me get and extra $1500pm to pay up front? And others for that matter, living off a fixed income.

Section 101 of the Senate Bill only removes the caps on the repayment amounts. This occurs when a person underestimates their income and receives too much APTC. The person would have to repay the entire excess during reconciliation at tax filing. The APTC process remains in place under the proposal.

 

[Chuckanut]

While we argue/discuss how we as a society pay for medical care, the 2000 pound elephant in the room is the high COST of medical care in the USA as compared to the rest of the world.

 

[ducky911]

What bugs me about changes in health care is the " talk " without action on lowering costs. They talk about it but do nothing.

I'm on Medicare starting this year. If I wasn't my cost for insurance would have been $29,000/year for the two of us with a dual deductible mess that covers nothing. Well little.

The total time I spend with a doctor per year is less than an hour...I take no prescriptions...wife goes a bit more and takes three prescriptions...give her two hours per year

29k.....3hours doctor time and three pills a day...where does that money go?...nuts

 

[W2R]

Numerous posts deleted and will remain so. Please review our Community Rules.