Tag Archives: ACA

Red Myths, Rural Realities

Paul Krugman recently looked at the effects of Trump’s policies on rural America, and found–to no sentient person’s surprise–that the effects have been disastrous.

Economists, reports Politico, are fleeing the Agriculture Department’s Economic Research Service. Six of them resigned on a single day last month. The reason? They are feeling persecuted for publishing reports that shed an unflattering light on Trump policies.

But these reports are just reflecting reality (which has a well-known anti-Trump bias). Rural America is a key part of Donald Trump’s base. In fact, rural areas are the only parts of the countryin which Trump has a net positive approval rating. But they’re also the biggest losers under his policies.

As Krugman points out, whatever Trump’s campaign rhetoric might have promised, his actual policies have been aligned with (okay, dictated by) Congressional Republican priorities–what Krugman calls “G.O.P. standard”: big tax cuts for corporations and rich people, accompanied by cuts to the social safety net.

The only real deviation from GOP orthodoxy has been the tariffs, and Trump’s evident belief that trade wars are “easy to win.” Even the farmers who have been a reliable part of Trump’s base are beginning to recognize that they will bear the brunt of the substantial injuries caused by those wars.

As for the tax and social safety net cuts…

The Trump tax cut largely passes farmers by, because they aren’t corporations and few of them are rich. One of the studies by Agriculture Department economists that raised Trumpian ire showed that to the extent that farmers saw tax reductions, most of the benefits went to the richest 10 percent, while poor farmers actually saw a slight tax increase.

At the same time, the assault on the safety net is especially harmful to rural America, which relies heavily on safety-net programs. Of the 100 counties with the highest percentage of their population receiving food stamps, 85 are rural, and most of the rest are in small metropolitan areas. The expansion of Medicaid under the Affordable Care Act, which Trump keeps trying to kill, had its biggest positive impact on rural areas.

It is fair to suggest that many rural Americans are unaware of the variety of ways in which Medicaid expansion and other social programs support farm country; some of those benefits are indirect (which doesn’t mean they aren’t critically important). The impact of the tariffs, however, is hard to miss.

What about protectionism? The U.S. farm sector is hugely dependent on access to world markets, much more so than the economy as a whole. American soybean growers export half of what they produce; wheat farmers export 46 percent of their crop. China, in particular, has become a key marketfor U.S. farm products. That’s why Trump’s recent rage-tweeting over trade, which raised the prospect of an expanded trade war, sent grain markets to a 42-year low.

If Trump succeeds in plunging us into a full-blown trade war, which certainly seems more likely than not, Krugman says American imports and exports will both shrink — and since farmers rely disproportionately on exporting, they will be the biggest losers.

The harm being done to rural America by Trump leads to that perennial question: why do so many of the people bearing the brunt of his ignorance continue to support him?

Krugman delicately suggests that it has to do with “cultural factors”–by which he means hostility to immigrants and resentment of coastal elites they believe look down on rural America. (What Krugman calls hostility to immigrants is, if the research is to be believed, part of a much larger and more ingrained hostility to non-whites and non-Christians.)

Krugman thinks that rural America’s support for Trump may start to crack as the negative effects of his policies become too obvious to miss. I’m less sanguine.

When we so-called “elitists” talk about “voting ones interests,” we are almost always referring to economic interests. When I listen to Trump supporters–when they post angry diatribes on Facebook or are interviewed for a new program–what I hear is a very different view of what constitutes their interests.

Economic reality be damned. Trump voters are defending their vision of America, and that vision is white, heterosexual, and fundamentalist Christian. So long as they believe Trump is hurting people who fall outside that narrow category, he’s their guy.

 

About Those Right-Wing Judges…

As most of you know by now, a conservative judge in Texas struck down the entire Affordable Care Act, ruling it unconstitutional.

The decision is a reminder that when judges are appointed on the basis of party loyalty rather than legal acumen, the results can hurt a lot of innocent people.

Legal scholars who have reviewed the decision believe it is badly flawed and will be overturned, but Daily Kos recently enumerated the consequences should it be upheld.

The most obvious loss would be that part of the law that forbids insurance companies from excluding coverage of pre-existing conditions. But as the author noted, if the law were really to disappear, that’s just a part of what would be lost.

As many as 17 million people could lose their coverage in a single year. The 15 million people covered under Medicaid expansion could lose their coverage. The improvements to Medicare that have saved the program billions of dollars—and reduced prescription drug costs for seniors—would be erased. Young people wouldn’t be able to stay on their parents’ insurance until they’re 26. The ban on annual and lifetime caps would be gone, and medical bankruptcies would escalate. Having lady parts would again cost women more than men, and being over age 50 would cost everyone more again. Limits on out-of-pocket costs would be gone. The tax credits that 9 million people are receiving to help them pay premiums would be gone.

The post focused on the political fallout of the threatened losses. (Even Republicans concede that the issue hurts them.) But the real lessons aren’t partisan.

There are two obvious “take-aways” here.

First is the incredible amount of damage that can be done by elevating ideologues to the bench. This sort of “smash and burn” judging is a direct result of viewing the federal courts as a partisan political prize rather than a constitutional safeguard to be protected by the appointment of dispassionate, knowledgable and qualified legal scholars.

The second is equally obvious. As important as the ACA is, as much of a step forward that it represents, it falls far short of what Americans need and most other wealthy countries have long had. Not only is it vulnerable to the sort of judicial assassination we’ve just experienced, it is simply insufficient.

It would be poetic justice–not to mention actual justice–if this effort by a radical judge prompted Congress to pass Medicare for All, or at least a “public option” allowing citizens of all ages to “opt in” to the program.

Did Your Health Insurance Premium Go Up? Thank Donald Trump

There’s a reason the Republicans are frantically trying to load the federal bench–including the Supreme Court– with ideological conservatives: given Congress’ refusal to discharge its constitutional duty to oversee the executive branch, the courts are the only recourse for Americans opposed to the criminal enterprise that is the Trump Administration.

There are currently hundreds of challenges to that administration making their way through the courts, and a number of them are critically important. One of those involves the “take care” portion of the chief executive’s job description–the duty to “faithfully execute” the laws of the land.

People who depend on the Affordable Care Act–and all citizens who believe that Presidents have such a duty –should be rooting for the success of a lawsuit recently filed by four cities. 

Vox introduced its report on that lawsuit thusly:

Abbe Gluck argued, in October 2017, that President Trump’s “sabotage” of the Affordable Care Act violated his duty under the Constitution to ensure laws passed by Congress are executed. This week four cities — Baltimore, Chicago, Columbus, and Cincinnati —filed a suit making that very claim.

Here’s the essence of the argument:

Modern American history has never seen as full-scale an effort to sabotage a valid law as we have with President Trump and the Affordable Care Act — a law whose legality has been upheld twice by the US Supreme Court.

The president has a legal obligation, under Article II of the US Constitution, to “take Care that the laws be faithfully executed.” That means he must make sure that our laws are implemented in good faith and that he uses his executive discretion reasonably toward that end.

His agencies likewise have a legal obligation, under the Administrative Procedure Act — the statute that sets the rules for our entire federal regulatory apparatus — not to use their power to engage in arbitrary action.

The intentional, multi-pronged sabotage of the ACA that we have seen during Trump’s presidency — reaching new heights since attempts by Congress to repeal the law failed — violates both Trump’s constitutional obligations and quite possibly the obligations of his Department of Health and Human Services.

Like the pending lawsuits alleging violations of the Emoluments Clause, the take care clause has rarely–if ever–been the basis of a lawsuit.  At least in modern times, it certainly hasn’t been the basis of a case against a president, and that is entirely understandable: most legal scholars agree that presidents need a fair amount of discretion in enforcing the laws. Demonstrating that the person in the Oval Office is purposely undermining a law rather than exercising discretion is extremely difficult. Usually.

But this, of course, is Donald Trump–idiot extraordinaire. Far from masking his motives (making proof difficult),  he has trumpeted and tweeted them.

The ACA requires the federal government to support the open enrollment period — in which individuals must sign up for insurance or lose their chance to do so. The ACA requires the federal government to, among other things, maintain a website and work with local “navigators” and other groups to educate consumers and encourage them to sign up for insurance.

Trump instead set out to make open enrollment a failure.

He cut the enrollment period in half, from three months to six weeks. He shut down the federal enrollment website for nearly 12 hours every Sunday during the period — a crucial window when working Americans might enroll. He has canceled already- scheduled events in which federal officials had planned to visit states and help with enrollment. He cut advertising for enrollment by 90 percent, from $100 million to $10 million, even though his administration charged insurers on the exchanges user fees to generate money for that same advertising. (Those fees far exceeded $10 million.)

One day before the new budget year began on September 1, he announced a 40 percent cut to those navigator programs — after promising them $60 million in grants in May, and afterhis administration had said it would support navigators in order to partly offset the obstacles erected by the curtailed enrollment period.

Why would President Trump want to stifle open enrollment? Because that would seriously weaken the ACA’s insurance markets, which require a mix of healthy and sick customers to be stable. In line with that ambition, he also signed an executive order last week that directs his agencies to consider policies that would allow the sale of new group and short-term plans lacking many ACA protections. These alternative plans are likely to pull even more healthy individuals out of the insurance markets.

The same day, Trump announced his plan to cut off important cost-sharing payments that the ACA promises to insurers to compensate them for reducing what individuals have to pay in premiums…  creating extreme instability in the insurance industry… And Trump made clear that his goal in cutting off the funds was to harm he law. He tweeted the same day the policy was announced: “ObamaCare is causing such grief and tragedy for so many. It is being dismantled …”

Knowledgable observers calculate that premiums would have declined this year, rather than increasing, if not for Trump’s sabotage. That’s bad enough, but if a President can get away with eviscerating rather than enforcing valid laws with which he personally disagrees, the rule of law becomes meaningless.

 

Sabotage

While the media and the country are being distracted by the daily crazy/sleazy coming from Washington, the Trump Administration is working feverishly behind the scenes to dismantle the rules: rules that protect us from dirty air and water, from discrimination in housing and education, and rules that guarantee us access to health care, among others.

The unremitting attack on the Affordable Care Act has been particularly effective. The GOP may not have been able to repeal it outright, but regulatory sabotage has been the next best tactic. Thanks to the administration’s actions–neutering and threatening to eliminate provisions of the ACA that were included in order to keep premiums affordable, health insurance rates continue to rise.

According to Larry Levitt at the nonpartisan, respected Kaiser Foundation,

New analysis: Insurers did very well in Q1 of 2018 in the individual market under the ACA. If not for looming repeal of the mandate penalty and expansion of loosely-regulated plans, we’d be looking at modest premium increases and even decreases for 2019.https://www.kff.org/private-insurance/issue-brief/individual-insurance-market-performance-in-early-2018/ 

Evidently, however, the administration has decided that killing affordability by raising costs was too incremental; a recent article from The Washington Post reported on a much more direct attack.

The Trump administration took another major swipe at the Affordable Care Act, halting billions of dollars in annual payments required under the law to even out the cost to insurers whose customers need expensive medical services.

In a rare Saturday afternoon announcement, the Centers for Medicare and Medicaid Services said it will stop collecting and paying out money under the ACA’s “risk adjustment” program, drawing swift protest from the health insurance industry.

Risk adjustment is one of three methods built into the 2010 health-care law to help insulate insurance companies from the ACA requirement that they accept all customers for the first time — healthy and sick — without charging more to those who need substantial care.

As the article goes on to explain, two of the three methods were temporary;  risk adjustment, however, was to be permanent. Federal health officials are supposed to annually calculate which insurers had relatively low-cost consumers, and which had more expensive customers. Those with the lower-cost customers would make an adjustment payment to those whose customers were more costly.

This idea of pooling risk has had significant practical effects: encouraging insurers to participate in the insurance marketplaces the ACA created for Americans who cannot get affordable health benefits through a job.

In its announcement, CMS said that it is not going to make $10.4 billion in payments that are due to insurers in the fall for expenses incurred by insurers last year.

The announcement that payments due under the law would simply not be made is just the most recent measure taken by the Trump administration to demolish a law the GOP was unable to repeal legislatively. (It’s a tactic Trump is undoubtedly comfortable with–throughout his “successful” development career, he routinely stiffed architects, engineers and contractors. Wheelers and dealers who are willing to ignore the terms of contracts to which they are party are unlikely to have qualms about ignoring the obligations imposed by laws to which they are subject. But I digress.)

The administration has taken a number of steps to dismantle the ACA through executive powers.

Last year, health officials halved the length of the annual sign-up period for Americans to buy ACA health plans and also slashed by 90 percent the federal funds for advertising and other outreach efforts to urge people to enroll. Last October, the president ended another important subsidy to insurers: cost-sharing reduction payments, which cushioned them from the law’s requirement to provide discounts on deductibles and other out-of-pocket costs to low-income customers.

This year, the Department of Labor and HHS have worked to make it easier for people and small companies to buy two types of insurance policies that sidestep benefits required under the ACA and some of the law’s consumer protections.

There have been a couple of lawsuits in the lower courts over past calculations of these payments, with inconsistent results, and the administration blamed the withholding of funds on one of those decisions–a transparently trumped-up excuse. (Pun intended.)

“Risk adjustment is a mandatory program under federal law,” said Scott Serota, president of the Blue Cross Blue Shield Association. “Without a quick resolution . . . this action will significantly increase 2019 premiums for millions of individuals and small business owners. . . . It will undermine Americans’ access to affordable coverage, particularly for those who need medical care the most.”

Matt Eyles, president of America’s Health Insurance Plans, noted in a statement that the timing of this latest move could be particularly disruptive, because this is the season during which insurers around the country decide whether to take part in ACA marketplaces for 2019 and, if so, what rates to charge. “This decision . . . will create more market uncertainty and increase premiums for many health plans,” Eyles said.

Of course it will. That’s the whole intent.

And if thousands of people are bankrupted or die as a result? Too bad. They weren’t Republican donors anyway.

As The Bullets Find Their Mark..

I will never understand the GOP obsession with repealing Obamacare.

I could certainly understand efforts to improve it, or even replace it with a different mechanism (not the smoke and mirrors sort of replacement that Trump yammered about but was unable to describe, but a different way to deliver actual healthcare).

It is hard for me to accept that there are people who genuinely believe poor folks aren’t entitled to medical care, that being unable to afford a doctor means you don’t deserve one. On the other hand, I recall that telling–and chilling– moment in a GOP debate when Ron Paul was asked what should be done with people who don’t have insurance, and the audience members yelled “let them die.”

So there’s that…

Even though Paul Ryan and his cronies couldn’t manage a complete repeal of the Affordable Care Act, they did manage to make it less workable. They didn’t kill it–they just made it more incoherent and costly.

According to Michael Hiltzik in the L.A. Times,

Those fiscal geniuses in the White House and Republican-controlled Congress have managed to do the impossible: Their sabotage of the Affordable Care Act will lead to 6.4 million fewer Americans with health insurance, while the federal bill for coverage rises by some $33 billion per year.

Also, by the way, premiums in the individual market will rise by an average of more than 18%.

These figures come from the Urban Institute, which on Monday released the first estimate of the impact of two GOP initiatives. The first is the elimination of the individual mandate, which is an offshoot of the GOP tax-cut measure signed by President Trump in December. The measure reduced the penalty for not carrying insurance to zero as of next Jan. 1.

The second is Trump’s plan to expand short-term insurance plans, which don’t comply with many of the ACA’s essential benefits requirements and allow insurers to reject or surcharge people with preexisting medical conditions or histories.

Both of these provisions siphon younger, healthier people out of the insurance pool–an entirely foreseeable (and indeed, widely foreseen) consequence. When the pool of insured individuals contains older, sicker participants not offset by as many young healthy ones, insurers must raise premiums.

Because government premium subsidies rise in tandem with premium increases, the cost of subsidies borne by the government will rise by $33.3 billion next year, or 9.3% — to $391.4 billion from $358.1 billion under existing law.

It isn’t only taxpayers who will get hosed by the changes Trump is so proud of. The article goes through a variety of ways in which people needing health insurance will get screwed over, and I encourage you to click through and read the whole analysis.

It’s hard to disagree with Hiltzik’s conclusion:

The damage estimate can’t be restricted to the immediate impact on individuals and families, the researchers observed. “As healthier enrollees exit for short-term plans, insurers will by necessity reexamine the profitability of remaining in the compliant markets. This may well lead to more insurer exits from the compliant markets in the next years, reducing choice for the people remaining and ultimately making the markets difficult to maintain.”

In other words, the Republican sabotage will continue to undermine health coverage in the U.S. The only alternative, it becomes clearer with every day, is some form of single-payer, Medicare-for-all coverage. That’s increasingly becoming part of Democratic Party orthodoxy, and it’s about time.

One more reason why we need a wave election in November.