Affordable Care is Simply Not Affordable

HealthCareGovSiteNew Orleans    The more studies that are done, the more time that passes, the more it seems impossible to get around the core issue embedded in the compromises of the Affordable Care Act: it’s just not affordable for lower income families.

The government’s projections for the current signup period are frankly modest at about nine million signups, rather than the twenty million projected several years ago for this period. Given the number of states that continue to boycott the expansion of Medicaid, which is where a lot of the gap for the uninsured continues, the budget offices are finding the predicted costs of Obamacare are about 20% lower than originally expected.

Furthermore, the mandate is not pushing enough people into insurance who don’t have it, particularly among lower waged workers. Studies are finding that at about $40,000 the maximum participation is achieved. Lower income families are simply paying the penalty, because it’s cheaper than the insurance bite.

Reports from employers are very depressing, though not surprising. Having represented big health care employers with sorry health plans for decades and seen the abysmal participation figures, we were hardly shocked, but still reading figures for huge food service companies with tens of thousands of employees and their reports of only 500 workers out of 25,000 actually signing up for employer insurance is ridiculous. The workers are blocked from access to ACA marketplace subsidies and cost sharing because they have opted out of corporate insurance, but they have opted out because the costs are too high and the benefits are too crummy with essentially catastrophic coverage and deductibles as high as $6000. Who can afford any of that on $10 or $15 per hour?

Increasingly, it seems clear we have a little bit of something for health insurance, but it’s only a bit better than nothing, and under the private company and corporate-centered regime, it’s too pricey and too paltry. We need real national health insurance, but that means a more significant governmental investment, and that is a bridge way past the level of political consensus.

It is also way past the level of public support, which fuels the continued opposition to Obamacare. When even the primary beneficiaries of the program among low-and-moderate income families are still priced out of the market, who is left to show the program the love it needs and deserves?

Half-stepping clearly has only gotten us halfway to where we need to be. We shouldn’t be surprised, but that doesn’t make it any easier to live with the disappointment or the continued perilous state of national health protection in the United States for low-and-moderate income families.


Arkansas Health Care Battleground Focuses on Stopping Enrollment

Toney Orr, Local 100, speaking in support of private option at the Arkansas Capital.

Toney Orr, Local 100, speaking in support of private option at the Arkansas Capital.

Little Rock  The so-called unique “private option” in Arkansas where a federal Affordable Care Act waiver allows federal money to purchase insurance from private companies for low-income families continues to be a year-by-year battleground.  Importantly this program along with Medicaid expansion, both navigated by Democratic Governor Mike Beebe through a Republican legislature, has already allowed 100,000 people to gain insurance.  Earlier this week on a 5th vote by the Arkansas House another year’s extension was approved by a supermajority vote of 76-24, finally fulfilling a commitment from the Republican speaker that they would keep voting until the measure passed since not doing so would open up a $90 million budget hole.

            There were prices paid for the extra votes, and most of them were blatant agreements to discourage any effort by the state and its Insurance Commission to increase enrollment in the program, joining Texas and other state in aggressive attacks against navigators and other assistors.  An amendment to the bill, enabling its final passage, expressly forbade any further expenditures by the Insurance Commission through advertising or outreach to increase participation in Obamacare.  This is not conjecture.  Here is the description from the conservative National Journal:

One of the main amendments, written by Republican state Rep. Nate Bell, prohibits any state funds from going toward promotion or outreach of the ACA in the state. This includes enrollment in the private option, as well as the overall exchange. Bell—an unabashed critic of the private option and the health care law—has said he ultimately wants the program to fail, and that this amendment is intended to stymie enrollment.  “I believe it’s important as a conservative that we recognize the situation we’re in,” he said on the House floor during an earlier vote last month. “When we can defeat bad policy, we should do so. When we can’t defeat bad policy, it’s our responsibility to do everything we can to influence it and make it as closely aligned with our philosophy and policy as we can.”

            By July 1st 600 consumer assistors around the state of Arkansas will be laid off due to the amendment.  Calls from the Insurance Commission staff to navigators have already begun, begging for help, but Congress in initially funding the HHS navigator program only funded the work for one year, ending August 15th, so the notion that six to ten health care organizers can pick up the slack for six hundred is absurd, not even considering the fact that navigators obviously work under the direction of the Center for Medicaid Services of HHS and not a state agency. 

What a mess, and worst, similar to every other state, huge numbers remain to be enrolled, and no matter the Obamacare-hate, it’s the number of new health care participants who are in fact saving the program.  The Arkansas Democrat-Gazette caught this clearly in interviews with some of the vote switchers who saved the bill:

Rep. Kim Hammer, R-Benton, announced he would vote for the bill after previously opposing it. “There are people who will be hurt if I don’t vote for this,” Hammer said. “And I don’t want to see those innocent people hurt because of that.”  Hammer — who joined Reps. Les “Skip” Carnine and Mary Lou Slinkard in switching to yes votes — said he had not “betrayed” opponents of the bill and would not shy from voting against it next year if the program is not successful. “I haven’t stepped away from it,” he said. “I plan on coming back in January. And it better be successful. Otherwise it will be voted down.”

This is a battleground where we can’t win unless we are on the field, but both the stakes and the measures of victory are crystal clear.  We don’t win and keep affordable healthcare and coverage for hundreds of thousands of lower income families in Arkansas unless there is a robust and aggressive enrollment program, beating the bushes and bringing people under coverage.  The opposition understands this, but the days are now being numbered on how long navigators and others can be kept on the streets.

Talk about being asked to fight with our hands tied behind our backs!



Rising Obamacare Enrollment Can’t be Stopped

aca_chartNew Orleans   The massive battleground that the Republicans have made of implementation of the Affordable Care Act has no strategy to deal with a ticking time bomb that could blow up in their faces, and that’s the problem of math – people are voting for the program with their feet in increasing numbers through their enrollment.  The Republicans have to worry where the tipping point will be and whether or not they will have enough time to get on the right side of the scale before the weight collapses on them.   Clearly some politicians have already come to that conclusion, but the recent enrollment estimates hasten their days of decision.

Current estimates are that 6 million Americans will enroll in Obamacare by the March 31st or whenever the spring deadline hits, since I would still bet there will be a small extension in the final days of the period.  Additionally, expanded Medicaid is estimated to capture 8 million additional Americans.  Admittedly, this 14 million is not the 16 million the Administration had originally projected, 7 in Obamacare and 9 in Medicaid, but 14 million is still a heckuva lot of people – and voters.    The falloff from expectations of course lies with the botched website rollout.  Nonetheless, the ball is now rolling, and experts also predict that Obamacare will rise to 25 million Americans enrolled when the calendar hits 2017.

Certainly, there will still be plenty of sound and fury from conservatives on the short term run-up to the mid-term elections for Congress, but the calendar and the increasing enrollments are unforgiving, if they rise as expected going into the 2016 Presidential election, which has to concern Republican strategists.  If nearly 25 million have enrolled by the time voters go to the polls in 2016, that is a huge block that is likely to start remembering who said and did what to Obamacare and to vote with those who are likely to protect their benefits, not those who are still part of the monkey wrench gang.  Look to Social Security for a model of political behavior on sacred cow entitlements.

The nonpartisan Congressional Budget Office released a report indicating that the equivalent of 250,000 workers per year might be impacted by lost hours and conversions to part-time status as the employer mandates take hold in 2015 and forward.  The Republicans and the headlines jumped on the 10 year total of an equivalent of 2.5 million jobs affected, but it is unclear if the tradeoff in hours was compared to the trade-up in the same worker equivalents suddenly being covered by health insurance, and how that balanced out economically.  Once the fur stops flying, it will be easier to tell whether this will nudge the scale at all even on the short term.

For a change the Administration could get lucky.  If job growth and wage hikes pick up with the improving economy, losing some hours will be lost in the wash.  There are now 131.1 million jobs in the USA.  250000 jobs is .0019 percent of total employment where hours are being lost on this exchange or less than 2 thousands of a percent.  I’m not saying it’s good news for any worker, but I am saying that this is not a voting block and likely to be soon lost in the pile of new enrollments in Obamacare and new jobs and hours in the growing economy.


Subverting Competition in Healthcare May Force Price Controls

ruralhealthclinic-jeuaNew Orleans   There are obvious glitches in the Affordable Care Act that the politicians will handle.

One of them, as I’ve argued before, is going to be extending the deadline for enrollment to escape penalties past March 31, 2014, and that assumes that the government doesn’t waive the penalties entirely for the first year, which will more likely be the action taken if there continue to be huge systemic problems in enrollment.  The reasons are simple.   Politicians won’t take the heat from something that is obviously not fair to their citizens.   It is equally obvious as President Obama has argued that come hell or high water, they will fix the online process.   This is his legacy program and he does not want the enrollment problems to be in his official biography and eventual obituary.

Interestingly, there is another huge political problem looming in the Senate that perhaps was not as anticipated, but may have been the most effective obstacle created by the continued Republican rearguard actions, especially at the state level where half of the governors and their state legislatures have blocked Medicaid expansion and state managed marketplace exchanges. That problem, as a recent New York Times article indicated, lies in the widely disparate pricing for policies in rural areas, where healthcare is scarcer anyway.   No matter how urban the country is now, we have become no small number of Tea Party Congresspeople coming from areas where rural interests still dominate, and the weight of more rural states is still strong in the Senate where population is irrelevant to voting strength.

Talk about the irony of being hoisted by your own petard!  We have a private insurance company dominated healthcare model in the Affordable Care Act, because ideologically the notion of government managed and run healthcare like Britain or Canada was past the pale.  Our system would privilege private insurers and get the job done through the almighty power of free competition, by God!  Well, it turns out, not surprisingly, when politicians refuse to expand the insured base through Medicaid expansion and delay the marketplaces, then private insurers don’t want to come into those states, and these same market forces leave one or two companies in those situations with a virtual monopoly for providing the coverage, and prices do not go down, but in fact even in some situations increase.  So from place to place in rural areas, rates for the same coverage may be three and four times higher.   You can feel the political heat from here!

The solution would be that the government caps prices, but price controls might even be more inflammatory for the real conservatives than the problem they have now created, probably inadvertently given the low level of economic education even by supposed free market advocates.   As conservatives get over the fact that they can kill Obamacare and are forced to reckon with the ongoing reality of its impact in their districts, this will be a problem they will not be able to avoid.   It’s going to be interesting to hear the contorted arguments and watch the policy gyrations as they argue against price controls that would balance the cost for all Americans, and try to figure out a way to put the government’s finger, if not whole fist, on the scale to get some cost balance, since that’s only fair and their constituents are going to be calling for it, and loudly.