One Year Later:
What if Congress Had Repealed the Affordable Care Act?

For too long, too many hard working Americans paid the price for policies that handed free rein to insurance companies with few protections for patients or providers. Nearly two years ago, President Obama signed health reform – the Affordable Care Act – into law. The law gives hard working families the security they deserve, makes insurance more affordable, ends the worst insurance company abuses and makes preventive care free for millions of Americans and everyone enrolled in Medicare.

One year ago yesterday, on January 19, 2011, the House of Representatives voted to repeal the law, and take us back to the days when insurance companies had the power to decide what care residents of the United States could receive – allowing them to once again deny coverage to children with pre-existing conditions, cancel coverage when people get sick, and place lifetime or low annual dollar limits on the amount of care people can get, even if they need it. What’s more, without the law, insurance companies could overcharge for insurance just to boost their profits.

Here are some of the statistics about what would have happened if Congressional Republicans had succeeded in repealing the Affordable Care Act:

• 2.5 Million More Uninsured Young Adults. – 2.5 million young adults have been able to stay on their parent’s health insurance thanks to health reform.

• 2.65 Million Seniors Pay $1.5 Billion More for Prescription Drugs. The Affordable Care Act provides a 50 percent discount on covered brand name prescription drugs for seniors and people with disabilities who hit the donut hole. This discount has saved 2.65 million seniors more than $1.5 billion through October 2011.

• 24.2 Million Seniors Pay More for Preventive Care. The Affordable Care Act makes preventive care like mammograms and colonoscopies free for everyone with Medicare. Through November 2011, 24.2 million seniors have received free preventive services.

• 45,000 Americans With Pre-Existing Conditions Remain Uninsured. As of November 2011, the Affordable Care Act’s Pre-Existing Condition Insurance Plan has provided insurance to 45,000 Americans who have been locked out of the insurance marketplace because of a pre-existing condition.

• Insurance Companies Free to Cap Care for 102 Million Americans. Under the Affordable Care Act, insurance companies cannot drop your care when you get sick, or place a lifetime limit on your care. Today, the 102 million Americans whose health plan included lifetime dollar limits have seen their coverage expanded.

• Insurance Companies Free to Drop Coverage for up to 15 Million Americans. The Affordable Care Act finally put an end to one of the most abusive practices of the insurance industry: retroactively canceling coverage for a sick patient based on an unintentional mistake in their paperwork. Before the health care law was signed, most of the 15 million people purchasing coverage in the individual market were vulnerable to this policy. Rescission often leaves people suddenly responsible for past expenses and with no coverage to pay for needed care.

• 41 Million Pay More for Preventive Care. Approximately 41 million Americans are now enrolled in health insurance plans that must provide preventive services without cost sharing thanks to health reform.

• More than 6,000 Businesses Pay Nearly $5 Billion More to Cover Early Retirees. The Affordable Care Act has provided $5 billion to a reinsurance program for businesses and other health insurance plan sponsors to help cover the cost of caring for retirees who aren’t old enough to join Medicare. These funds help lower the cost of coverage to retirees, workers, their families, and their employers.

• Less Transparency of Insurance Company Rate Increases on 34.8 Million Americans. In every State and for the first time ever, insurance companies are now required to publicly justify their actions if they want to raise rates by 10 percent or more and publicly post this information. 28 states and the District of Columbia received $109 million in new resources to help fight unreasonable premium increases and protect consumers – which would not have been available with a repeal of the law.

• Less Accountability for 75 Million Americans with the Repeal of the 80-20 Rule. Under health reform, insurance companies must spend at least 80 percent of your premium dollar on medical care rather than advertising, overhead and bonuses for executives. If they don’t, insurance companies will have to provide consumers a rebate for those excessive profits.

• No New State-Based Private Health Insurance Marketplaces. In the last year, 29 States received over $700 million in grants to establish Affordable Insurance Exchanges, which will give American families and small businesses the same health insurance options as Members of Congress through competitive health care marketplaces.

• $750 Million Less to Prevent Disease. The Affordable Care Act’s Prevention and Public Health Fund provided States, communities, and health care providers $750 million to prevent disease keep people healthy.

• $350 Million Less to Fight Fraud. The Affordable Care Act included $350 million in new resources to fight fraud and, in FY 2010 alone, 931 individuals were charged with health care fraud. The law also created new tools to help detect and prevent fraud before it starts, including state of the art predictive modeling and data-mining techniques like credit card companies use.

• Over $100 Billion in Higher Deficits. The Affordable Care Act will reduce the deficit by $100 billion over ten years and reforms being implemented right now, like the Partnership for Patients, are saving even more – up to $50 billion over the next 10 years in Medicare savings.

As they stump across South Carolina, top-tier GOP candidates are fond of boasting how quickly they, as president, would do away with the Affordable Care Act. Never mind that the law’s most important provisions are hugely popular with the majority of Americans.

In response, Boston Globe columnist John McDonough penned a nuts-and-bolts piece, in which he urges voters and the press to ask GOP candidates whether they would repeal specifically those popular provisions. In fact, he prepared a list of 50 questions for everybody to put to anti-ACA politicians. A sampling:

If you are elected President, are you committed to repealing the section of the Affordable Care Act (section # in parenthesis) that:

1. Prohibits health insurance companies from imposing lifetime or annual benefit caps on health insurance policies and consumers? (1001)

2. Prohibits health insurance companies from rescinding an individual’s insurance coverage because of an error or misstatement on a coverage application not connected to fraud? (1001)

3. Requires health insurances to cover proven clinical preventive services without co-pays or deductibles? (1001)

4. Permits parents to keep their adult children up to age 26 on their health insurance policies? (1001)

5. Requires health insurers to provide enrollees with a clear summary of benefits and coverage not to exceed four pages? (1001)

6. Requires health insurers to spend no more than 15 or 20 cents of every premium dollar on profit, marketing, administrative costs as opposed to medical expenses? (1001)

7. Sets national standards for administrative simplification to reduce the paperwork burden on patients, providers and insurers? (1104)

8. Prohibits health insurers from refusing to cover individuals based on pre-existing medical conditions? (1201)

9. Requires the establishment of health insurance exchanges in each state to provide an easy, online way for consumers to compare and buy health insurance? (1311)

10. Provides tax credits to income eligible individuals to be able to afford to purchase health insurance? (1401)

Those are the first 10. McDonough has 40 more.

And he’s right. We’re letting the anti-reform crowd get away with calling the whole law bad, while most Americans agree that most of its content is good. Let’s start hammering the Obamacare detractors on what exactly they would like to repeal and see if they really support shutting the terminally ill and others out of our healthcare system.

Charleston’s Post & Courier appears to have embraced the sketchy practice of running columns by industry-sponsored columnists, who inevitably blur the crucial line between independent commentator and shill. In this case, former P&C columnist Ken Burger has returned to the paper, but now with backing from Roper Medical Center. Nothing personal against Burger, but red flags are flying.

Gary Schwitzer at Health News Review asks some of the right questions, including:

• How will the column explore “the major issues facing us nationally”?
• Will it be only Roper’s perspective?
• Will it truly be a national perspective?
• Who decides which stories are “untold” and should be addressed in the column? And how they will be addressed?
• Will, for example, untold stories of overdiagnosis and overtreatment be told in this health care provider-sponsored column?
• While the health care provider boasts on its website, “We were the first in the state to bring you CyberKnife and the first in the Lowcountry to offer the da Vinci robot,” will the column explore some of the growing questions about some of the non-evidence-based proliferation of such technologies? (An example of Cyberknife questions here; just the latest on many robotic surgery questions here.)
• While the health care provider boasts on its website about $125 screening for cardiac calcium scoring (among other screenings), will the column explore evidence-based recommendations such as that by the US Preventive Services Task Force that recommends against such screening in low-risk people?

Here’s hoping that some P&C shotcaller rethinks this decision…

Gov. Nikki Haley’s email influence flap sheds light on the struggle of states that don’t want to implement reform themselves but don’t want federal intervention.

By Doug Trapp

Jan. 9, 2012

A South Carolina state commission concluded in late 2011 that neither a state nor a federal health insurance exchange is feasible, mirroring the position pushed by South Carolina Gov. Nikki Haley before she created the commission. The panel instead called for a private insurance marketplace to be run by health plans and modeled on travel search engines.

State leaders around the nation are vigorously debating whether to implement state health insurance exchanges as outlined in the national health system reform law, or to allow a federal health exchange. Both would provide a marketplace for new individual and small group health insurance and coordinate Medicaid enrollment. The health reform law requires either a state or federal exchange to be implemented, although states later can take over a federal exchange.

But some state leaders are concerned that cooperating with the federal government could come with high costs. So far, 13 states have enacted legislation to create exchanges, according to the National Conference of State Legislatures.

Some states have sent mixed signals on the national reform law. A majority of states have accepted at least one federal grant to help pay for exploring the feasibility of a health insurance exchange, but several of these states at the same time are suing the federal government to block implementation of the law.

South Carolina is one of these states. In late 2010, the state’s Dept. of Insurance accepted a $1 million federal exchange planning grant — requested by then-Gov. Mark Sanford’s administration in August 2010 — while the state pursued a joint lawsuit to block the health reform law.

Haley, a first-term Republican governor, pushed to avoid implementing either a state or a federal health exchange. This would limit the appearance that her administration was allowing the Democratic-supported health reform law to move forward in her state, according to emails provided in December 2011 by the South Carolina Dept. of Health and Human Services to The Post and Courier of Charleston.

Haley issued an executive order on March 10, 2011, creating a committee to study the feasibility of health insurance exchanges. “The whole point of this commission should be to figure out how to opt out and how to avoid a federal takeover, NOT create a state exchange,” she wrote in a March 31, 2011, email to her staff and Anthony Keck, director of the South Carolina health department.

Haley appointed five of the 12 members of the exchange planning committee and designated three others to serve — including Keck — because of their positions in her administration. The remaining four members were appointed by the leaders of the South Carolina House and Senate.

A third exchange option

Haley’s office directed questions about the exchange committee’s deliberations to Keck, who said the panel was not unduly influenced by Haley or anyone else. “Everyone came to the table with an opinion,” he said. “I don’t think there’s anyone who could say that all of the opinions didn’t get a fair hearing.” More than 40 people served on the committee and its four subcommittees, he said.

Some exchange commission members said they were disappointed in Haley’s hard-line position on health exchanges. But they also said the panel’s final report reflects the committee’s deliberations during more than 30 meetings, not influence from Haley, who they said did not contact any of them directly.

The commission concluded in November 2011 that the state was not able to create its own exchange under the deadlines imposed by the national health reform law. The panel also recommended the creation of a private health insurance exchange modeled on travel search engines at no direct cost to the state, among other recommendations. Such a private exchange would not handle Medicaid enrollment.

Everyone on the exchange committee knew that Haley opposed the national health reform law, said commission member Casey Fitts, MD, a general surgeon in Charleston. “This was something that was openly discussed throughout the process.” Dr. Fitts was appointed by South Carolina Senate President Glenn McConnell.

Dr. Fitts said he preferred a state exchange when he joined the committee. He changed his mind during the process because he came to believe that the state could not afford to create its own exchange, not because of any outside pressure.

He said he doesn’t fault Haley for favoring a private-sector health exchange, but he said she has sent mixed messages on the type of exchange she would support. “How she’s handled this and what she’s done has been very frustrating to me.”

State Sen. Mike Rose — also appointed by McConnell — said he wasn’t aware that Haley had made up her mind on exchanges and had pressured her Cabinet to fall in line behind that position. “That’s not what I would have preferred,” Rose said.

He said many of the tasks designated for health exchanges will require help from the federal government, including verifying individuals’ incomes and enforcing tax penalties. This raises questions about how much flexibility states really have regarding exchanges. Also, the state has had numerous problems with its child support payments registry, which is one of the reasons Rose said he favors a private exchange that compares only private insurance premiums.

“Our state’s not competent enough to do it,” Rose said. “If the federal government wants to take it over, that’s their prerogative.”

Tim Ervolina, president of the United Way Assn. of South Carolina, said he thought Haley had influence on the commission because she created it. But he didn’t think she directed the committee’s debate or its final report.

“Our recommendations were not political,” said Ervolina, who was appointed by Haley and described himself as politically liberal. He still believes the state should have a federal exchange, but that wasn’t the panel’s consensus.

The South Carolina Medical Assn. agreed with the exchange committee’s recommendations, said Gregory Tarasidis, MD, past SCMA president, who served on an exchange panel subcommittee.

Haley, Keck and the other exchange committee members said they are waiting for a federal response to the committee’s private exchange idea.

Exchange concept could prove popular

Several other states explicitly have declined to implement a state health insurance exchange as envisioned by the health reform law, or are unlikely to do so before the January 2013 certification deadline. These include Florida, Kansas, Louisiana, New Hampshire and Oklahoma, all of which returned at least part of their federal exchange planning grants, said Martha Salazar, a policy associate at the National Conference of State Legislatures.

However, those decisions may prove unpopular. Nearly 80% of Americans have a very or somewhat favorable view of the creation of “health insurance exchanges or marketplaces where small businesses and people who don’t get coverage through their employers can shop for insurance and compare prices and benefits.” This is according to the Kaiser Family Foundation’s December Health Tracking Poll. Exchanges are backed by 92% of Democrats, 75% of independents and 62% of Republicans.

Haley has declined to pursue additional federal exchange planning grants. South Carolina spent $291,000 of its initial $1 million exchange planning grant on the committee work.

Federal Dept. of Health and Human Services spokesman Bennett Blodgett did not say whether HHS would try to recover the grant funds spent by South Carolina. But he said that if states choose not to create their own exchanges, residents of those states would be able to access a federally facilitated exchange.

By Kathleen Sebelius

For families and small business owners struggling with health care costs and accessibility, help is on the way. The health care law that takes full effect in 2014 will provide a competitive marketplace to buy coverage. In fact, these state-based Affordable Insurance Exchanges are already taking shape. Through these one-stop shops, consumers will be able to see all their options in one place. More than $700 million in exchange grants have been awarded to 29 states.

That’s important because Americans today badly need better insurance options. In the past, finding and enrolling in coverage was often complicated and confusing. Rates could jump by double digits without much warning. Families and small business owners who bought their own coverage were often priced out or locked out of the system. And insurance companies could refuse to cover people with pre-existing health conditions.

The new insurance exchanges and other reforms in the Affordable Care Act mean that insurance companies will have to compete for your business, driving down prices. And, beginning in 2014, all Americans — whether they change jobs, retire early, or start a business — will have a way to access quality, affordable coverage in this new marketplace.

Last month, my department took an important step toward making that marketplace a reality by releasing a proposed approach to “essential health benefits,” the basic standard of coverage that all plans in this marketplace will have to offer.

Comprehensive coverage

This approach will ensure that all plans offered in this marketplace are comprehensive, without the gaps in coverage that too many consumers have faced. Some plans didn’t even cover basic preventive care. Others had so many holes that they provided almost no security if you got really sick. For example, 62% of individual market plans do not cover maternity coverage, 18% do not cover mental health services, and 9% do not cover prescription drugs today.

That’s why essential health benefits are so important. To ensure that no plans offered to small business or individuals have these kinds of gaps, the new health care law outlines 10 areas of basic coverage, prescription drugs, pediatric care and hospital services, which are now offered in good employer-based plans around the country.

For consumers, this means you won’t have to read every line of the fine print to know that the plan you buy will protect you if you get sick. And by establishing a basic standard for coverage, and outlawing discrimination of pre-existing health conditions, insurance companies will have to compete on things like price and customer service.

But we also know that health care is different in every state, and that the coverage that works in Florida might not work in Nebraska. Under the approach we have outlined, states will have the flexibility to pick their own standard from among the most typical, popular and proven employer plans in their own state.

National research indicates that the standard plan options we’ve suggested are currently very similar in every state, and since each state will have to meet the 10 categories laid out by the law, the 2014 essential health benefits will not differ greatly from state to state.

But instead of having to build a health plan from scratch, this approach will give states the flexibility to use proven employer models that have already been priced and purchased in the state.

Progress to be monitored

As the specific benefit plans are developed, we’ll be watching closely to make sure consumers are benefitting. And in 2016, we will evaluate and adjust the guidelines if necessary.

The health reform law also gives us several tools to improve health, deliver better care and lower costs. While our approach to essential health benefits must balance comprehensiveness and affordability, the real opportunity to address cost reduction lies with patient safety, care coordination and quality incentive programs already underway thanks to the Affordable Care Act.

Through these efforts, our ultimate goal is to make sure the insurance market works better for consumers. Insurance needs and health systems vary state to state, and experience tells us that the best way forward is not to mandate a one-size-fits-all answer. Instead, our approach gives states the flexibility to take their own paths, while ensuring they all end up in the best place possible: with an Affordable Insurance Exchange that offers access to comprehensive, quality, affordable health insurance to small business owners and individuals who currently have few good choices in an expensive and broken market.

Kathleen Sebelius is secretary of Health and Human Services. She was previously the governor of Kansas from 2003 to 2009.

Over at National Journal, Sophie Quinton rightly notes that one of the GOP’s fiercest crusaders against Obamacare has fallen by the electoral wayside. In fact, that candidate’s entire campaign was founded on dismantling healthcare reform.

Oh, well, Michelle. The people have spoken.

Igor Volsky at Think Progress also jumped on this point a little later, concluding that:

…with the mother of health care repeal now out of the race, yesterday’s results showed that opponents of Obamacare don’t have rule of the roost, despite the GOP’s incessant attacks against Obama’s signature reform legislation. In fact, most Americans still support large portions of the law. The latest Kaiser tracking poll finds that while 44 percent of voters have an unfavorable view of reform, 50 percent want to expand or keep it in place, with only 37 percent supporting repeal. A majority favor its most popular elements like easy-to-understand benefit summaries and tax credits for small businesses.

Then there’s this:

In an op-ed for The Record (Bergen Co., New Jersey), Seton Hall professor and policy wonk Frank Pasquale provides sound argument for a constitutional right to health care. Supposing that the Supreme Court eventually sides with ACA opponents and rules that the government has no right to order citizens to purchase health insurance of pay a fine, due to the financial damage inflicted by such expenses, Pasquale asks, “Why can’t there be a parallel monetary right not to be bankrupted by health care costs?” Legal precedents and and our nation’s founding texts lead him to this graceful conclusion:

For many Americans in these tough economic times, rights to education, housing, health care and food are a lot more meaningful than the right to be free of an insurance mandate.

We the people can locate these rights in a Constitution and a Declaration of Independence rich with grand and sweeping language. If those who hate health reform can use our nation’s founding texts to undermine the ACA, those who care about meeting basic human needs need to gear up to use them to do quite a bit more.

America can become the City upon a Hill envisioned by John Winthrop in his 1630 sermon “A Model of Christian Charity.” We can preserve a baseline of education, housing, health care and food for all by resisting the race-to-the-bottom style of globalization that’s hollowed out our economy.

We can locate these ideals in a Constitution and a Declaration of Independence that address actual conditions of life, not just abstract ideals. A government “of the people, by the people, and for the people” should do no less.

According to The Business Journal of Greenville, Spartanburg & Anderson, Uncle Sam has awarded S.C. $2.38 million in Medicaid bonus money for doing the right thing, making it simpler for low-income families to enroll their kids in the Children’s Health Insurance Program.

The performance bonus payments are funded under the Children’s Health Insurance Program Reauthorization Act. To qualify, states must surpass a specified Medicaid enrollment target. They also must adopt procedures that improve access to Medicaid and the Children’s Health Insurance Program, making it easier for eligible children to enroll and retain coverage.

Performance bonuses help offset the costs states incur when enrolling lower-income children in Medicaid. By ensuring that states streamline their enrollment and renewal procedures, the bonuses also give states the incentive to adopt long-term improvements in their children’s health insurance programs.

Of course, this is the first time South Carolina has qualified for the federal bonus program, given our long and hallowed tradition of scorning the poor. S.C. Appleseed has fought for years to get the S.C. Department of Health and Human Services to implement the bureaucratic efficiencies that only now have qualified us for this much needed federal funding. Unfortunately, the Sanford administration always was for ideology over individuals, even if that meant adhering to a policy that contradicted another of its closely held principles. In this case, that meant having separate state agencies duplicate each others’ work, thereby slowing and complicating the Medicaid enrollment process.

You read that correctly: The Sanford administration – that full-throated champion of drowning government in the bathtub – insisted that a bloated, redundant and wasteful state bureaucracy was preferable to helping low-income children access quality health care through Medicaid.

By Kelly Kennedy

WASHINGTON – More than 2.65 million Medicare recipients have saved more than $1.5 billion on their prescriptions this year, a $569-per-person average, while premiums have remained stable, the government plans to announce today.

That’s because of the provision of the health care law that put a 50% discount on prescription drugs in the “doughnut hole,” the gap between traditional and catastrophic coverage in the drug benefit, also known as Part D.

And, as of the end of November, more than 24 million people, or about half of those with traditional Medicare, have gone in for a free annual physical or other screening exam since the rules changed this year because of the health care law.

“We’re very pleased with the numbers,” Jonathan Blum, director of the Center for Medicare, told USA TODAY. “We found the Part D premiums have also stayed constant, despite predictions that they would go up in 2012.”

The Department of Health and Human Services announced in August that 2012 Medicare prescription drug plan premiums would average about $30 a month, compared to $30.76 in 2011.

Starting this year, seniors who reach the doughnut hole in prescription benefits receive a 50% discount on name brand prescription drugs. Drug companies must provide the discount to participate in the prescription plan. Before the health care law took effect, Medicare patients had to pay full price for their prescriptions once they reached the gap in coverage.

The prescription data are through the end of October.

Seniors are becoming more engaged in their care, Blum said, citing the hundreds of forums Medicare has conducted about the changes. “The sentiment is that Medicare is trying to keep them healthy and out of the hospital,” Blum said.

Preventive benefits aren’t free, because taxpayers are paying for them, says Michael Cannon, health policy studies director for the Cato Institute, a libertarian think tank. “There is no such thing as a free lunch,” he said.

Robert Moffit, a senior fellow at the Heritage Foundation, a conservative think tank, said the services may help catch diseases early. But it’s too early to tell if the overall savings in Medicare will justify the costs of the preventive care. “This should prove to be a worthwhile experiment.”

It’s too early to determine if the wellness exams are catching health problems early and therefore preventing hospital trips, Blum said. However, he said, insurance premiums have not risen as much as in previous years.

Medicare beneficiaries can learn more about changing their plans at www.medicare.gov or 1-800-Medicare.