Monday, January 27, 2020

Comprehensive Enrollment and Cost Estimates for the Biden Health Plan, the Buttigieg Health Plan, the Warren Health Plan, and the Sanders Health Plan

In this hyper-partisan environment, I can't think of an organization that better fits the definition of bipartisan than the Committee for a Responsible Federal Budget.

Their mission is to keep the federal budget process honest and responsible. 

Its current board members include a veritable who's who of Washington, DC adults; Mitch Daniels, Leon Panetta, Tim Penny, Erskine Bowles, Kent Conrad, Vic Fazio, and Bill Gradison.

The Committee has just released a comprehensive evaluation of the leading Democratic candidates' health care plans.

It is required reading for any serious health policy wonk. Disbelieve their work at your own peril.

Here are their two summary charts on coverage and budget impact:


This first chart summarizes the net fiscal impact of each candidates plan on the deficit between 2021 and 2030:
"Under our central estimate, we find that Vice President Biden's health plan would increase the deficits by $800 billion over a decade, Mayor Buttigieg's plan would reduce deficits by $450 billion, Senator Sander's plan would increase deficits by $13.4 trillion, and Senator Warren's plan would increase deficits by $6.1 trillion."
The primary reason Buttigieg's plan has a lower cost than the similar Biden plan is that Buttigieg is more aggressive in controlling drug and provider prices.

The Committee has also qualified its estimates:
"Our estimates are rough and rounded, based on our best understanding of how campaign-level detail translates into specific policies, and subject to change as more details are made available."
That is a reasonable qualifier since the candidates' proposals are typically a few pages long in outline form––not the sort of legislative proposals that would follow later and could be scored by the CBO.

The second chart estimates the impact on coverage each plan would have:


From the report:
"Over the next decade, an estimated 30 to 35 million people will lack comprehensive health insurance at some point in a given year, depending on the year, estimator, and definition of coverage. All four plans we analyzed would reduce the number of uninsured individuals substantially. We estimate Biden would reduce the number of uninsured by 15 to 20 million, mainly by improving the affordability of health coverage and auto-enrolling low-income Americans. We estimate Buttigieg would reduce the number of uninsured by 20 to 30 million by improving affordability and implementing auto-enrollment as well as retroactively enrolling and charging premiums to those who lack coverage – essentially establishing a stronger version of an individual mandate. Finally, both Warren and Sanders would reduce the number of uninsured by 30 to 35 million by offering universal Medicare for All coverage to virtually every U.S. resident."

Taking this report at face value, Buttigieg would appear to offer voters the best bang for their buck––Buttigieg covers almost as many people as Sanders and Warren and does so as the only candidate that pays for his program.

However, Buttigieg's rosier outlook depends upon his taking substantially more money from the drug industry and health care providers than does the similar Biden plan and Buttigieg also brings back the very unpopular individual mandate––all very politically problematic.

Monday, January 13, 2020

Republican Health Care Reform: The Congressional Republicans' Irrational Opposition to Medicaid

Congressional Republicans have consistently, if not unanimously, opposed Obamacare's expansion of Medicaid.

Their opposition is irrational.

It is also unpopular with voters. In dark red states like Nebraska, Idaho and Utah voters recently went over the heads of their Republican legislators and governors by approving referendums to expand the program. And, Kansas is about to become the 37th state to expand Medicaid under Obamacare after a bipartisan agreement between the Democratic governor and Republican leaders in the legislature.

While Obamacare's individual health insurance reforms and subsidies have been a disaster for the middle class (See: Obamacare is "Stable" at an Incredibly Unstable Place), the Medicaid expansion in the states that have approved it has covered millions of people that would never have been covered otherwise––at a cost that could never have been less.

Republican opposition has centered around a number of arguments. Let's take a look at each of them.

Wednesday, January 8, 2020

Biden, Bloomberg, and Buttigieg Have the Health Plans That Can Become Law and Will Work

In an earlier post, I pointed out that there is no better chance of passing a Medicare for all health care plan through Congress in the coming years than there was in 1977, or 1993, or 2009.

Then Elizabeth Warren showed us just how politically unrealistic single-payer health care is when she released her funding plan and then quickly backtracked to the public option approach in the face of rapidly declining polls. See my post: Elizabeth Warren Backs Into the Public Option and Effectively Takes Medicare for All Off the Table for Democrats in 2021

In a separate post, I pointed out that single-payer advocates, like Sanders and Warren, have yet to answer the biggest financial questions surrounding putting the entire country on a single government reimbursement system: How will their paying providers Medicare rates for everything not bankrupt hospitals and doctors? And, if they don't pay providers these lower Medicare rates, how will their proposals save us any money?

In another post, I argued that the original Biden plan had the best chance of passage through the next Congress and contained all of the essential ingredients to fix what has been wrong with Obamacare for the first ten years of its life––in particular fixing the horrible impact it has had on middle-class consumers who buy their health insurance in the individual market.

Subsequently, Pete Buttigieg and Mike Bloomberg adopted proposals very similar to Biden's.

In another post I argued that with Trump and the Republicans not even having a plan, and based upon their policy efforts to date that would've made the individual market a lot worse, at least so far they aren't even in the running for who could do the best job of fixing the system.

So, to me, the conclusion is obvious:
  • Biden, Buttigieg, and Bloomberg have plans that could easily pass a Democratic controlled Congress.
  • Their plans would make the individual health insurance market workable for everyone in that market.
  • Their plans would preserve the Medicaid expansion that is working to provide health insurance to people that under no circumstances could afford coverage in any other system.
  • Their plans would continue the unqualified coverage of those with pre-existing conditions.
  • Their plans would leave intact the employer-based system that consumers still largely support.
  • Their plans would not create a financial upheaval among health care providers that a single-payer plan would.
I can't say that about any other candidate––Republican or Democrat.

That is not to say their proposals are perfect.

Their biggest problem being how they would pay for it.

For example, Biden and Buttigieg would use the repeal of many of the Republican tax cuts to help pay for their expansion of health care subsidies rather than use any repeal to pay down the federal debt and deficits that the Republican tax cuts created when they were passed––effectively adding much of the cost of their proposals to the national debt. Bloomberg has yet to detail how he would pay for his plan.

And, make no mistake, the Biden outline is a health insurance reform plan--it is not a plan to overhaul a health care system whose costs continue to expand at unaffordable levels.

But at this point one thing is clear to me, only Biden, Bloomberg and Buttigieg have plans that have a realistic chance of becoming law––and fixing the health insurance system.

Thursday, December 19, 2019

Health Care Special Interests Four Hundred Billion - Consumers Zero

That's the Congressional health care score card for December.

As the year winds down and must pass year-end spending bills are completed––and with that any chance of attaching and approving health care legislation––the special interests have won big and consumers have lost big.

Employers, unions, and insurance companies won big with the repeal of the "Cadillac" tax on high cost benefit plans at a cost of $200 billion over ten years as well as the repeal of the health insurance tax (HIT), and the 2.3% medical device tax sales tax.

The total cost for repealing just these things will add about $400 billion to the deficit over a decade and are part of a mammoth $1.4 trillion spending bill larded up for lots of different interests.

Wednesday, December 18, 2019

Buttigieg and Biden Spend What They Would Gain Repealing the Republican Tax Cuts on Health Care

Shouldn't any gain from repealing the Republican tax cuts on the wealthiest go toward fixing the debt and deficit problems these tax cuts have contributed to?


Democratic presidential candidates Joe Biden and Pete Buttigieg both rely on repealing some of the Trump tax cuts––particularly those for the "rich"––to pay for their very similar and incremental health care plans that rely upon making a government-run public option available to consumers.

On one level that notion can be attractive to Democratic voters turned off by the 2017 Republican tax cuts.

But when those tax cuts were passed, the Congressional Budget Office (CBO) estimated those cuts would add $1.6 trillion over ten years to the deficit. The Democrats were apoplectic over the Republican irresponsibility of it all.

Wednesday, December 11, 2019

Greed Outranks Compromise in Congressional Attempts to Fix Surprise Medical Bills

There are few things in our health care system that are more unfair than surprise medical bills. Consumers think they have good coverage and are getting treatment in their health plan network only to get a huge unexpected bill in the mail because it turned out that something like the anesthesiologist at their recent surgery wasn't covered.

How were they to know that? As you're sitting on the gurney about to be rolled into surgery do you need to do a provider roll call asking each to confirm their network status?

The worst of these examples often has to be with air ambulances sending patients bills for tens of thousands of dollars they had no reason to expect. As the patient lays there with burns over 60% of their body and they need to be transferred to the regional burn center, are they supposed to say, "Before you put me on the helicopter, what is this going to cost?

Now, every politician I know of says that all of this needs to end.

But, they are yet to end it.

Monday, December 9, 2019

The Trump/Republican 2020 Health Care Plan

The Republicans don't yet have a health care plan less than a year before the 2020 elections.

But based upon their 2017 Obamacare repeal and replace efforts, as well as a major document recently issued by the House Republican Study Committee, what might a Republican plan look like?

Monday, December 2, 2019

Elizabeth Warren Backs Into the Public Option and Effectively Takes Medicare for All Off the Table for Democrats in 2021

Medicare for all is dead because Democratic voters aren't buying it.


Fixing Obamacare and adding a public option is the health care policy territory first staked out by Democratic Presidential candidate Joe Biden.

Writing about Biden's plan recently on this blog, I said:
IF the Democrats capture the White House, keep the House, and take over the Senate, no matter who they elect as President, this Biden health care outline, not Medicare for all, will likely be the plan Democrats embrace in 2021.
Not even I thought Elizabeth Warren would act so quickly to move off her only days-old detailed Medicare for all plan and onto about the same place all of the leading Democratic candidates, save Bernie Sanders, sit on health care––just fixing Obamacare and adding a public option.

Tuesday, October 29, 2019

Medicare for All––the Bernie Sanders and Elizabeth Warren Health Care Plans

The Question That Single-Payer Medicare for All Advocates Need to Answer


You are probably thinking that question is, How are you going to pay for it?

Ultimately, yes.

But, I will suggest there is another critically important issue that is part of the overall question about how it will be paid for––What will your plan do to our existing health care system?

Medicare and Medicaid cost less than commercial insurance because Medicare and Medicaid pay providers––doctors, hospitals, and other health care providers–– a lot less for their services.

Advocates argue their single-payer Medicare for all health care system will overall cost us all a lot less. They are right that their systems can be a lot less expensive by expanding Medicare to everyone––primarily because government payment rates are so much smaller.

But here's the hitch––paying Medicare rates on behalf of all patients would literally bankrupt the system we have.

Wednesday, October 23, 2019

The Public Option's Silver Lining?

Joe Biden's Health Insurance Plan Would Fix the Individual Health Insurance System and Have the Potential to Politically Stabilize the Entire Private Health Insurance Market for Decades to Come

Biden's Public Option


In a prior post, I argued that the Biden health plan directly takes on the most problematic parts of Obamacare by making individual market coverage affordable––and would therefore make the individual insurance system much lower in cost and therefore financially sustainable.

A lower cost individual market would also make the entire private insurance market more politically sustainable––if people find their coverage affordable why move to a complete government takeover such as Medicare for all?

As part of his plan, Biden also calls for a "public option."

Monday, October 21, 2019

Joe Biden's Health Insurance Plan Would Fix the Individual Health Insurance System

IF the Democrats capture the White House, keep the House and take over the Senate, no matter who they elect as President, this Biden health care outline, not Medicare for all, will likely be the plan Democrats embrace in 2021


The Biden health care proposal directly takes on the big things that haven't worked in Obamacare.

Wednesday, October 16, 2019

Obamacare is "Stable" at an Incredibly Unstable Place

The Democrats Want to Move Beyond Obamacare Because We Have No Other Choice

 

Before I start talking about the presidential candidates' health care plans, let's review just exactly where we are with the Affordable Care Act (Obamacare).

Monday, October 14, 2019

There is Now No More Support for a Medicare For All Single-Payer Health Care Than There Was in 1977, or 1993, or 2009

Buy HMO Stocks––They're a Bargain

The more things change the more they stay the same.

With many of the Democratic presidential candidates' flirtation with Medicare for all, the topic is once again front and center going into the 2020 presidential campaign.

Just like it was when Jimmy Carter ran on a Medicare for all platform in 1976––and it turned out there weren't the votes for it in 1977 even though Carter had a filibuster-proof 61 Democrats in the Senate and a whopping 292 Democratic House seats. In fact, Carter failed to move any significant health care legislation.

In 1993, the Clintons didn't even try to move a single-payer plan even though the Democrats controlled 57 Senate seats and 258 House seats because only about half of the House Democrats favored a single-payer system.

The same for 2009 when both Hillary Clinton and Barack Obama ran on health care platforms during the primaries that looked a lot like the eventual Obamacare because again only about half of the House Democratic caucus favored a single-payer program.

Now in 2019 we are in the very same place we were in 1977, 1993, and 2009––only about half (118 as of September 6th) of the House Democratic caucus now supports the Medicare for all proposal introduced by Progressive Caucus Chair Pramila Jayapal (D-WA).

Wednesday, January 16, 2019

Is the Drug Industry an Existential Threat to the Private Health Insurance Business?

At a time when many Democrats are calling for a single-payer health insurance system, are the drug companies inadvertently driving the system on a course to that end?

Consider this.

Thursday, November 8, 2018

What Neither the Republicans Nor the Democrats Understand About Obamacare

The 2018 Elections Were Not About Obamacare--They Were About Health Insurance Security 

 

The 2018 midterm elections weren't a tsunami for Democrats--more like a blue wave hitting a red wall.  

 

Democrats are claiming the election vindicated Obamacare because they were successful in gaining control of the House of Representatives by criticizing losing Republicans for their votes to repeal the Affordable Care Act--including its key consumer protections.

 

My sense is that both Democrats and Republicans have missed the critical point.

Both sides don't understand that this was not about Obamacare. It was about health insurance security.

Friday, May 11, 2018

The Simple, Obvious, Time Tested Way to Reduce Drug Costs

I give the President great credit for shining his spotlight on the ridiculous place the U.S. finds itself over drug prices. They are way too high, the private market has proven incapable of dealing with it––PBMs have only made the drug market more opaque, and the biggest drug purchaser in the world, the U.S. government, has been politically unwilling to deal with it.

All while other industrialized countries have nowhere near the problem.

What is even more frustrating is to see an easy solution that has worked for years in these other industrialized countries that, rather than being a single-payer government-run solution, is as American-style free market as it could be.

Thursday, March 8, 2018

The CIGNA - Express Scripts Merger––So Much for Price Transparency and Competition

CIGNA just announced that it will buy pharmacy benefit manager (PBM) Express Scripts for $67 billion. In December, CVS said it would buy Aetna for $69 billion.

Already, UnitedHealth, through its Optum data technology and OptumRx pharmacy benefit manager subsidiaries, has detailed health care utilization information on over 115 million consumers, four out of five hospitals, 67,000 pharmacies, 100,000 physician practices, 300 health plans, and government agencies in 34 states and D.C.

Remember the good old days when we complained about the health insurance company oligopoly with just a few players controlling most of the market share in any given market?

We appear to be quickly on the way to a new and different kind of oligopoly controlling an even wider swath of the market with these new health care system aggregators being created.

Wednesday, January 31, 2018

Bezos, Buffett, Diamond, the Latest Newbies on the Health Care Block

I found it incredible that health care stocks tanked on Tuesday in response to an announcement from the Amazon, Berkshire Hathaway, and JPMorgan Chase CEOs that they were, as employer payers, going to become game changers in the health care market.

I have seen this movie before. Dozens of times over the last twenty-five years. The first time was when the leading employers in the Minneapolis-St. Paul market began the same effort in the early 1990s. That, and any other such initiative I have seen over the decades, went essentially nowhere.

But, this week, reporters were agog with the notion that these titans of business were going to wade in and change the health care world. After all, together these companies had a combined population of a million-people covered under their health benefit programs.

That is about as many people as Rhode Island and Delaware Blue Cross combined cover. So, I am not quite sure how these CEOs will bring a game changing critical mass to any provider bargaining table.

Wednesday, November 15, 2017

GOP's Obamacare Tax Scheme Will Create an Insurance Nightmare for the Middle Class

Senate Republicans just announced that the repeal of the individual mandate (in the form of reducing the penalty tax to zero) will be in the Senate Finance Committee's version of tax reform.

The individual mandate has never been successful toward the objective of attracting people to the program. There are much better ways to do that.

But killing the mandate while simultaneously opening up the market to cheaper stripped down alternatives would combine to create unintended consequences the Republicans haven't appeared to comprehend.
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