White House press secretary Sean Spicer offered a number of attacks and claims during a news briefing dominated by the new Congressional Budget Office report on the House Republican replacement bill for the Affordable Care Act. The report estimated that 24 million fewer people would have health insurance in 2026 if the law were approved in its current form, causing political headaches for the effort to replace Obamacare. Here’s a guide to his rhetoric.
“CBO coverage estimates are consistently wrong and more importantly do not take into consideration the comprehensive nature of this three-prong plan to repeal and replace Obamacare with the American Health Care Act.”
Spicer dings the CBO for having greatly overestimated the number of people who would buy insurance on the Obamacare exchanges, in particular a projection that 23 million would be on the exchanges by 2016; it actually was 10 million.
But this was just one part of a larger estimate — how many would gain insurance — that CBO got largely right. CBO projected that 30 million people (or 11 percent of the population under 65) would not have health insurance in 2016, when the actual number turned out to be 27.9 million (10.3 percent).
So Spicer is playing a bit of a shell game here. He is trying to discredit CBO’s larger coverage estimate — that 24 million fewer people would have insurance by 2026 than under current law — by focusing on an error in an element of the larger forecast. But apples to apples, CBO got the larger forecast mostly correct.
A 2015 study by the Commonwealth Fund concluded, “The CBO’s projections were closer to realized experience than were those of many other prominent forecasters.”
As for the “three-prong plan,” the two other elements have not been unveiled and thus CBO could not consider them. The third element — major changes in insurance regulations — would require the support of at least eight Democrats in the Senate, which is highly unlikely at this moment.
“In the portion of its analysis, the focus is on what the office is really about, the CBO concedes that the American Health Care Act would actually reduce the deficit by over $330 billion and bring health insurance premiums down 10 percent.”
This is an odd statement. The CBO projection of the impact of the deficit over 10 years is derived from its estimates of the impact on health-insurance coverage. If the White House does not believe the coverage estimates, then officials cannot at the same time tout the deficit-reduction forecasts. Either both are right or both are wrong.
As for the 10 percent reduction in health insurance premiums, that’s a prediction for 2026, comparing the replacement to a projection for current law. Moreover, CBO says that’s because insurance premiums would spike so much for older people (20 percent to 25 percent higher for a 64-year-old), many older people would drop out of the insurance markets. That means the pool of people obtaining insurance would be younger and healthier, thus resulting in a modest decrease in premiums.
“So you’ve got almost 20 million people in America who have said that they don’t want Obamacare and they’ll either pay a penalty or have applied for a hardship.”
According to a Jan. 9, 2017, letter from IRS Commissioner John Koskinen to Congress, only 6.5 million taxpayers paid the “shared responsibility” payments in 2015. That’s actually a decrease from 2014, when 8 million taxpayers made a payment. Moreover, CBO estimates that on average, about 3 million people will pay the penalty for being uninsured in any given month in 2016.
Spicer uses the phrase “hardship” to suggest people receiving waivers are doing this under duress, but this is misleading. Exemptions are granted for a number of reasons, but the most common one is that an individual has income below a certain threshold and lives in a state (led by Republicans) that did not expand the eligibility for Medicaid. (The law offered Medicaid to nearly all low-income individuals with incomes at or below 138 percent of poverty, or $27,821 for a family of three in 2016). The second most common exemption is if a citizen lives outside of the United States. People also do not need to pay a penalty if they would have had to pay more than 8.13 percent of their income (in 2016) to obtain health insurance.
“The CBO number says that 14 million people in the first year alone will lose coverage. It doesn’t take a ton of analysis to recognize that that doesn’t make any sense logically. You can’t only have nine-plus million people on the exchange and say in the first year alone when there’s no touch to Medicaid or anything else, you’re just removing the individual mandate that forced people to buy something that they didn’t want in the first place, that’s gonna lead to 14 million people.”
Spicer seems to be having trouble with the math here, so we will help him. Table 5 of the CBO report explains exactly how this works. First of all, the 14 million number reflects the second year (2018), not the first year. In the first year, the number of uninsured increases by 4 million compared with current law. In the second year, CBO projects that 5 million fewer will have Medicaid coverage, 6 million fewer will have individual coverage and 2 million fewer will receive insurance from employers. (The tax credits in the proposal creates some incentives for employers to stop providing coverage.) That rounds up to 14 million when including marginal effects in other insurance coverage.
“You’ve got 175 million Americans that get their insurance through their employer. And frankly, right now, they’re the ones who are paying higher and higher premiums.”
Actually, under the Affordable Care Act, employer-provided plans often became stronger, and no longer had lifetime caps or limits on preexisting conditions. Moreover, the rate of increase in health-care premiums slowed, though experts differ on how much that can be attributed to the ACA. The Kaiser Family Foundation estimates that cumulative premium increases were 63 percent for 2001-2006, 31 percent for 2006-2011 and 20 percent for 2011-2016.
“[Americans are] getting a system that’s failing and that is collapsing on its own.”
The CBO actually said the market was predicted to be stable for the next 10 years: “The nongroup market would probably be stable in most areas under either current law or the legislation.”
“Talk to somebody that’s on Medicare or Medicaid. Ask them if the doctor and services that they used to be getting are available to them. I know so many times now, when you walk into the doctor, they have a sign that says we no longer accept Medicaid. I mean, that used to be a given, almost.”
There’s not much data to support this. We looked into it in depth when House Speaker Paul D. Ryan made a similar Two-Pinocchio claim that “more and more doctors just won’t take Medicaid” under Obamacare.
Health-care analysts measure Medicaid patients’ access to care by looking at whether patients are able to get basic primary care, have a usual source of care or had a visit to the doctor in the past year.
There are mixed outcomes because state programs vary. But in general, children and adults enrolled in Medicaid are as likely to have a usual source of medical care as those with private insurance, according to a November 2016 brief by the Medicaid and CHIP Payment and Access Commission (MACPAC), a nonpartisan legislative branch research agency, studying 2014 National Health Interview Survey data.
MACPAC found adults with Medicaid were as likely to have a usual source of medical care as those with private coverage. Medicaid beneficiaries also were as likely to have seen a doctor in the past year as adults with private insurance. Compared with uninsured adults, Medicaid enrollees were considerably more likely to have seen a doctor in the past year.
But Medicaid enrollees do face more barriers — such as delays because of transportation problems and difficulty finding doctors who accept their insurance — compared with those with private coverage. Medicaid enrollees, on average, face more delays in getting appointments than those with private insurance. And Medicaid patients have more difficulty finding specialists who will treat them, compared with people with private insurance.
“We cannot just hit 60, I think this is something that should bring people together. I think there is bipartisan bicameral support for almost every one of these things because there’s no one that doesn’t benefit. I mean, who could be against allowing insurance to be sold over state lines?”
It’s not as simple as Spicer suggests.
Interstate insurance sales could lead to fewer people getting insured, reduce insurance options for consumers and prevent regulators from protecting consumers in their states, according to an analysis by the National Association of Insurance Commissioners and the Center for Insurance Policy and Research.
States differ in their insurance requirements, so customers in one state might buy cheaper policies in states that don’t require insurance coverage for certain treatments. Interstate sales could start a “race to the bottom” by allowing companies to choose their own regulators and insure the healthiest people, according to the analysis.
Further, the New York Times reported: “The trouble is that varying or numerous state regulations aren’t the main reason insurance markets tend to be uncompetitive. Selling insurance in a new region or state takes more than just getting a license and including all the locally required benefits. It also involves setting up favorable contracts with doctors and hospitals so that customers will be able to get access to health care. Establishing those networks of health care providers can be hard for new market entrants.”
“It’s not about them, it’s about patients. But I think what it means for them is that they finally get to create more choice and more plans and allow people to chose a plan that fits them. Right now they don’t have that choice and, frankly, in more and more markets, companies like Anthem, United Health, Cigna are pulling out — Aetna — because they don’t have the choice and because of the government mandate.”
Aetna had cited financial losses pulling out of the state exchanges, but a U.S. District Court judge found the company also had an ulterior motive: to “improve its litigation position” in a proposed merger with Humana.
“U.S. District Court Judge John D. Bates wrote that Aetna, pushing for a $37 billion merger with Humana since summer of 2015, decided to leave 17 counties in three states to improve the likelihood that the deal would be approved — including one where the business was doing well. Florida was the company’s third most-profitable exchange market in 2015 and the beginning of 2016,” The Washington Post reported in January 2017.
“I think the big difference, just so we’re clear, is that we posted this bill online, the Speaker had it out there, the President tweeted it out. Anyone in the country and anyone in the world, could read it. That’s a vastly different approach than after it’s being done, told, after we pass it you can read it, which is what Speaker Pelosi said.”
The Nancy Pelosi quote cited by Spicer is often taken out of context, as she inelegantly tried to make the point that media coverage had obscured the content of the legislation. This is the full quote, made during a speech given by then-Speaker on March 9, 2010, as the law neared final passage:
“You’ve heard about the controversies within the bill, the process about the bill, one or the other. But I don’t know if you have heard that it is legislation for the future, not just about health care for America, but about a healthier America, where preventive care is not something that you have to pay a deductible for or out of pocket. Prevention, prevention, prevention — it’s about diet, not diabetes. It’s going to be very, very exciting. But we have to pass the bill so that you can find out what is in it, away from the fog of the controversy.”
We previously gave Four Pinocchios to White House budget director Mick Mulvaney for also claiming that the passage of the Affordable Care Act was not transparent. There were numerous public hearings– at least 20 in the House–and the versions of the bills were posted online for people to read.
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