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… pundit janitors mopping up after the gop

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Come on, man.

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Damn right I heard that as a threat.

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Since we are repeating ourselves, let me just say fuck that.

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You are here: Home / Anderson On Health Insurance / A few mechanical points about replacing the ACA

A few mechanical points about replacing the ACA

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Just a few points that need to be made as the Republicans finally caught the car that they were chasing and can now repeal and replace the ACA.

First the ACA is really good for their base voters who don’t have employer sponsored coverage and the Republican think tank plans are really bad for those same voters:

Secondly, the talk right now is the repeal and replace components are to be split.
The mechanics are fairly straightforward. Congress would pass the FY 2017 Budget resolution that calls for reconciliation on healthcare in the first week of January. A reconciliation bill that zeroes out all subsidy spending on the ACA passes. The funds will sunset on 12/31/2018 for Exchange subsidies and Medicaid expansion so there will be a 22 month bridge period. That bill gets signed by early February 2017. Repeal is in the books and if nothing happens 20 million or more people lose their insurance on 1/1/19.

Replace is a more nebulous concept. Now that there is a hard deadline, the thinking is that something gets passed through normal order with some Democratic votes as Democratic Senators won’t want to hurt their constituents.  The rumbling that the Senate Republicans won’t kill the filibuster makes this very interesting as a bill that needs at least eight or nine Democratic defectors means everyone is responsible for the outcome and no one is blamable in 2020.

Best case scenario is the Replace bill (of some sort) is passed late summer or early fall. Let’s say is signed on October 1, 2017 with a go live date of January 1, 2019.

There is a problem here. Any big bill will have major rule making. Any big bill will require insurers to reconfigure and retweak their systems. I worked 70 hour weeks from roughly July 2012 to October 2013 to get my little part of the QHP Exchanges to a point where the user facing chunk was minimally functional. I then spent another six months getting all of the back-end mechanics of directory and network information working cleanly in an operational, no human intervention sense.  (I was up 53 of the 60 hours before October 1, 2013 launch date getting the final network directory ready to launch).

The ACA had roughly a 45 month ramp up period from signature to going live on the major components. The REPLACE bill would have 14 months. And honestly, the functional time frame is shorter as any insurance company changes need to have a code freeze at least three months before the open enrollment period for effective testing. We could hold a hundred million claims for the first quarter of 2019 but that would be BAD (TM). So assuming an October 1, 2018 open enrollment period, the insurers need to have their changes in the final test environment by the middle of July which means development specifications for minor changes need to be developed by January 2018. And that means CMS or whatever other federal entities that need to issue rules and guidance will have less than three months to issue the rules/regulations, take comments, modify proposals and send out final regulations.

That is impossible.

If the replace bill is signed in April, 2017 a 1/1/19 go-live date is vaguely plausible. I’ll be very glad that I’m not a plumber anymore but it is vaguely plausible.  If the Replace Bill is anything more than a rebranding of the law and a dropping of subsidies, required actuarial value and essential health benefits, insurers need at least eighteen months from the signature to get something together and preferably 18 months from when CMS issues the big rules to get a good launch.  If it is just a rebrand and a chopping twelve to eighteen months is needed to not have a fiasco of a roll-out.

Reader Interactions

41Comments

  1. 1.

    Jeffro

    Can’t they just rename it TrumpCare, give extra stickers to the “economically anxious” when they visit their primary care doctors, declare victory and call it a day?

    Oh wait…that’s right…taxes on higher incomes help pay for the Affordable Care Act’s provisions…never mind…

  4. 4.

    lollipopguild

    When a lot of the white people who voted for Trump find themselves being screwed and tattooed by the GOP who do you think that they will blame? Obama and the dems. Some of these people will die because of their loyalty to the GOP but i assume that they will die happy.

  6. 6.

    raven

    Today in insurance wonderland! My bride fell and broke her wrist this morning. Urgent Care was really good and we got in to see an Orthopod in less than 2 hrs. The PA was a really nice fellow and, after he looked at the X-rays, said they need to install a plated. They even had a hand man that was going to do it tomorrow. The admin lady said that since we were BCBS we were covered. I had been trying to contact BCBSGA all day and got the same stupid fucking voice message saying to call dating business hours. We were all ready and I emailed our HR person just to bitch about BCBS. Amazingly she called and had a live BCBS person on the call. The BCBS HMO lady said there was ZERO chance that they would pay for surgery outside of Georgia. I started to be pissed but realized she was just the messenger so I thanked her and that was that. Now we realize we can get nothing done by rushing home in the morning so, despited the fact that the girl is in quite a biota pain, we’re going to stay here until sunday. We rent from a friend and she said we’d work out the remains week rent so here we are!

  7. 7.

    Major Major Major Major

    @Tractarian: I think he’s saying that the merely wildly implausible is a replacement that mostly keeps things the same; more plausible is killing the whole thing and bringing us back to 2009; and impossible is a replacement that changes anything outside of those two possibilities.

  8. 8.

    Mary G

    @raven: Motherfuckers. I hate HMOs with the heat of a thousand suns. I’m sorry, Raven and Ravenette. That is pain, bad pain. When I broke my ankle and I had to sit and wait for hours because they had to get the ortho in from the golf course and they couldn’t give me pain meds in the ER, I was ready to strangle somebody. The idea of waiting all weekend is terrible.

  9. 9.

    SiubhanDuinne

    @raven:

    I’m really sorry that your bride is in pain. I hope at the very least the urgent care folks loaded her up with painkillers.

    Our health care system is so fucked. Best to you and the girl, and I hope you can resume the remainder of your vacation at a more auspicious time.

  10. 10.

    Baud

    The funds will sunset on 12/31/2018 for Exchange subsidies and Medicaid expansion so there will be a 22 month bridge period.

    So after the 2018 elections? Why should Dems work with them then?

  13. 13.

    Gin & Tonic

    @Mary G: I once broke my shoulder skiing. The ski area had a good clinic, x-ray and all that, but I was there by myself, with a rented car, facing a 45-minute downhill mountainous drive back to my hotel. So they said “well, we can’t give you any painkillers because of the nature of the drive.” That was fun.

    Sorry about the circumstances Raven – hope your bride gets through this as easily as possible. Hell of a way to start a vacation.

  17. 17.

    Bailey

    Does any of this require re-building the online exchanges? Using the same gov’t approved contractors that screwed the pooch on the original HealthPlan.gov exchange? Because one thing I don’t see happening is all the tech giants in the world coming to Trump’s rescue as they did for Obama.

  18. 18.

    Steeplejack (tablet)

    Shorter: The Republicans don’t care if “replace” works. They just want to “repeal.”

  20. 20.

    RepubAnon

    The Republican plan to kill the Affordable Care Act is simple: repeal the individual mandate, leave the rest alone. The pool of insured will trend sick, claims will rise, which will drive the insurers out. The Republicans will then regretfully close it down – their poison pill having done its job.

  21. 21.

    Suzanne

    Call Paul Ryan’s office and take his dumbshit healthcare survey. 202-225-3031.

    You might have to call a couple few times in order to get through, but be persistent.

  23. 23.

    kindness

    Replace is fiction. Republicans can promise all they want they won’t bring anything forward. They really don’t care if 20 million lose coverage. I think they think they’ll be able to blame Democrats. It’s worked for everything else so I shouldn’t blame them.

  25. 25.

    Suzanne

    @RepubAnon: Apparently it’s even slightly more devious than that: they want to take away the individual mandate but replace it with a requirement for continuous coverage. Everyone likes the part about people not being denied insurance or paying more for pre-existing conditions, but they’ll only let you stay at the rate you’re at if you keep continuous coverage. If your coverage lapses, then you have to pay rates similar to what they were before the ACA for people with pre-existing conditions. So it’s essentially an individual mandate without calling it that.

    Fuckers. FUCKERS.

  31. 31.

    raven

    @Mary G: Sorry, we watched 2 episodes of “The Crown”! The career from the Urgent Care and the Pod was good. I had thing nagging feeling that BCBS HMO wouldn’t pay and I’m glad we found out before we ran up what would be a whopper bill that we had to pay. The Urgent Care gave her 20 medium weight pain killers so we’ll see. Things are a bit cranky around here right now.

  32. 32.

    Irony Abounds

    Have we learned nothing yet? The Republicans will blame whatever clusterfuck they create on Obamacare and the media will go right along with them. The only way they get blamed for anything is if the privatization of Medicare also blows up in their face at the same time so Dems can lump the two together. And I’m not sure Dems are bright enough to do it or the rubes in Trumpland can put two and two together.

  34. 34.

    Jay S

    Paul Ryan making noises about Medicare being bankrupted by the ACA might mean he’s looking for a grand bargain that attacks Medicare. That might be enough overreach to keep ACA alive at least for a while.

  37. 37.

    low-tech cyclist

    @Arclite:

    Won’t the health insurance companies lobby against this? They’re losing 20M off the rolls.

    They won’t be happy about losing the 20M, but if they lobby against it, it’ll be quiet and in private.

    You see, while the poor and working classes don’t have any class solidarity, the rich and the big corporations do. Over the past several years, it’s become clear that they’re willing to accept GOP legislation that dings a particular industry as long as the damage isn’t too bad, because overall, if they support the GOP across the board, they’ll all benefit way more than enough to make up for the dings.

  38. 38.

    gene108

    Richard, why do you assume the Galtian overlords, who sign your paycheck care, if the front end or back end will work for customers?

    They will be able to legally incorporate in the state with least insurance regulations, because Republicans will allow selling insurance across state lines, so it is not like any of them will face any regulatory hurdles.

    Blue states that somewhat try to control insurance companies will get bitched at, though they will no longer have any power, because their insurance companies will be governed by whatever red state races to the bottom first. Thus you get blue state voter backlash.

    And if everyone is collectively racing to the bottom, it is not like customers will find a better alternative elsewhere.

  39. 39.

    low-tech cyclist

    So assuming an October 1, 2018 open enrollment period, the insurers need to have their changes in the final test environment by the middle of July which means development specifications for minor changes need to be developed by January 2018.

    I work on a big statistical survey, and we have conversations like this all the time when discussing possible changes to the survey, just with different specific wonkish details. So not only do I totally get this, but I’m also used to the lack of comprehension of outsiders or way-higher-ups about why you can’t change everything and have it into the field in three months or less.

    Yeah, this is gonna be a shitshow.

  40. 40.

    D58826

    Richard I am so disappointed. You are probably one of the last hold outs to the silly idea that facts matter and 2 + 2 =4

  41. 41.

    No One You Know

    @Arclite: Health insurance companies are not getting the federal money the ACA was supposed to give them. They may not have had much of a problem with this as you think.

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