From an upscale assisted living center in Seattle, 87-year-old Brendan Wall has some advice for members of Congress eager to repeal the Affordable Care Act: Slow down.
“They haven’t said what they’re going to replace it with or how they’re going to replace it,” said Wall, who taught philosophy and religion for more than 30 years.
“I think it’s a major crisis, and I hope to God they take enough time to think about it and act on it so that the thing will work.”
Wall lives at Merrill Gardens, a complex near downtown Seattle where anxiety runs high over the transition to a new administration in Washington, D.C. And while the evolving drama may not affect him directly, he and other seniors here fret about the Donald Trump administration’s vow to repeal and replace the Affordable Care Act and what it will mean for their children and grandchildren.
Wall and five other residents responded to a Kaiser Health News request for area seniors willing to share their views about health care as Trump takes over and pressure mounts on Capitol Hill to repeal the Affordable Care Act. In a news conference, Trump again called the health law “a complete and total disaster,” and said he intends to move quickly to replace it with something “far less expensive and far better,” though he offered no specifics.
The view from Merrill Gardens offers a snapshot of a larger national debate about the successes and failures of President Barack Obama’s signature legislation. Its residents live in liberal King County, where less than 22 percent of voters chose Trump. But only 125 miles away, in a rural district that voted for Trump, Republican Rep. Jaime Herrera Beutler says seniors’ anxieties over repeal of the Affordable Care Act are misplaced.
“Seniors are right to be concerned about the future of ACA, but not because of congressional Republicans’ plans,” spokeswoman Amy Pennington said in an email. “The law’s fundamental flaws, phony finances and broken promises will cause it to collapse on its own — Medicaid expansion, exchanges and all.”
At Merrill Gardens, residents are more politically engaged than in many parts of the country. They avidly follow the news through local newspapers, TV, the internet and radio.
The group that showed up for an open meeting in the complex’s private dining room ranged in age from early 70s to late-80s. They included retired education, business and health professionals. Loree Wagner, a center spokeswoman, said the organizers did not ask for political affiliation.
“I find this moment especially challenging,” said Dick Kirkendall, 88, a retired University of Washington history professor who specialized in the presidency of Harry S. Truman. “I have a hard time seeing what’s ahead, a harder time than I’ve ever had. I have a harder time knowing what my president is going to do.”
Everyone in the room said they had few complaints about their existing health insurance coverage through Medicare, Medicare supplements, private pensions and Veterans Affairs programs.
But they said they fear that proposed changes — including plans to privatize Medicare and revamp Medicaid and Social Security — will mean less care for their families and the poor.
“My opinion is not to touch Medicare or Medicaid,” said Terry Doucette, 76, a former admitting department manager for a local hospital. “I mean, people are dependent upon it and there needs to be a warning time and coming together in a real thoughtful way, making everything work together, especially for the least fortunate.”
Herrera Beutler said she supports plans to protect Medicare and Social Security for seniors in the future.
In addition to Wall, Kirkendall and Doucette, the group included John Ball, 73, a former developer, Sandra Wiatr, 80, a former school nurse in the Chicago public school system and Dr. Harold Ellner, 89, a retired urologist.
Overall, they sympathized with the frustrations of those who criticized the ACA, which created online health exchanges that expanded coverage to millions, but also saw sharp rises in costs and, in some cases, limited coverage choices.
“The Obama thing had been moving out of control, particularly for middle-class people whose insurance premiums have gone up and their deductibles are unbelievable,” Wall said. “They’re out of this world. I think they had to do something.”
But they also echoed the views of a recent Kaiser Family Foundation tracking poll that found that while one in five Americans support repeal alone, three-quarters either oppose repeal entirely or want to wait until details of a replacement plan are complete. (KHN is an editorially independent program of the foundation.)
The answer is not to scrap the plan that expanded insurance to 20 million people while offering no alternative, said Ball, who only obtained regular insurance when he qualified for Medicare eight years ago. He still lives with consequences of untreated injuries, including a broken clavicle that healed badly after a rugby injury years ago.
“I’m distressed at the proposal that we chuck out the baby with the bath water,” he said. “I’ve seen the backside of no insurance and living with something you hoped wouldn’t be considered a pre-existing condition. I have a pretty strong identification with those people who didn’t have insurance and were suddenly brought into the fold of Obamacare.”
In her work as a school nurse, Wiatr saw many students with asthma whose families couldn’t afford medication inhalers to control the potentially life-threatening disease. When she managed a family practice clinic, she saw people try to cut medical costs at the expense of health.
“There were people who didn’t do lab tests, who took only half of their medication because they couldn’t afford it,” she said. “I am very upset because I think our politicians don’t have a clue how difficult it is for people to receive medication and adequate health care.”
Ellner, the urologist, worked for a local Planned Parenthood clinic after he retired and flatly said he supports a universal, single-payer health system.
“Obamacare seems to have been a way station on the way to universal health care and now it’s not only being challenged, it’s being threatened,” he said.
The situation now calls for compromise and compassion from political leaders, said Doucette. “What I want to do is simply get the hard-headed guys from both parties to meet and really want to do this instead of wanting to win,” she said. “Now, we’ll see what Trump does. He has all these ideas and he thinks everyone else is on a lower level. I would like to see them work together.”
KHN’s coverage related to aging & improving care of older adults is supported by The John A. Hartford Foundation. This report is made available by Kaiser Health News under a Creative Commons License.
Republican governors who turned down billions in federal dollars from an expansion of Medicaid under President Barack Obama’s health care law now have their hands out in hopes the GOP-controlled Congress comes up with a new formula to provide insurance for low-income Americans.
The other GOP governors, such as Ohio Gov. John Kasich, who agreed to expand state-run services in exchange for federal help — more than a dozen out of the 31 states — are adamant that Congress maintain the financing that has allowed them to add millions of low-income people to the health insurance rolls.
With Congress starting to consider plans for annulling and reshaping Obama’s overhaul, Republican governors and lieutenant governors from 10 states met privately for more than two hours last week with GOP members of the Senate Finance Committee and raised concerns about how lawmakers will reshape Medicaid.
“They’re worried about how it all works out,” Finance panel chairman Orrin Hatch, R-Utah, said after the session in a Senate office building.
GOP senators and governors stressed the need for giving states more flexibility to shape their Medicaid programs. That’s a change that worries Democrats, who say some states would inevitably end up covering fewer people or offering skimpier benefits.
Arkansas Gov. Asa Hutchinson said governors could find savings by being allowed to impose “work incentives” for some beneficiaries.
Kasich suggested shifting people who earn just above the poverty level from Medicaid to the online exchanges that Obama’s law created for buying coverage.
“I think they understand this is not simple and I think they know they have to get it right,” Kasich said.
A chief worry by governors was whether states that accepted extra federal money to expand Medicaid to more people would lose that extended coverage.
Sen. John Cornyn, R-Texas, said afterward that “it ain’t going to happen,” though he did not detail how.
In a letter he carried to Capitol Hill, Kasich warned that repealing Obama’s law without an alternative in place could interrupt health care coverage for hundreds of thousands in Ohio and urged he “be granted the flexibility to retain the adult Medicaid coverage expansion.”
Ohio has added roughly 700,000 recipients to the program since the law took effect in 2013.
Unlike Kasich, 19 Republican governors — including Scott Walker of Wisconsin — defied the Affordable Care Act’s mandate that states open up Medicaid to more people.
It was a major expansion of the state-federal health insurance system whose primary purpose has grown in its 52 years from backstop medical assistance for the poor to the go-to program for closing gaps in private health insurance system.
In the three years since the Affordable Care Act went into effect, Medicaid enrollment has grown by about 18 million people, to roughly 75 million, according to the federal Centers for Medicare and Medicaid Services.
Walker, seeking to win over conservative voters for his failed presidential bid, notably turned down more than $500 million for his state.
But with Republicans, backed by President-elect Donald Trump, pursuing repeal of the law, Walker and other GOP governors now are asking specifically for the Medicaid money and fewer rules for spending it.
On average, the federal government’s contribution accounts for 56 percent of a state’s Medicaid budget, making the financing terms under the health care law much more generous.
Republicans have long sought block grants or lump-sum payments for health care. The money has helped them maintain their budgets, while the relative lack of heavy regulation has allowed governors freedom to experiment with social services policy.
“Now that Barack Obama is no longer going to be at the White House, it is going to be much more palatable for Republican governors to seek additional funding,” said Ron Pollack of Families USA, a leading advocate for Obama’s law.
All Democratic governors in office when the law took effect in 2013 agreed to the expansion. Even Republican governors in 11 states agreed to expand Medicaid, some with specific waivers that still allowed them to claim the federal reimbursement.
Now, Republican leaders in states aren’t just asking for money they turned down. They’re asking to change the formula to get back what they lost.
The federal Medicaid formula is based in part on how many enrollees a state had as of 2016. By last year, Michigan, for instance, had added 630,000 recipients since accepting the Medicaid expansion.
But Medicaid in Kansas grew at a far slower rate, given Gov. Sam Brownback’s opposition to the federal law. Now, he wants Congress to change the formula to benefit his state.
Leading Republicans have vowed that even if they repeal most of the Affordable Care Act early in 2017, a replacement will not hurt those currently receiving benefits.
Republicans will seek to ensure that “no one is worse off,” said House Speaker Paul Ryan, R-Wis., in an interview with a Wisconsin newspaper earlier this month. “The purpose here is to bring relief to people who are suffering from Obamacare so that they can get something better.”
But that may be difficult for one big reason — Republicans have also pledged to repeal the taxes that Democrats used to pay for their health law. Without that funding, Republicans will have far less money to spend on whatever they opt for as a replacement.
“It will be hard to have comparable coverage if they start with less money,” Gail Wilensky, a health economist who ran the Medicare and Medicaid programs under President George H.W. Bush, said in an interview.
“Repealing all the ACA’s taxes as part of repeal and delay only makes a true replacement harder,” wrote Loren Adler and Paul Ginsburg of the Brookings Institution in a white paper out this week. It “would make it much more difficult to achieve a sustainable replacement plan that provides meaningful coverage without increasing deficits.”
The health law’s subsidies to individuals buying insurance and the Medicaid expansion are funded by two big pots of money.
The first is a series of taxes, including levies on individuals with incomes greater than $200,000, health insurers, makers of medical devices, brand-name drugmakers, people who use tanning salons, and employer plans that are so generous they trigger the much-maligned “Cadillac Tax.” Some of those measures have not yet taken effect.
However, the Congressional Budget Office estimated in early 2016 that repealing those provisions would reduce taxes by an estimated $1 trillion over the decade from 2016-2025.
The other big pot of money that funds the benefits in the health law comes from reductions in federal spending for Medicare (and to a lesser extent, Medicaid). Those include trims in the scheduled payments to hospitals, insurance companies and other health care providers, as well as increased premiums for higher-income Medicare beneficiaries.
CBO estimated in 2015 that cancelling the cuts would boost federal spending by $879 billion from 2016 to 2025.
The GOP, in the partial repeal bill that passed in January and was vetoed by President Barack Obama, proposed to cancel the tax increases in the health law, as well as the health premium subsidies and Medicaid expansion. But it would have kept the Medicare and Medicaid payment reductions. Because the benefits that would be repealed cost more than the revenue being lost through the repeal of the taxes, the result would have been net savings to the federal government — to the tune of about $317.5 billion over 10 years, said CBO.
But those savings — even if Republicans could find a way to apply them to a new bill — would not be enough to fund the broad expansion of coverage offered under the ACA.
If Republicans follow that playbook again, their plans for replacement could be hampered because they will still lose access to tax revenues. That means they cannot fund equivalent benefits unless they find some other source of revenue.
Some analysts fear those dollars may come from still more cuts to Medicare and Medicaid.
“Medicare and Medicaid face fundamental threats, perhaps the most since they were established in the 1960s,” said Edwin Park of the liberal Center on Budget and Policy Priorities, in a webinar last week.
Republicans in the House, however, have identified one other potential source of funding. “Our plan caps the open-ended tax break on employer-based premiums,” said their proposal, called “A Better Way.”
House Republicans say that would be preferable to the Cadillac Tax in the ACA, which is scheduled to go into effect in 2020 and taxes only the most generous plans.
But health policy analysts say ending the employer tax break could be even more controversial.
Capping the amount of health benefits that workers can accept tax-free “would reduce incentives for employers to continue to offer coverage,” said Georgetown University’s Sabrina Corlette.
James Klein, president of the American Benefits Council, which represents large employers, said they would look on such a proposal as potentially more damaging to the future of employer-provided insurance than the Cadillac Tax, which his group has lobbied hard against.
“This is not a time one wants to disrupt the employer marketplace,” said Klein in an interview. “It seems perplexing to think that if the ACA is going to be repealed, either in large part or altogether, it would be succeeded by a proposal imposing a tax on people who get health coverage from their employer.”
Wilensky said that as an economist, getting rid of the tax exclusion for employer-provided health insurance would put her “and all the other economists in seventh heaven.” Economists have argued for years that having the tax code favor benefits over cash wages encourages overly generous insurance and overuse of health services.
But at the same time, she added, “I am painfully aware of how unpopular my most favored change would be.”
Republicans will have one other option if and when they try to replace the ACA’s benefits — not paying for them at all, thus adding to the federal deficit.
While that sounds unlikely for a party dedicated to fiscal responsibility, it wouldn’t be unprecedented. In 2003 the huge Medicare prescription drug law was passed by a Republican Congress — with no specified funding to pay for the benefits.
Republished under a creative commons license via Kaiser Health News.
Hillary Clinton has been involved in the nation’s health care debate for more than 20 years and, as her campaign likes to say, she has the scars to prove it.
The Democratic presidential candidate failed in her 1990s effort to steer her husband’s universal coverage program through Congress, as the complex plan collapsed for lack of political support. Since then, she has tacked sometimes to the right on health care, and sometimes to the left.
Clinton is campaigning as the candidate of continuity and would leave all major health care programs in place. She has a long list of tweaks and adjustments that reflect her familiarity with policy and would expand the government’s role in health care.
Donald Trump calls President Barack Obama’s health care law “a disaster,” and vows to repeal it. He’d provide a new tax deduction for health insurance premiums, but also limit federal support for Medicaid, which covers low-income people. An independent analysis recently estimated his seven-point plan would cause 20 million people to lose coverage.
Trump’s ideas on health care have shifted over time, and his latest plan hews to basic GOP talking points. He’s expressed a belief that an economically advanced country like the United States can’t have people “dying in the street” for lack of medical care.
Here is a summary of their proposals:
The government’s premier health insurance program covers about 57 million people, including 48 million seniors and 9 million disabled people under age 65. It enjoys strong support from voters across the political spectrum, although its long-term financial outlook is uncertain.
CLINTON: She would authorize Medicare to negotiate drug prices with pharmaceutical companies, and she supports allowing patients to import lower-cost prescriptions from abroad. Medicare beneficiaries represent a big share of the market for medications.
Clinton would also allow people ages 55-64 to buy into Medicare, although her campaign has not released much detail on how that would work.
TRUMP: He promises not to cut Medicare, and has suggested that other Republicans like House Speaker Paul Ryan made a political mistake by calling for major changes. But it remains unclear how Trump’s proposed repeal of “Obamacare” would affect its improvements to Medicare benefits, including closing the prescription drug coverage gap known as the “doughnut hole.”
Earlier, Trump spoke approvingly of giving Medicare legal authority to negotiate prescription drug prices, but that idea currently is not mentioned in his health care plan. Instead, he also supports allowing drug importation.
The federal-state program for low-income individuals covers more than 70 million people, from pregnant women and children to elderly nursing home residents. Under Obama’s health care law, states can expand the program to include more low-income adults. Medicaid has sometimes carried a social stigma, but polls show the program has a solid base of public support.
CLINTON: She’d work to expand Medicaid in the 19 states that have yet to take advantage of the health law. She’s proposing three years of full federal funding for those states, the same deal given to states that embraced the law right away.
TRUMP: In 2015 Trump told an interviewer: “I’m not going to cut Social Security like every other Republican. And I’m not going to cut Medicare or Medicaid. Every other Republican’s going to cut.”
But his campaign plan would convert Medicaid into a block grant, ending the open-ended federal entitlement and capping funding from Washington. Over time, such an approach is likely to result in a big cut.
About 177 million people under age 65 have private health insurance, with nearly 9 in 10 getting their coverage through an employer. Rising out-of-pocket costs such as insurance deductibles and copayments are a sore point with consumers.
CLINTON: She has proposed a new tax credit of up to $5,000 per family, or $2,500 for an individual, for households that face “excessive” out-of-pocket costs. The credit would be refundable, meaning that people who don’t owe income tax could still get money back. An independent analysis of her plan defined “excessive” costs as exceeding 5 percent of household income.
Clinton would also require insurers to cover three sick visits to the doctor each year without patients needing first to meet their plan’s deductible, the annual amount patients pay before their insurance kicks in.
TRUMP: He has no similar proposals on out-of-pocket expenses but has called for requiring hospitals, clinics and doctors to disclose prices so patients can shop around to reduce costs. And he would expand the use of tax-sheltered health savings accounts, used to pay for medical expenses not covered by insurance.
More than half of U.S. adults take prescription drugs, and according to a recent Kaiser Family Foundation poll most of those patients report no major problems affording their own medications.
But consumers have been alarmed by the introduction of breakthrough drugs costing tens of thousands of dollars a year, along with a spate of seemingly random price hikes for older medications. More than 3 out of 4 say the cost of prescription drugs is unreasonable. A majority favors government action to curb costs.
CLINTON: She has several proposals, including a new government board with the power to penalize drug companies for “unjustified, outlier price increases,” a monthly limit of $250 on patients’ copayments for prescription drugs, lowering the period of protection from generic competition for biologic drugs from 12 years to 7 years, and requiring drug companies to provide rebates for medications used by low-income Medicare recipients.
Those ideas are on top of Medicare negotiations and allowing patients to import lower-cost prescription drugs from abroad.
TRUMP: In addition to backing drug importation, he also has called on Congress to remove barriers to competition from lower-price, equally effective medications.
The 2010 Affordable Care Act expanded coverage for the uninsured and made carrying health insurance a legal obligation for most people. It offers subsidized private insurance for people who don’t have access to a job-based plan, along with a state option to expand Medicaid.
About 11 million people are covered through the law’s private insurance markets, while the Medicaid expansion has added at least 9 million to that program. It’s unclear if all those people were previously uninsured, but experts say the law deserves most of the credit for 21 million gaining coverage since its passage. Americans, however, remain deeply divided over “Obamacare.”
CLINTON: She wants to strengthen Obama’s signature law. Clinton would resolve a “family glitch” that denies health insurance subsidies to some dependents, sweeten subsidies for people buying coverage on the health law’s markets, and offer a new government-sponsored insurance plan to compete with private companies.
Her proposals would expand coverage to about 9 million more uninsured people, according to a recent study by the Commonwealth Fund and the RAND Corporation.
But Clinton would repeal the law’s tax on high-cost insurance, known as the “Cadillac Tax.” Many economists are critical, saying repeal of the tax would eliminate a brake on costs.
TRUMP: He would completely repeal the 2010 law and start over again. Trump has proposed a tax deduction for health insurance premiums, and also allowing insurers to sell policies across state lines, a longstanding GOP idea.
Critics say a deduction, usually claimed after the end of the tax year, wouldn’t do much to help lower-income people squeezed to pay premiums.
And the idea of selling across state lines has been opposed in the past by state insurance commissioners and attorneys general, who warned that it would undercut consumer protections. The insurance industry is divided, with smaller companies fearing it would favor major insurers.
Florida health officials are investigating four mysterious cases of Zika infection that do not appear to be related to travel.
The four cases were detected in the Miami-Dade and Broward counties.
Investigating whether Zika is being carried by mosquitoes locally, scientists plan to survey houses and people within a 150-yard radius of the cases, which is the flying radius of the insect.
U.S. experts also were baffled last week by a Zika case in Utah in which a care-giver caught Zika after tending to a dying elderly man with the virus.
The cases have raised the possibility that mosquitoes in the U.S. have begun to spread the virus.
Congress left for a seven-week vacation without giving the Obama administration any of the $1.9 billion it’s seeking to battle the Zika virus. But the Centers for Disease Control and Prevention will begin making awards totaling nearly $60 million to states, cities, and territories to support efforts to protect Americans from Zika virus disease and adverse health outcomes that can result from Zika infection, including the serious birth defect microcephaly, according to a statement issued by the agency,
“Local, state and territorial health departments are on the front lines in the fight against Zika,” said CDC director Tom Frieden in a prepared statement.“These CDC funds will strengthen state and territorial capacity to respond to Zika virus, an increasingly concerning public health threat for pregnant women and babies. We hope Congress will provide the additional resources we need to fully support the Zika response.”
Due to congressional inaction, the CDC has to borrow the money to combat Zika from funds intended for flu, hurricane relief and other emergencies. The CDC has warned that it may have to delay testing for a vaccine if Congress continues to deny adequate funding to fight the disease.
The CDC has awarded $812,000 to Wisconsin to fight the Zika virus. Wisconsin Republicans, led by Gov. Scott Walker, apparently will allow the state to take the money, even though they’ve steadfastly refused to accept federal funds to expand Medicaid for poor families in the state. They oppose federal programs on philosophical grounds, saying such efforts represent “big government.”
Democrats have said that Walker’s refusal of federal Medicaid expansion has forced state taxpayers more to cover fewer people in the BadgerCare Plus health plan. If Walker had accepted the money, 87,000 more adults a month would have been served under the state’s health plan.
Walker’s rejection of Medicaid expansion, combined with his massive tax breaks to the very wealthy, has contributed to a $2.2 billion budget deficit.
According to estimates by the non-partisan Legislative Fiscal Bureau, the state could have saved more than $500 million over three and a half years by accepting federal Medicaid expansion. Wisconsin will lose about $1.8 billion in 2022 for rejecting the federal funds.
Meanwhile, Wisconsin taxpayers are still pouring money into the federal program, but it’s going to other states.
How Zika can spread
- Bites from mosquitoes that carry the virus
- Maternal transmission from mother to baby in the womb
- Unprotected vaginal, oral or anal sexual intercourse – although rare, the virus can persist in semen
- Zika virus has been found in other bodily fluids, including saliva and urine, but it is unknown whether it can spread through these routes
- Blood transfusion — very likely but not confirmed
New reform introduced by U.S. Sen. Tammy Baldwin would ensure that states that opt to expand eligibility for Medicaid can access the same federal funds as states that expanded the health care program before 2014, under the Affordable Care Act.
“I support this legislation because it is my hope it will point our state in the right direction,” Baldwin, a Democrat from Wisconsin, said in a news release.
The Affordable Care Act has provided federal financial support for states to expand Medicaid programs to provide health care coverage to individuals up to 138 percent of the federal poverty level.
The federal government, under the ACA, pays the cost of expansion for the first three years for the states that enrolled in 2014 and phases down to a 90 percent match rate for the sixth and subsequent years.
In a lawsuit over the expansion program, the U.S. Supreme Court ruled that states could opt-in or opt-in and 19 states — mostly those with Republican governors — opted out.
Republican Gov. Scott Walker has refused to expand Medicaid eligibility in Wisconsin and instead he shrunk the BadgerCare program.
Baldwin said the governor has put “politics ahead of progress and taken our state in the wrong direction,” kicked Wisconsinites off their coverage and created a coverage gap.
She said she hoped the States Achieve Medicaid Expansion Act of 2016 would provide the incentive for states to opt-in and expand Medicaid programs, as well as assist the seven states that expanded after 2014.
“In the states that haven’t expanded Medicaid, many adults living near the poverty level are now unable to afford health care,” said Jon Peacock, research director of the Wisconsin Council on Children and Families.
He said existing law makes expanding Medicaid a good deal but the SAME Act would create an even better deal. “It would be fairer to give all the states the same incentive to close a gap in affordable coverage for adults near the poverty level,” Peacock said.
Studies show states that expanded Medicaid eligibility saw direct and indirect benefits in job growth, earnings growth, increased gross state product, increased state and local revenues and reduced uncompensated care and hospital costs.
In an analysis released last year, the Kaiser Family Foundation estimated the economic impact of expanding eligibility in Wisconsin would be $1.3 billion and the creation of 10,500 jobs.
“Congress should pass this bill. The president should sign. And Gov. Walker and the Legislature should … expand BadgerCare to cover 83,000 more people and save state taxpayers more than a billion dollars over the next 10 years,” said Mike Bare of Community Advocates Public Policy Institute.
Baldwin introduced the bill along with Democrats Mark Warner of Virginia, Debbie Stabenow and Gary Peters of Michigan, Claire McCaskill of Missouri, Jon Tester of Montana, Tim Kaine of Virginia and independent Angus King of Maine.