Donald Trump and the Republican Congress, fall into the latter category and they control the lever of the federal government.
What is wrong with the healthcare system? Is there anything right with it? What might it look like should it be repealed and replaced? What would the repeal and replacement actually look like?
These were the topics of discussion during a recent interview with a national healthcare expert, Sally C. Pipes, who writes a bi-weekly column for Forbes.
Ms. Pipes is the president, CEO, and Thomas W. Smith in Health Care Policy at the Pacific Research Institute and is one of the nation's most prominent healthcare scholars.
Below is a summary of the first part of my interview with her. Towards the mid-point of the discussion, the conversation turned to the difficult issue of the repeal and replacement. That transcript follows the video, both which are below.
Please watch the video for the exact comments.
Pies said that tight after the inauguration the effort is to repeal and replace Obamacare since so many people were disaffected and have been disaffected by Obamacare and particularly with the premium increases, the high deductibles.
She thought there was a chance Mr. Trump would win and so, with the victory, she is “cautiously optimistic” though because she said there are “few things in his plan that I don't agree with” but the names “that are being touted for the Secretary of HHS, there's some very good name there including Dr. Tom Price Member of Congress is very good on healthcare and medical doctor. “So cautiously optimistic that Obamacare will be repealed and replaced”. The expert said, “that would have of course be done through budget reconciliation because the Republicans have over only 51 seats in the Senate and to actually repeal the whole bill they would need at 60 votes so that in order for it not to be filibustered”.
In response to a question what are the things she does not like about the current law, the list was long. She said, “there are a number of things that I don't like about it-- the individual mandate, the employer mandate, the way the subsidies were set up, the essential benefits plan which means that insurers have to provide a plan that covers all of these various rulesmandatesregulations. So there are many aspects of it I don't like. The individual mandate $695 dollars or 2.5% of income because you know it didn't encourage young people to sign up for Obamacare. I don't like the mandate that it was put on employers, I don't like the Independent Payment Advisory Board which was part of it but it never actually being implemented by the President and I'm hoping that it will be removed in the repeal. I also don't like the Medicaid expansion part 19 states have not extended their Medicaid programs but it led to tremendous increase in cost now the additional 15 million people that signed up for Medicaid under the expansion plan many of them now instead of going to the doctor the problem is that doctors won't take these Medicaid patients because the reimbursement rates in the government or so low, so contrary to whatthe PresidentObama wanted more of these medical people are now going to emergency room for their care which was not supposed to happen. “
Pipes also said, “there are about 75 million people in America on Medicaid now but so many of them are having a hard time getting an appointment with a doctor, the waiting list are long or doctors are saying we are not taking these Medicaid patients, so emergency room which is very expensive care is on the upswing according to the latest studies that we have just seen. Those states that did take the extra funding the 31k from the District of Columbia are finding that the tremendous increase costs in their budget even though they're getting funds from the feds for the expansion plan. “
“I think what what's going to be interesting will be to see what that what Trump what the reconciliation bill looks like and if the Medicaid expansion is going to be eliminated, what will the Secretary of HHS do and of course your former governor Bobby Jindal is one of the short names.”
“Trump has said that he and in the same way that I do and that the Speaker of the House Paul Ryan does--that the best way would be for the feds to send the money in a block grant to the state and let the state design their Medicaid program one that best suits the residence of state of Louisiana. “
“I know when you look at the size of the US population where what 330 million people in 2016 the administration and the Centers for Medicare & Medicaid Services said that 12.8 million people had signed up for Obamacare and of course eighty-five percent of those people are eligible for the subsidies from the federal government but it's a very small number and they've actually the HHS the Department of Health and Human Services have downgraded at 12.8 million.”
“About 11.1 million, it will probably go even further down when all is said and done, because a lot of people that sign up do not pay the premium”. Pipes also said there are issues as to whether the patients can prove that they're American citizens “so it's a tremendous cost for a very small number of people and then when you look at the difficulties that these people are having because of the premium increases--so say--you have 20 million people about say 11 million on the exchanges and then about 9 million signed up for individual coverage-- know when you're looking at premium increases for next year on average of twenty-two percent and for those people and the healthcare.gov in 39 states with their premium increases are going to be supposedly twenty/twenty-five percent increase contrary completely to what the president said American people when he said the average family would see their premiums go down by twenty-five hundred dollars. So premiums are way up a lot of these people these people that are that that now have coverage 20 million people are finding it difficult to pay the premium but with a deductible in the range of six thousand dollars for an individual and about 12,000 for a family they have coverage but they can't afford to use it because they can't afford to pay that deductible, so what good is having insurance if you can't can't afford to use it? So we need to get rid--repeal and replace Obamacare and we need to get rid of the essential benefit plan so a lot of these people could then get the type of plan that they can actually afford and suit their needs and they don't have to cover all of these essential mandates which add twenty to fifty percent to the cost of premiums.”
Below is the second half of the interview with Sally Pipes. This is the transcribed text and it specifically deals with the issue of the process of repeal andreplace it.
The reason I am emphasizing this part of the conversation is because it focuses on the actual process. I have been confused and somewhat upset over what I have considered being games played, in this case, by the Republican Party, in connection with the repeal and replacement process. Over the roughly five years process since the passing and the implementation of the legislation, the “cause of existence” for many republicans has been repeal Obamacare and replace it with a different structure.
The Republican Congress has actually attempted to repeal Obamacare around 60 times. Early this year, the legislation actually passed the Congress but was vetoed by President Obama.
At no time during the 60 attempts has there been a replacement available if, somehow, the law had been repealed. Which, to me, meant that either the Republican Congress engaged in the repeal process purely for political show, or, they entered into the repeal Obamacare without any backup plan.
Which meant, the Democrats passed a law on a partisan basis, impacting one-sixth of the economy without the Congressional members even reading the legislation and the Republicans tried to end the law in a way that could have caused massive disruption to almost all insurance plans including Medicaid.
Over the past few years, election after election, the focus was upon Obamacare, lawmakers used it for political purposes, making statements such as “the first day I take office, I will repeal the law”. Even Donald Trump said he would repeal Obamacare on day one of his administration.
For two years, I have written about this issue and the impact a sudden repeal would have upon the healthcare industry, pointing out, in my view, the dangerous andfalse promisesthe Republican Party has been making, including the current President-elect.
Indeed, the Affordable Care Act is in trouble. Whether it will fail and how it will be fixed or replaced is another issue. The question is, can the Republicans create an approach to health insurance that is market driven, that reduces costs, makes insurance accessible to as many people as possible and without pre-existing injury coverage protections. That remains to be seen, but, I think all of us would like to see them succeed in trying.
Here is that part of the interview:
SABLUDOWSKY: Let me throw something out toyou,because I am really looking for an answer to one major issue as I see. And let me just give you background, about it real quick, about 2 years ago, maybe more than 2 years ago, in a conversation I was having with other attorneys, I was thinking, if they repeal Obamacare that means that you repeal something, it's over, the law is over. So that's something I asked my fellow attorneys, so what happens If you
Repeal? You have nothing right? You go back to where you were? I mean what happens? So you have this ending. So I started to investigate, I started writing about it. We had a couple elections, I started asking, “somebody tell me what to do here , tell me what the answer is here”. And I wrote about it during the election, the most recent election, I still haven't gotten any answer about it. And I did see on CBS, the question was asked about interruption, and he (Trump) denied that there would be any interruption in the coverage and said that he wanted to have preexisting conditions coverage, and of course the insurance for those of 27 age 27 years old, I believe, I don't get it, I don't see how-- I'm not saying that Obamacare should stay, but I just don't see the connection. How do you end it suddenly and still have insurance?
PIPES: It is not going to end suddenly, I mean, if they do repeal the major budget part of the Obamacare under budget reconciliation they're going to have to have a replacement agenda ready to go. Whether it can be part of that reconciliation or whether they're going to introduce new legislation but as Trump has said and Paul Ryan has said and as I have said-- first of all, there will be a transition period for the exchanges so probably a two-year transition and you have to remember that a number of the insurers--Aetna, United, Humana, Anthem are probably not going to be, they're going to get out of a lot of the exchanges next year--Anthem is only going to be in four states--so but the exchanges will continue for two years
PIPES: the people....
SABLUDOWSKY: If the law is repealed, though, if the laws repealed
PIPES: It can't be repealed, though. It can't be fully repealed, that is theissue,because they're only going to be able to use budget reconciliation which will only get rid of the budget part of Obamacare
PIPES: And, then, they're going to come in with a replacement that you know allows the exchanges to continue for two years, kids to stay on their parents plans to age 26--the idea about the people with pre-existing conditions that--these are people that are in the individual market not employer-based, but they would be able as long as they continue to pay theirspremiumsthey couldn't have a tremendous increase. And, then there will be high-risk pool introduced about 25 billion dollars over ten years from thefeds,so that people with pre-existing conditions would be able to purchase affordable coverage in those high-risk pools. So those things are going to happen because they can't repeal a whole law under the present
PIPES: 51 people in the Senate
SABLUDOWSKY: Even if they had 60 if they repealed it, if there was nothing to replace it, insurance companies could say "well, I'm sorry but you know you're covered under Obamacare, it doesn't exist anymore" see that's one ofthingsthat have really have had a problem with because you know, for over 60 times Republicans were saying" we're going to repeal, "we're going to repeal, but it would end insurance for these people
PIPES: Well itwon't,because as I said, there's going to be and it's been promised by Trump and by right---there will be a replacement agenda
SABLUDOWSKY: This time. Yea, this time, because of reconciliation
PIPES: But there will be a replacement agenda, if you look at what's in Paul Ryan's "A better Way", they're going to get rid of the employer mandate, the individual mandate, that insurance companies will then be able to offer a variety of products that have different types--I want a health care plan that covers alcohol rehabilitationishould be able to get one but you shouldn't have to buy one that you have to bear the burden of what it what it cost, cost me, so, we'll have a state-based tort reform, we will block grant Medicaid, there will be changes to the Medicare program because which when it came into being in 1965, people only lived to age 65. Why should people like Warren Buffett be eligible for Medicaid? We will have, it will level the tax code, so that, because people who have a hundred andfifty fivemillion people who have employer-based coverage, they get their coverage tax-free. But if you're in the individual market, you have to buy your coverage with after-tax dollars. We need to level that playing field and then allow, what will happen is they will also bring in age-based refundable tax credits so if you're younger you're your tax credit will be lower if you're older it will be higher, and it would go to you the person, so that you can purchase the type of coverage that you need.
PIPES: So we've got aged-based refundable tax credits, we will have high-risk pools, we will be able to people who keep their coverage on a continuous basis won't be subject to huge increases intherecosts, so there's a number of things that are in a replacement plan--it's not going to be Obamacare is gone and there's nothing to replace it.
SABLUDOWSKY: Ok, so two last questions, one, in terms of the reconciliation thatmeansit will be, assuming that it passes and I have no doubt that it will, that means what will happen? It will be defunded. Parts will be defunded
PIPES: But only parts of it will be defended and, of course, they have to also, through a continuing resolution, get a budget passed because until September302017. So they will under the reconciliation, they will end the individual employer mandate, the subsidies, the Medicaid expansion and IPath, but then they're going to, right away, we introduce this replacement plan which I've talked aboutwhat whatthe components of that will be so people will not be left at the 20 million people who have either exchange coverage or individual market, they will not be turfed out onto the street. But they will have options, to get a different type of plan, and as I said, a lot of those people who have plans now can't afford to use them so it's basically useless.
SABLUDOWSKY: Ok ,when they introduce a replacement plan I mean immediately?
PIPES: Well there are two ways they can do it--one they would introduce the reconciliation bill which would include repeal and replace or they will do the reconciliation bill and then shortly after that they will re-intro, they will introduce the replacement plan. I mean, I'm not part of the transition team of the administration, so I don't--but those are those that that's what's out there thatthere'stwo ways that it'll be done.
SABLUDOWSKY: And just, I guess, the last question on this point and that is-- if they repeal, I mean, they would have to have the replacement plan sewed up, tied up,imean becauseotherwisethey will be a gap
PIPES: Right, and they've made that very very clear, so the replacement plan, so the American people--i think the reason that Trump won the election is--because when the people realized what was going to happen to them in 2017 with their premiums, their deductibles and the small network of doctors and hospitals that are available--and in many states they would only have access to one plan, and many states only HMO plan, which the American people don't like--so this is what, the American people want this, and the newly elected president and the house and members of the Senate realize this--so they're on board to bring that replacement plan in right away, either as part of the repeal and replace or repeal with a second replacement plan, right away right after the inauguration as well.
SABLUDOWSKY: I really appreciate you're explaining this, I'msurehave some other questions that you may hopefully in a futuretime..right now,ireally do appreciate--I need to think about the various things that you'vesaid,and try to figure out whether or not,I'm sure the House needs to look at that, alsoidon't know that they really have thought through this, but hopefully
SABLUDOWSKY: I hope they have, they ran, they ran on it, they promise to the American people
PIPES: Yes, but it was reallygeneralthough, I mean, we'll going to repeal and replace you know they didn't go through this system, the questions
"A Better Way", which is the Ryan plan, which is a really good plan, now the issue is they have to turn that into a legislative bill and then bring out the cost, how much it's gonna cost-- they have a lot of work to do, but that's what we the taxpayers are paying them for.
Absolutely, thank you so much.