Part II: The Senate’s “Better Care”

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Mitch McConnell and the Senate Republicans introduced their revised Better Care Reconciliation Act (BCRA) yesterday. As of this morning, both Sen. Susan Collins and Rand Paul have opposed a motion to proceed on bringing the bill up for consideration to vote. This leaves the Affordable Care Act (ACA) repeal-and-replace in uncertainty, as 3 “No” votes would be enough to doom any chances of passing the Senate. Experts have said that they don’t expect the changes in this bill to alter the CBO’s previous estimate that 22 million could lose their health insurance coverage if passed. This may not matter, as Republicans have made it evident that they could try to push for a vote before the CBO concludes its analysis of the new bill.

Here are the main revisions from the previous bill, with some perspective from Vox:

Cuts to Medicaid remain unchanged, as does the shrinking of Medicaid expansion that more than 30 states have accepted and new patients have found satisfying. Both Republican opposition and citizen outcry thus far have been focused at these severe cuts to Medicaid, which covers half of the births in this country and 1 in 5 Americans, including 2 in 5 children and 2 in 3 nursing home residents. Shrinking the ACA’s program to expand Medicaid is also significant. The CBO has concluded in a separate analysis that these proposed cuts would shut off additional states from accepting Medicaid expansion, and would force some states that have accepted it to drop out, resulting in millions losing coverage.

Denying coverage based on pre-existing conditions has returned to Republican’s healthcare legislation. However, it has become more complicated (likely on purpose), so we’ll spend a little more time discussing it.

You may remember that the first rendition of BCRA left out what the House bill (AHCA) included concerning pre-existing conditions. But Sen. Ted Cruz has offered a new amendment included in the revised BCRA that returns a backdoor option for denying those with chronic health problems. As long as health insurers offer a comprehensive plan – that is, one with essential benefits that the ACA requires to be provided – they can also offer skimpier, deregulated plans. These deregulated plans give more control to insurers in raising costs so high that individuals with pre-existing conditions cannot afford to pay them. Thus, those with chronic health problems will be forced to buy the more expensive and comprehensive plans.

This has several avenues of predictable outcomes that all lead to an unstable marketplace. Ultimately two types of coverage will form: (1) cheap, barebones coverage for rich, healthy individuals, and (2) expensive (or unaffordable), comprehensive coverage for poor, sick individuals. This is explained by Vox author, Sarah Kliff:

Health policy experts know exactly how this would play out: Healthy people would pick the skimpier plan, while the comprehensive plan would essentially become a high-risk pool for sicker Americans.

Individual market enrollees would likely game the system too. A couple expecting a baby, for example, would be expected to upgrade to the [comprehensive] plan that covers maternity care for one year before returning to the cheaper plan they had before.

This tipping of the scales alone could be enough to make comprehensive plans too unaffordable for most individuals, forcing them out of coverage. Those looking to join a comprehensive plan will still be eligible to receive a tax credit in BCRA. However, out-of-pocket costs for deductibles and premiums would remain unbelievably unaffordable. For example, the CBO estimates that a 64-year old earning $11,500 would still need to pay $4,800 for a comprehensive health insurance plan.

Pre-tax money could be used to pay for premiums. Americans enrolled in health savings accounts (HSA), nearly 29% of workers, could now use this money to pay for premiums in addition to their co-pays and co-insurances. This is a great added benefit to those with HSAs, but falls short as a stand-alone option for those who struggle to afford health insurance premiums in the first place. And, as you may know if you have an HSA, this often doesn’t cover the entire cost of a premium.

Wealthy Americans would get less of a tax cut in the revised BCRA. The previous bill included more than $500 billion in tax cuts for high-income individuals and manufacturers. Republican writers decided to extend both a 0.9% investment tax and 3.8% Medicare payroll surtax from ACA that target wealthier individuals.

Keeping these two taxes in place would net the government an estimated $231 billion in revenue over the next decade, and eliminate some of the benefits high-income Americans would have received under the first draft.

Finally, the revised bill provides $45 billion to combat opioid abuse. But as Joshua Sharfstein, professor at the Johns Hopkins Bloomberg School of Public Health, says

The $45 billion they’ve added is a drop in the bucket compared to the amount of money that would be lost in the Medicaid cuts ($800 billion). It’s a tiny fraction of what Medicaid is already providing millions of people.

Think about it. Those addicted to and abusing pain-killing drugs need actual care through sustained coverage – which Medicaid provides – rather than an indiscriminate number of dollars. When you consider that funding for this opioid abuse program constitutes less than 6% of the total cuts imposed to Medicaid, it is sadly apparent that this is included mostly as political leverage. That is, ammunition for BCRA’s supporters to attack those who oppose the bill as a whole for any other legitimate reason.

Despite these poorly addressed flaws, a vote could happen this week. The voice of the people has made a difference at each step of the healthcare reform process. With just 12% approval and millions of lives at stake, BCRA will require sustained pressure on our elected officials. You can use the Trumpcare Toolkit to reach make your voice heard, and if you’re a member of the medical community searching for the right words, here is a great perspective to get you started.

Image: Digg

H.R. 1628, Better Care Reconciliation Act

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The Congressional Budget Office (CBO) and Joint Committee on Taxation (JCT) released their completed report on the Senate’s highly anticipated “Better Care Reconciliation Act” (BCRA) earlier today. In general, the major provisions of this bill are:

  • Elimination of the individual and employer mandates
  • 3-year phasing out of Medicaid expansion in 2021 and a general cut to Medicaid (which covers 1 in 5 Americans and probably a lot more than you think)
  • Basing premium taxes on age, income, and geography (like Obamacare and unlike the AHCA’s age-based income tax)
  • Tax cuts for the wealthy by repealing Obamacare tax increases
  • Allowing states to apply for a waiver that permits insurance companies to deny their enrollees essential benefits, some of the most fundamental services to healthcare
  • Ending cost sharing subsidies to low- and middle-income individuals in 2020 (though Trump may end these earlier)
  • Defunding of Planned Parenthood for 1 year

The CBO concluded that 15 million individuals would lose their health insurance next year under BCRA, and ultimately 22 million would be forced out of coverage by 2026. This is similar to the respective 14 million and 23 million figures from the CBO report on the House’s version, AHCA.

Though the report estimates that premiums would increase by up to 20 percent (relative to Obamacare) in the first couple of years, they would eventually become cheaper in 2020. However, this would largely be a result of a decrease in services covered by health insurance companies under BCRA.

Bluntly, yet still shocking, the CBO states that this bill would save costs by shunning both elderly and low-income individuals from even purchasing a coverage plan “despite being eligible for premium tax credits.” Overall, the cuts in BCRA could result in a death spiral of drastically increased premiums as younger, healthier individuals drop from a pool composed greatly of older, sicker individuals that require more health services.

Finally, the money breaks down as such:

  • $772 billion cut to Medicaid
  • $408 billion reduction in subsidies for nongroup health insurance
  • $107 billion to states and insurers for various purposes
  • $210 billion to reduce collections of penalty payments from employers and uninsured
  • $541 billion tax cut for high-income individuals, manufacturers, and excise taxes
  • Overall, a net reduction of $321 billion

Image: PBS

How Housing Can Be Tailored to the Autistic Community

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Medical professionals, especially osteopathic physicians, are trained to look at patients holistically. But are clinicians truly assessing an individual’s needs and their goals?

We should challenge the textbook notion that autistic patients require supervision. An apartment complex in Pittsburgh, PA is set to open doors to those diagnosed with autism spectrum disorder (ASD). The project emerged from a shared vision of facilitating independent life for people with autism through affordability and special architectural design. Sweetwater Spectrum, a development of shared homes in California, had a similar idea and was built with acute attention to accommodation, which includes on-site support staff:

It has a community center, farm, greenhouse and pool. The homes have noise-dampening ceilings and quiet heating and air conditioning systems for residents who are hypersensitive to loud sounds.

These apartments parallel the backdrop of a rise in autism rates. According to the CDC, we are at a historic high for the number of people diagnosed with ASD.

Here’s the part that gets – unfortunately – tangled up in a mess called politics. Medicaid is currently the main payer for ASD management, but the Trump administration plans on transitioning Medicaid to a block-based grant system, and then to halt Medicaid expansion altogether. This means that despite the prevalence of autism, we may see a decline in funding for its treatment/management.

Should Medicaid’s possible fadeout worry you, the future health practitioner, and your ASD patients or others who rely on Medicaid? To this, I would say, “Hey, I know of this FANTASTIC blogcast called Diagnostocracy, which will cover the turbulence and impact of the public insurance system in the future, so stay tuned…because it’s a great site.”

Our focus should shift focus to being better at “medicine outside of medicine.” As a society, we have tunnel vision for the next breakthrough in technology or easy pharmaceutical quick-fix, but we should lend ourselves to simple yet effective out-of-the-box thinking (like building a heart pump with supplies from Home Depot). Prescribing personalized housing to facilitate an autistic patient’s well-being goes beyond the clinic room.

With that being said, let us continue to reassess our definition of patients’ needs and goals and what practicing medicine really means.

Image: AOA

(Just wanted to give a quick thanks to Keifer W., Leigh G., and Roy L. for editing this post!)