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You are here: Home / Anderson On Health Insurance / A few notes on Replace

A few notes on Replace

by David Anderson|  December 15, 20163:29 pm| 45 Comments

This post is in: Anderson On Health Insurance, Because of wow., Election 2018, Free Markets Solve Everything, I Reject Your Reality and Substitute My Own

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This tweet tree is an interesting indicator of the behind the scenes Replace state of play:

@jenhab @bobjherman How much if any money they’re willing to pony up will tell a lot about the replacement package.https://t.co/lCWiCduJEO

— Harris Meyer (@MHHmeyer) December 15, 2016

The first thing in health policy is to always follow the money.  Covering sick people means spending money.  The question is always how much money and who is spending that money.  We’ll know very quickly if there is an actual replacement plan that is way too heavily focused on HSAs but actually tries to provide some useful coverage to a reasonable number of Americans or if it is a Potemkin plan by looking at the top line CBO scoring of the expense of the coverage provisions.  This runs into a potential Norquist problem but the money is the big thing to review.

This piece from the Washington Examiner is interesting regarding the Norquist problem:

Republicans are searching for a way to capture savings from repealing Obamacare in a piggybank they could later use to fund a replacement.

It’s not clear how or if such a maneuver would work, but if Republicans are successful, it could overcome the tricky political problem of paying for whatever health reform they try to put in the Affordable Care Act’s place….

If Republicans find a way to set that money aside, in a bank account of sorts, they could use it to pay for measures that are more palatable to conservatives but still expensive, such as the age-based tax credits House Speaker Paul Ryan has proposed to help Americans buy health insurance.

 If this is a convoluted work-around of a self-imposed constraint, then there is a chance in hell that there could be a vaguely adequately funded bill.  I am not betting the house on it, but I might bet one soccer game referee fee on it.

Republicans are considering up to a 4-yr transition period for Obamacare repeal https://t.co/cqvtVqtVVP

— Jennifer Haberkorn (@jenhab) December 15, 2016

There have been numerous wonks tearing their hair out about the mechanics of implementation.  My estimate derived from my time spent as a low level plumber :

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….

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 the discussion is now on a four year transition period, some semblemance of reality may be at least temporarily be injected into the conversation.  Three years after a signature on the Replace Bill is a bare minimum and four years is a reasonable build-out time.

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45Comments

  1. 1.

    Chip Daniels

    December 15, 2016 at 3:37 pm

    There is going to be a lot of smoke and dust thrown into the air by the GOP, wanting to make it very complex and confusing.
    While health care IS in fact complex, the basic principles are what we need to be adamant and unyielding and rabidly inflexible on.

    Namely, that young and healthy people have a moral responsibility to pay for old and sick people; This is the core of civilization, where adults care for children, and young care for the elderly.

    All the sparklers and handwaving distractions will be an attempt to evade this basic concept. Its also why the GOP is in a dilemma, since most Americans really like the core concept.

  2. 2.

    Central Planning

    December 15, 2016 at 3:40 pm

    It’s a timebomb. Trump will tank the economy and employment (and just about everything else.)

    A Democrat will get elected and then healthcare will go away for the majority of the needy population. Guess who will get blamed? Hint: Democrats.

  3. 3.

    hoodie

    December 15, 2016 at 3:44 pm

    Kinsley Gaffe in the Meyer article:

    Tom Miller, a health policy expert at the conservative American Enterprise Institute, argued it wouldn’t be politically smart to rush through a repeal of the Medicare payroll tax and the ACA’s other revenue provisions without carefully thinking through the consequences. Republicans should use those taxes as leverage to gain support from insurers and other industry groups, while considering which ones to keep to pay for their replacement tax credits.

    Plus, they need to think about the optics of handing out a big tax cut to wealthy people while rolling back the ACA’s Medicaid expansion. “That won’t look real good,” he said. “It plays into the old story line of, ‘We took care of rich Republicans and other folks will just have to get along.’ ”

    Yeah, old stories hang around because they tend to be true.

  4. 4.

    Barbara

    December 15, 2016 at 3:44 pm

    I sort of lost my cool at a weekly job related lunch today, at which a political type (and mostly nice guy) was giving the down low on how repeal would happen fast and it would put a lot of pressure on Dems. I pointed out that any “delay” meant that the repeal could be repealed and he said no way, and began talking about the article in Politico blah blah blah. Well, I lost my cool a little because my brother depends on ACA. And now, the time period has gone from two or three to as long as four years. They must be scared shitless. Democrats need to let them twist in the wind on this all on their own. Anything that delays the effective date of repeal makes ultimate repeal much more difficult — people get more and more used to benefits and the political winds can change again. I said this before, but the MMA in 2003 had a provision that required Medicare to start laying the groundwork for transition to Ryan type reforms and it was repealed before it was ever implemented. Anything that is done on a going forward basis can be reversed.

  5. 5.

    Richard Mayhew

    December 15, 2016 at 3:46 pm

    @Barbara: Yep, and I think the Dems are playing it right —“Sure, we’ll sign onto modifications of the ACA, here is a list of 53 of them that we want to tweak but could not over the past five years…. but the essence needs to hold true”

    I’m betting any Replace bill will count on at least 80 Dem votes in the House and 15 in the Senate to be part of the minimal winning coalition

  6. 6.

    Barbara

    December 15, 2016 at 3:48 pm

    @hoodie: When I asked this same guy about Medicaid expansion he started talking about how it was all going to get rolled into Medicare reform. Not only would that then mean that they are paying wealthy people as they pull the rug out from underneath poor people but that they are breaking Trump’s explicit promise not to cut back Medicare or Social Security. They can’t help themselves. They just don’t empathize with regular people enough.

  7. 7.

    Iowa Old Lady

    December 15, 2016 at 3:50 pm

    If they just repeal it outright, aren’t they also repealing those taxes that support it?

    ETA: And then what happens when they try to “replace”? Will they pass taxes?

  8. 8.

    dr. bloor

    December 15, 2016 at 3:52 pm

    Like Trump, they’re mostly acting like the dog that caught the car. What else happens in four years? Let me think for a minute…

  9. 9.

    Barbara

    December 15, 2016 at 3:52 pm

    @Richard Mayhew: Perversely, the House is where they are really weak. They just can’t get rid of the crazies.

  10. 10.

    Chip Daniels

    December 15, 2016 at 3:55 pm

    @Barbara:
    I’m assuming the guy was either a)young or b) well off.

    And yeah, there are plenty of those types who are happy to shitcan all social programs.

    But there are tons more middle aged Boomers or poverty level Millenials who are not keen on losing Medicaid or Medicare.

  11. 11.

    Barbara

    December 15, 2016 at 3:57 pm

    @Iowa Old Lady: So, the taxes will be repealed and the effective date of that action will be delayed. They can’t repeal the substantive ACA related provisions without more votes, and McConnell will not let the Senate repeal/replace substantive coverage on party line vote and will preserve filibuster for this reason if no other. They have no idea how they will fund the replacement.

  12. 12.

    Richard Mayhew

    December 15, 2016 at 3:57 pm

    @Chip Daniels: marketing campaign is “I love Mom and Dad but I don’t want to live with them again….”

  13. 13.

    Barbara

    December 15, 2016 at 3:58 pm

    @Chip Daniels: Well, yeah, of course. He’s both.

  14. 14.

    Roger Moore

    December 15, 2016 at 4:01 pm

    @Chip Daniels:

    Namely, that young and healthy people have a moral responsibility to pay for old and sick people; This is the core of civilization, where adults care for children, and young care for the elderly.

    Exactly. We talk about this as insurance, but it’s still fundamentally redistribution between the healthy and the sick. This is fair, because nobody is guaranteed to remain healthy for their whole lives, so the people who are providing today will be provided for in the future and/or were provided for in the past.

  15. 15.

    germy

    December 15, 2016 at 4:01 pm

    Why don’t they just leave it in place
    and rename it “TrumpCare”
    then everyone will be happy.

  16. 16.

    Pogonip

    December 15, 2016 at 4:03 pm

    @Barbara: They were stuck; they had to promise repeal because of their base. I wish politicians would worry less about bases and more about citizens.

  17. 17.

    Barbara

    December 15, 2016 at 4:03 pm

    @Roger Moore: But old people have been voting against the interests of young people for a while now. The social contract NEVER cuts only in one direction, even when it comes to paying for health care. If it does, it’s over for everyone and that includes old people, and really, they need to understand that.

  18. 18.

    Inmourning

    December 15, 2016 at 4:04 pm

    I would be completely effed if they change Medicare. Also too, SS. I am at the stage of my life where all my financial planning has relied on these two core programs. I still work part time and pay taxes for the programs. I am so upset about this I can hardly function. I call my representatives often, and urge others to do the same.

  19. 19.

    Pogonip

    December 15, 2016 at 4:05 pm

    @germy: That’s probably pretty much what’ll happen except it’ll be called something like Freedomcare or Patriotcare.

  20. 20.

    Belafon

    December 15, 2016 at 4:06 pm

    I missed something. What “savings” would they get from repealing the ACA, considering it’s a net negative on the budget?

  21. 21.

    germy

    December 15, 2016 at 4:08 pm

    @Pogonip: Maybe they can leave Social Security alone and rename it the Paul Ayn Rand Ryan Fund?

  22. 22.

    Chip Daniels

    December 15, 2016 at 4:12 pm

    @Roger Moore:
    One of the worst argument fails is when we get suckered into the idea that Medicare and SS are somehow insurance programs.
    This then lets the other side point out how most working age people pay far more into it than they get, which is the “every man for himself” argument that relies on the illegitimacy of the social contract.

    We need to repeatedly hammer on the idea that it is a transfer program, and rightfully so. There is nothing wrong with asking young healthy people to pay for those who are sick and old.

  23. 23.

    germy

    December 15, 2016 at 4:16 pm

    @Chip Daniels: Chris Wallace, during the final debate, repeated the slander that these are “entitlements” that are “bankrupting” our nation.

  24. 24.

    Barbara

    December 15, 2016 at 4:18 pm

    @Belafon: Yes, that’s a problem, but there were also taxes that were passed specifically to fund parts of the ACA. That’s what they are talking about. In case you have to ask, that would be a bonanza to insurance companies and people earning over $200,000. I mean, in case you had any doubt in your mind whatsoever . . .

  25. 25.

    Barbara

    December 15, 2016 at 4:20 pm

    @Richard Mayhew: What Dems should do is introduce “Medicare for All” and insist on it being the replacement. People understand that just as well as they can understand “Repeal the ACA.”

  26. 26.

    germy

    December 15, 2016 at 4:22 pm

    @Barbara: Foolishly, I was sort of counting on HRC winning and expanding medicare to everyone 55 and above.

    I like medicare for all but I doubt I’ll see it in my lifetime.

  27. 27.

    gogol's wife

    December 15, 2016 at 4:40 pm

    @Inmourning:

    Is there any way we can get a “give me my money back” movement? Since we’ve all been paying into these programs for our whole lives?

  28. 28.

    schrodinger's cat

    December 15, 2016 at 4:43 pm

    @gogol’s wife: Excellent idea, that’s what we should do.

  29. 29.

    Mnemosyne

    December 15, 2016 at 5:05 pm

    @gogol’s wife:

    I’ve been paying into Social Security since I was 12 years old and working a few hours a week in my dad’s office. (He was a lifelong Republican, but the old-fashioned kind who actually followed the law by paying me minimum wage and withholding taxes.) You’d better believe I want my money back if Social Security isn’t going to be an option for me. With interest.

  30. 30.

    Bill

    December 15, 2016 at 5:17 pm

    @Chip Daniels:

    Namely, that young and healthy people have a moral responsibility to pay for old;

    I’m kinda done with this idea. The elderly have repeatedly taken an IGMFY approach to anyone under 50. Particularly on healthcare. There’s no reason they should get special status. Either we take care of everyone or the Olds can have the same shitty healthcare options as everyone else. Personally I’m happy to start a “we push you out to sea on an iceberg so you’re not longer a burden” non-profit.

  31. 31.

    Emma

    December 15, 2016 at 5:17 pm

    @gogol’s wife: This! This! We want it back with interest.

  32. 32.

    hoodie

    December 15, 2016 at 5:25 pm

    @Mnemosyne: Oh, they’ll give you a lump sum back alright, but nowhere near that amount and probably not near enough to live on into your eighties. Then they’ll force you to put it into the market or banks, where it will be eaten up by fees and/or low yields.

  33. 33.

    cmorenc

    December 15, 2016 at 5:26 pm

    The GOP plan WILL adequately fund health care for the elderly – ice floes are cheap to come by in an age of global warming, and the only somewhat expensive part will be funding shipping the elderly to the ice floes to die inuit-style.

  34. 34.

    Mart

    December 15, 2016 at 5:33 pm

    Thank you President Joe Lieberman.

  35. 35.

    Bill

    December 15, 2016 at 5:36 pm

    There isn’t going to be a replacement. They are going to repeal the ACA and leave Americans floundering without health insurance again. “Repeal and replace” was just a slogan for campaign purposes.

  36. 36.

    Mart

    December 15, 2016 at 5:43 pm

    @Emma: We want it back with interest.

    From Politico so there is that http://www.politifact.com/truth-o-meter/article/2013/feb/01/medicare-and-social-security-what-you-paid-what-yo/… “The Urban Institute, a non-partisan research institute in Washington, produces statistics on this topic annually. Institute researchers figured out what people turning 65 in various years have already “paid in” to the system and what can expect to “take out” after they reach age 65″…

    “According to the institute’s data, a two-earner couple receiving an average wage — $44,600 per spouse in 2012 dollars — and turning 65 in 2010 would have paid $722,000 into Social Security and Medicare and can be expected to take out $966,000 in benefits. So, this couple will be paid about one-third more in benefits than they paid in taxes”…

    “For an average-wage-earning, two-income couple turning 65 in 2010, the pay-in, pay-out ratio for Social Security by itself will actually be slightly negative —- the couple will have paid $600,000 in lifetime Social Security taxes and will receive only $579,000 in lifetime Social Security benefits. (Remember, the couple didn’t literally pay out $600,000; that’s the current value of what they paid out over the years, plus an additional 2 percent they may have gotten had it been invested.)”

    If you don’t die early, you come out ahead.

  37. 37.

    Emma

    December 15, 2016 at 5:47 pm

    @Mart: Compound interest is a marvelous thing.

  38. 38.

    Iron City

    December 15, 2016 at 5:48 pm

    That was all figured out in the early 1940s….boxcars are fairly cheap and it doesn’t take many guards/ dogs to keep old people in line. Or maybe just make self driving electric mobility scooters available to everyone over 65 and do the operational testing for self driving and loose lots of test subjects at the same time.

  39. 39.

    mai naem mobile

    December 15, 2016 at 6:31 pm

    I kind of had this figured out but watching the past few weeks I really saw clearly that the GOPs attitude towards healthcare and the elderly is if you didn’t make or inherit enough money to cover your health care and/or retirement expenses,you need to accept living in poor health and having a crappy lifestyle and then die quickly, since you aren’t contributing anything to the world.

  40. 40.

    Michael

    December 15, 2016 at 7:24 pm

    They’ve had SIX fracking years to come up with SOMETHING.

  41. 41.

    Jack the Second

    December 15, 2016 at 7:29 pm

    @germy: I really wish that the Republicans only problem with the ACA and the rest of the safety nets was that they didn’t do it.

    But it isn’t; they have had plenty of opportunities to help build something in this country and the closest they got is Reagan’s unfunded directive forcing ERs to not let people die on their doorstep untreated.

    A lot of Republicans fundamentally do not believe the state should be in the business of helping people. It exists to maintain Law and Order and that is it. Repealing everything and replacing nothing is the best case scenario for this crowd.

  42. 42.

    PaulWartenberg2016

    December 15, 2016 at 9:58 pm

    There’s an easier solution, Republicans:

    1) JUST FCKING FIX THE ACA SO YOU DON’T HAVE TO WASTE YOUR TIME DREAMING UP A HALF-ASSED PLAN THAT WON’T WORK.

    2) Rename the revised ACA AmeriCare or RepubliCare so you can take the credit.

    3) Go on your fcking golf retreats with your lobbyist buddies for the rest of 2017.

    DONE.

  43. 43.

    Slaughter

    December 15, 2016 at 11:46 pm

    The Republicans can’t come up with a new plan because this is their plan, co-opted by Obama to get something passed.

  44. 44.

    low-tech cyclist

    December 16, 2016 at 10:52 am

    @Central Planning:

    It’s a timebomb. Trump will tank the economy and employment (and just about everything else.)

    A Democrat will get elected and then healthcare will go away for the majority of the needy population. Guess who will get blamed? Hint: Democrats.

    Yeah, that’s my thought too. And then if they still have a majority in either house of Congress, they’ll keep the new Dem President from fixing anything.

    I was so looking forward to having one Dem President who didn’t have to start her Presidency by having to clean up after the damned elephants. Even with the massive resistance that the GOP was already gearing up for, at least she’d have started with a government, an economy, and a world situation that were generally in good shape.

  45. 45.

    low-tech cyclist

    December 16, 2016 at 11:05 am

    @PaulWartenberg2016:

    There’s an easier solution, Republicans:

    1) JUST FCKING FIX THE ACA SO YOU DON’T HAVE TO WASTE YOUR TIME DREAMING UP A HALF-ASSED PLAN THAT WON’T WORK.

    2) Rename the revised ACA AmeriCare or RepubliCare so you can take the credit.

    3) Go on your fcking golf retreats with your lobbyist buddies for the rest of 2017.

    DONE.

    Hell, even call it TrumpCare, for all I care.

    But it won’t happen. Even if the Republicans give the rich every last thing they want, it still won’t taste as sweet to them as they feel it should unless they can also crap all over poor people as part of the deal.

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