GOP ACA Replacement Imminent....Predictions

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fskimospy

Elite Member
Mar 10, 2006
87,501
54,311
136
A few things to keep in mind:
I've only seen a 66 page bill at this point. There seems to be quite a bit of stuff from the GOP talking points missing (sales across state lines, changes to tax credits, etc.). Trump has tweeted that more is coming. At this point I'd say it's not unreal to assume that this is the tip of the iceberg. As such a lot of this in conjecture based on what I've heard may be coming.

That being said the change from the mandate penalty to the continuous coverage penalty is subtle but dramatic. The former says "For each year you don't have insurance you must pay" and the latter says "If you don't have insurance you must pay when you get it." The mandate penalty amounts to negative punishment (if you don't do this thing you will be punished) and the continuous coverage penalty amounts to positive punishment (if you do this thing after waiting you will be punished). While the efficacy of the mandate penalty is certainly debatable it's my personal belief that it will have worked better than the continuous coverage penalty. Let's examine them more closely.

Under the mandate penalty a taxpayer must pay a surtax to the federal government for each month, after a grace period, in which they did not have minimum essential coverage. The surtax was calculated as a percentage of the taxpayer's income and capped at a fixed dollar amount each year. The goal of the individual mandate penalty was to "encourage" younger and healthier people, who might ordinarily eschew health insurance, to enter the risk pool and keep overall premiums in check. In 2016 the surtax was 2.5% of adjusted gross income, capped at $695 per person per year.

Hypothetical scenario: Unmarried male, no children, age 27. Graduated from college, lives in Las Vegas, earns $38,000/year. If this person were to go the entire year without health insurance they would pay a surtax of ($38,000 x 0.025 = $950 > $695) $695. A Catastrophic plan is available off the Exchange for $165.53 per month, or $1,986.36 for the year. While income is below 400%FPL there are no tax credits available because of premium prices in Las Vegas. If we assume that the person does not buy insurance they pay $695 per year, a savings of $1,291.36 per year. And that assumes that they actually pay the $695, which is avoidable if you do your taxes correctly. That same person, faced with a continuous coverage penalty, will absolutely pay nothing for not having insurance. When it eventually comes time to buy insurance he faces a one-time surcharge of 30%. Based on 2016 numbers the surtax is $1,986.36 x 0.3 = $595.91, a one-time charge less than what he would have been paying each year. That leads me to believe that the continuous coverage penalty will lead to more "young invincibles" sitting out coverage, not fewer, which will likely cause premiums to rise.

Then you have to figure in the deterrent effect of the continuous coverage penalty. The mandate penalty goes away when you buy insurance, the continuous coverage penalty is TRIGGERED when you buy insurance. This could very well mean that people who don't buy insurance become less likely to buy with each year that goes by (since premiums go up with age the penalty also goes up with age). Think of it like auto insurance. I know people say to shop around for auto insurance every 6-12 months to get the best deal but there's a catch: that only works for relatively undiscounted premiums. Many (most?) insurers offer huge discounts for longevity plus low incident rate ("3 Year Accident-Free," etc.). They also don't match or carry over longevity with other insurers. So if I have a great discount (30%+) for longevity there's practically no chance that another insurer will be able to beat my rate off the bat. Now, it may be possible that another insurer's base rates are lower than my current rate so that in the long run I would be better off switching and working toward that new 30%+ discount, but it's difficult to make that decision. The same holds true with the continuous coverage penalty. I'm young and healthy and I don't need insurance, and there's no penalty anyway so why bother. Oh, now I'm 30 and the premiums are $200/month plus a $60/month surcharge? I guess I can take care of this infection on my own? Now I'm 35 and premiums are $400/month plus a $80/month surcharge. Well, I guess I'll wait for my knee to heal on its own. 40 years old with $600/month in premiums and surcharge, I guess I'll skip that colonoscopy. It becomes a treadmill of being uninsured that makes the penalty worse the more you need it until at some point the cost of care is going to overwhelm the penalty cost and you purchase, at which point you're going to contribute to a spoiling risk pool and drive overall premiums up even higher.

This is similar to what I thought. I think this sort of incentive mechanism would create a high risk of the dreaded 'death spiral' as it seems to actively encourage adverse selection. It's hard for me to imagine that many insurers would even want to participate in such a market where they are forced to charge healthy people more money even if they don't want to and are then prevented from charging sick people more money even if they do.

I just don't see how guaranteed issue and community rating works without a mandate or something that approximates it.
 

sactoking

Diamond Member
Sep 24, 2007
7,632
2,891
136
Just saw a summary article from a source I trust. I was correct in that there are two bills, one of which I haven't seen. Major provisions worth noting from the summary article (some mentioned before):

  • Preexisting conditions exclusion, guaranteed availability, guaranteed renewability, age 26, and OOP max are all still in.
  • Health status underwriting, annual and lifetime caps, and discrimination prohibitions are all still in.
  • Eliminate hospital disproportionate share funding.
  • $10 billion in Medicaid funds only to non-expansion states.
  • Eliminates planned parenthood funding for 1 year.
  • Cost sharing reductions are eliminated.
  • Mandate penalty is out, 30% 12 month continuous coverage penalty is in.
  • Individual and employer mandate penalties are out, retroactive to 2016, but the mandates themselves remain (thanks to the Byrd rule).
  • "Onerous" employer reporting requirements remain.
  • Age band from 3:1 to 5:1.
  • Actuarial values and metal tiers are out. This may make shopping confusing as all get out.
  • $500,000 expense deductibility cap for pay to insurance executives is out.
  • Tanning tax is out,
  • Branded Rx drug tax is out.
  • Medicare unearned income tax on incomes >$200,000 is out.
  • Cadillac tax is out until 2025 at which point it reappears (likely a budget trick for long-term CBO scoring).
  • HSA/FSA prohibition on OTC meds is out.
  • HSA/FSA prohibited use penalty is reset to original 10%/15%.
  • $2,500 annual FSA contribution limit is out.
  • Medical device tax is out.
  • Medical expense deduction on personal income taxes back to 7.5% from 10%.
  • Medicare 0.9% surtax on incomes >$200,000 is out.
  • The cap on how much premium tax credit you must repay if you estimate your income incorrectly is gone as of 12/31/17
  • Premium tax credits can be used for off-exchange and catastrophic coverage.
  • Premium tax credits cannot be used for ANY coverage covering non-rape/incest abortions
  • Premium tax credits indexed to age as well as income.
  • Income based premium tax credits are OUT in 2019
  • Small business tax credit is out.
  • Age indexed tax credits only beginning in 2019: $2,000/yr <30, $2,500/yr 30-39, $3,000/yr 40-49, $3,500/yr 50-59, $4,000/yr >60. Credits capped at $14,000/year or 5 people. Unused credits may be deposited into an HSA.
  • Tax credits phase out at $75,000/150,000 at a rate of 10% of the amount in excess of the phase-out point.
  • Lifting directly from the summary analysis: "The tax credit is not be adjusted for geographic differences in health care costs, and the 2 to 1 age adjustment would fall far short of making up for the 5 to 1 ratio allowed under for age rating. Younger and wealthier individuals in low cost areas of the country would be better off than under the ACA, but older and poorer individuals and individuals in higher cost areas would be worse off. The Kaiser Family Foundation website offers an interactive map illustrating who wins and who loses.
  • Here is the KFF comparison map: http://kff.org/interactive/tax-cred...-act-vs-replacement-proposal-interactive-map/
  • HSA contribution cap raised to the individual's plan OOP max.
  • Spouses could make catch-up contributions to the same HSA
  • HSA could cover expenses incurred up to 60 days PRIOR to the creation of the HSA.
 

theeedude

Lifer
Feb 5, 2006
35,787
6,197
126
Does one have to be in the individual market to get the credit, or everyone gets it, even if they have employer care?
 

Blackjack200

Lifer
May 28, 2007
15,995
1,688
126
They don't keep it confusing to benefit them. They keep it confusing because it would be very expensive to fix. Most hospitals don't have very large dedicated IT staffs to easily make these changes. Non-medical technology in hospitals is really out of date.

Honestly, I just don't think that's good enough at this point.
 

Jhhnn

IN MEMORIAM
Nov 11, 1999
62,365
14,684
136
Just saw a summary article from a source I trust. I was correct in that there are two bills, one of which I haven't seen. Major provisions worth noting from the summary article (some mentioned before):

  • Preexisting conditions exclusion, guaranteed availability, guaranteed renewability, age 26, and OOP max are all still in.
  • Health status underwriting, annual and lifetime caps, and discrimination prohibitions are all still in.
  • Eliminate hospital disproportionate share funding.
  • $10 billion in Medicaid funds only to non-expansion states.
  • Eliminates planned parenthood funding for 1 year.
  • Cost sharing reductions are eliminated.
  • Mandate penalty is out, 30% 12 month continuous coverage penalty is in.
  • Individual and employer mandate penalties are out, retroactive to 2016, but the mandates themselves remain (thanks to the Byrd rule).
  • "Onerous" employer reporting requirements remain.
  • Age band from 3:1 to 5:1.
  • Actuarial values and metal tiers are out. This may make shopping confusing as all get out.
  • $500,000 expense deductibility cap for pay to insurance executives is out.
  • Tanning tax is out,
  • Branded Rx drug tax is out.
  • Medicare unearned income tax on incomes >$200,000 is out.
  • Cadillac tax is out until 2025 at which point it reappears (likely a budget trick for long-term CBO scoring).
  • HSA/FSA prohibition on OTC meds is out.
  • HSA/FSA prohibited use penalty is reset to original 10%/15%.
  • $2,500 annual FSA contribution limit is out.
  • Medical device tax is out.
  • Medical expense deduction on personal income taxes back to 7.5% from 10%.
  • Medicare 0.9% surtax on incomes >$200,000 is out.
  • The cap on how much premium tax credit you must repay if you estimate your income incorrectly is gone as of 12/31/17
  • Premium tax credits can be used for off-exchange and catastrophic coverage.
  • Premium tax credits cannot be used for ANY coverage covering non-rape/incest abortions
  • Premium tax credits indexed to age as well as income.
  • Income based premium tax credits are OUT in 2019
  • Small business tax credit is out.
  • Age indexed tax credits only beginning in 2019: $2,000/yr <30, $2,500/yr 30-39, $3,000/yr 40-49, $3,500/yr 50-59, $4,000/yr >60. Credits capped at $14,000/year or 5 people. Unused credits may be deposited into an HSA.
  • Tax credits phase out at $75,000/150,000 at a rate of 10% of the amount in excess of the phase-out point.
  • Lifting directly from the summary analysis: "The tax credit is not be adjusted for geographic differences in health care costs, and the 2 to 1 age adjustment would fall far short of making up for the 5 to 1 ratio allowed under for age rating. Younger and wealthier individuals in low cost areas of the country would be better off than under the ACA, but older and poorer individuals and individuals in higher cost areas would be worse off. The Kaiser Family Foundation website offers an interactive map illustrating who wins and who loses.
  • Here is the KFF comparison map: http://kff.org/interactive/tax-cred...-act-vs-replacement-proposal-interactive-map/
  • HSA contribution cap raised to the individual's plan OOP max.
  • Spouses could make catch-up contributions to the same HSA
  • HSA could cover expenses incurred up to 60 days PRIOR to the creation of the HSA.

So, uhh, tax cuts for people who don't need tax cuts & benefit cuts for people who need benefits, right?
 
Nov 30, 2006
15,456
389
121
Just saw a summary article from a source I trust. I was correct in that there are two bills, one of which I haven't seen. Major provisions worth noting from the summary article (some mentioned before):

  • Preexisting conditions exclusion, guaranteed availability, guaranteed renewability, age 26, and OOP max are all still in.
  • Health status underwriting, annual and lifetime caps, and discrimination prohibitions are all still in.
  • Eliminate hospital disproportionate share funding.
  • $10 billion in Medicaid funds only to non-expansion states.
  • Eliminates planned parenthood funding for 1 year.
  • Cost sharing reductions are eliminated.
  • Mandate penalty is out, 30% 12 month continuous coverage penalty is in.
  • Individual and employer mandate penalties are out, retroactive to 2016, but the mandates themselves remain (thanks to the Byrd rule).
  • "Onerous" employer reporting requirements remain.
  • Age band from 3:1 to 5:1.
  • Actuarial values and metal tiers are out. This may make shopping confusing as all get out.
  • $500,000 expense deductibility cap for pay to insurance executives is out.
  • Tanning tax is out,
  • Branded Rx drug tax is out.
  • Medicare unearned income tax on incomes >$200,000 is out.
  • Cadillac tax is out until 2025 at which point it reappears (likely a budget trick for long-term CBO scoring).
  • HSA/FSA prohibition on OTC meds is out.
  • HSA/FSA prohibited use penalty is reset to original 10%/15%.
  • $2,500 annual FSA contribution limit is out.
  • Medical device tax is out.
  • Medical expense deduction on personal income taxes back to 7.5% from 10%.
  • Medicare 0.9% surtax on incomes >$200,000 is out.
  • The cap on how much premium tax credit you must repay if you estimate your income incorrectly is gone as of 12/31/17
  • Premium tax credits can be used for off-exchange and catastrophic coverage.
  • Premium tax credits cannot be used for ANY coverage covering non-rape/incest abortions
  • Premium tax credits indexed to age as well as income.
  • Income based premium tax credits are OUT in 2019
  • Small business tax credit is out.
  • Age indexed tax credits only beginning in 2019: $2,000/yr <30, $2,500/yr 30-39, $3,000/yr 40-49, $3,500/yr 50-59, $4,000/yr >60. Credits capped at $14,000/year or 5 people. Unused credits may be deposited into an HSA.
  • Tax credits phase out at $75,000/150,000 at a rate of 10% of the amount in excess of the phase-out point.
  • Lifting directly from the summary analysis: "The tax credit is not be adjusted for geographic differences in health care costs, and the 2 to 1 age adjustment would fall far short of making up for the 5 to 1 ratio allowed under for age rating. Younger and wealthier individuals in low cost areas of the country would be better off than under the ACA, but older and poorer individuals and individuals in higher cost areas would be worse off. The Kaiser Family Foundation website offers an interactive map illustrating who wins and who loses.
  • Here is the KFF comparison map: http://kff.org/interactive/tax-cred...-act-vs-replacement-proposal-interactive-map/
  • HSA contribution cap raised to the individual's plan OOP max.
  • Spouses could make catch-up contributions to the same HSA
  • HSA could cover expenses incurred up to 60 days PRIOR to the creation of the HSA.
I'm curious to know how much this is going to cost. I imagine the CBO is currently working on it.
 
Reactions: DarthKyrie

First

Lifer
Jun 3, 2002
10,518
271
136
Boy, based on everything we've seen in this "phase 1" GOP replacement, looks like this is essentially a shitty version of ACA. Amazing how far the Republicans have lurched left by simply accepting the premise that the government must fund and subsidize people's health insurance, and in fact they don't really fully repeal Medicaid expansion until 5 yrs from now which is another way of saying it'll never happen (though it's still notable they so drastically reduce Medicaid here).

The GOP has now come full circle on health care, and in part we have Trump's progressive proclivities to thank for that. Combined with his skeptical stance on trade and saying no to slashing SS/Medicare, Trump is the best Republican trojan horse the Dems could have hoped for on the entitlement state just by virtue of the fact that he will help further instill the doctrine of gov't entitlements throughout society.

In 2015 the CBO did an analysis of repealing pretty much all of the taxes included in the bills this week. The estimate then was $1 trillion over ten years. I doubt that analysis will change much.

CBO analysis: https://www.cbo.gov/publication/51107

Even with dynamic scoring which (supposedly) takes economic effects of cutting taxes into account, you do seem to be right that it's going to roughly stay the same, (presuming no giant tax changes in subsequent proposals). $1T is just disastrously irresponsible, especially if you're a party of supposed fiscal conservatism.
 

soundforbjt

Lifer
Feb 15, 2002
17,788
6,041
136
Tea party (Freedumb Caucus) is on fox and they want to just repeal, and supposedly Rand has a plan he wants to push. They're claiming it (the house plan) would be a new entitlement.
 

Sea Ray

Golden Member
May 30, 2013
1,459
31
91
This is merely a starting point. My guess is the final version won't look anything like it. I'm glad they've put a plan out there. It's going to take a lot of back and forth to sort this all out. In the end there will be parts of it that conservatives love and hate; ditto for liberals. Obamacare sucked so bad I'm willing to let gov't roll the dice and come up with a new plan. I rarely want gov't to do such a thing but that's where I am on this one.
 

pcgeek11

Lifer
Jun 12, 2005
22,184
4,919
136
From what I've read elsewhere full coverage plans for women (i.e. those that cover abortion), will not receive tax credits.

There's no similar penalty for men's plans. So effectively women who choose full coverage plans will be subsidizing men's coverage.

Well men don't need abortions.
 

hal2kilo

Lifer
Feb 24, 2009
25,560
11,942
136
What ever piece of shit they end up with, you know damn well none of the bad effects will go into effect until after the 2018 mid terms.
 
Reactions: ch33zw1z
Feb 4, 2009
35,862
17,401
136
Reactions: DarthKyrie

pcgeek11

Lifer
Jun 12, 2005
22,184
4,919
136
In my opinion they are working on the wrong problem with health care.

The problem is the cost, not the insurance.

Like 50 dollars for a fucking Tylenol Capsule. 100 dollars for a bandage.
 
Reactions: DarthKyrie

fskimospy

Elite Member
Mar 10, 2006
87,501
54,311
136
I think it's DoA in the current form. Dems and hard right conservatives won't vote for this.

It's hard for me to see what form it could take that would make it through with 50 votes, much less 60 (if they don't kill the filibuster). The hard right doesn't want it because it's a new entitlement but anything that's acceptable to them is totally unacceptable to moderate Republicans. Who knows, maybe there's some compromise or one of the two groups capitulates but it seems like a very narrow window of one exists at all.

Then on top of that you have the tiny problem that the bill doesn't seem to accomplish literally any of the objectives set out for it. There's little reason to believe it would lower costs, it will decrease access, and it won't improve quality of care.

Sorry, there is one objective that it will accomplish: it will act as a massive tax cut for rich people. I can see Republicans conceding on every other aspect of this bill but I fully expect them to find some way to eliminate the ACA's taxes on the ultra rich.
 
Reactions: DarthKyrie
Jan 25, 2011
16,998
9,424
146
Leave it to the GOP to put forth a bill they can't pass in a house and senate they control.

Any luck they will filibuster their own bill again? That was amusing the last time.
 
Reactions: DarthKyrie

First

Lifer
Jun 3, 2002
10,518
271
136
This is merely a starting point. My guess is the final version won't look anything like it. I'm glad they've put a plan out there. It's going to take a lot of back and forth to sort this all out. In the end there will be parts of it that conservatives love and hate; ditto for liberals. Obamacare sucked so bad I'm willing to let gov't roll the dice and come up with a new plan. I rarely want gov't to do such a thing but that's where I am on this one.
Haha, this isn't much of a plan or roll of the dice, it's literally just a real shitty rip-off of ACA.
 
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