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Does the Affordable Care Act Guarantee Healthcare as a Right?

Does the Affordable Care Act Guarantee Healthcare as a Right? | Healthcare and Technology news |

In his recent celebratory remarks after the Supreme Court (SCOTUS) upheld the legality of subsidies/tax credits under the Affordable Care Act (ACA), President Obama had this to say: "Five years ago, after nearly a century of talk, decades of trying, a year of bipartisan debate -- we finally declared that in America, healthcare is not a privilege for a few, but a right for all." (1)

It would be good if this were true, but it is not. Healthcare as a right has been debated over many years, but is still not in place for all Americans as this country remains an outlier among advanced industrial countries around the world. Instead, despite the ACA, we continue to have a patchwork of ever-changing programs assuring access to health care for some people some of the time.

Let's look at what we do have in this respect. In the 1960s, Congress established a broad right to health care under statutory law by enacting Medicare, Medicaid, and the Children's Health Insurance Program (CHIP) for the elderly, disabled, people living in poverty, and children. In the 1980s it passed the Emergency Medical Treatment and Active Labor Act (EMTALA) requiring all Medicare-funded hospitals with emergency departments to provide appropriate emergency and labor care. More recently, Congress passed the Mental Health Parity and Addiction Equity Act (MHPAEA) in 2013, which assures a right to equal access to care for patients with medical and mental health problems. SCOTUS has established a right to health care for prisoners and has protected some limited rights for women's reproductive care (2), but has never interpreted the Constitution as guaranteeing a right to health care for all Americans. In fact, the words "health," "health care," "medical care," and "medicine" do not appear in the Constitution. (3) 

It is disingenuous to claim that health care is a right in the U. S. when we consider these inconvenient facts:

  • 35 million uninsured, plus another similar number underinsured.
  • The first question asked of us in seeking care is "what is your insurance?"
  • 21 states have opted out of Medicaid expansion under the ACA.
  • Medicaid eligibility and coverage varies widely from one state to
  • another, in many cases falling far short of necessary care.
  • As the costs of insurance and health care continue to rise and shift
  • more to patients, a growing part of the population cannot afford either and forgo seeking care.
  • More than 40 million Americans now have an account in collection for medical debt. (4)

This situation stands in sharp contrast to elsewhere in advanced societies. Healthcare has been recognized as a right since 1948 when the General Assembly of the United Nations adopted a Universal Declaration of Human Rights including access to health care. (5) The right to health care was also later adopted by the World Health Organization (WHO) in its Declaration on the Rights of Patients. (6) As a result, most of Western Europe, Scandinavia, the United Kingdom, Canada, Taiwan, and many other countries have one or another form of national health insurance assuring access to care for their populations. Here we spend twice as much and still have no universal access to health care.

Can we ever see this country coming around to universal access to health care based on medical need, not ability to pay? The record shows that we never can, or will, as long as we permit corporate stakeholders in our medical-industrial complex to call the shots, and as long as they succeed in perpetuating our exploitive for-profit system. There is a fix -- single-payer national health insurance, as embodied in H. R. 676, Expanded and Improved Medicare for All.

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Mixed Effects Are Seen on an Affordable Care Act Repeal

Mixed Effects Are Seen on an Affordable Care Act Repeal | Healthcare and Technology news |

The nonpartisan Congressional Budget Office said Friday that repealing the Affordable Care Act would significantly increase federal budget deficits and the number of people who are uninsured.

But, it said, repealing the law would also raise economic output because it would create incentives for some people to work more.

The estimates came in the first major study issued by the new director of the budget office, Keith Hall. It was also the first report to use new methods of fiscal analysis, according to instructions from the Republican majority in both houses of Congress.

Repealing the law would increase federal budget deficits by $137 billion in the decade from 2016 to 2025, Mr. Hall said in the report. In addition, he said, the number of uninsured people, estimated at 35 million under current law, would increase by 24 million if the law was repealed.

Mr. Hall itemized the likely changes: Fourteen million fewer people would be enrolled in Medicaid, and 18 million fewer people would have private insurance purchased on the open market or on public exchanges established under the health law. But eight million more would have coverage through employers.

The report came as consumers, lawmakers and politicians wait anxiously for a Supreme Court ruling on health insurance subsidies paid under the health care law to millions of people in more than 30 states.

President Obama has repeatedly threatened to veto legislation repealing the health care law, his biggest legislative accomplishment as president, but Republicans keep trying and stepped up their efforts this year after taking control of both houses of Congress.

Proposals to repeal the law are included in legislation being prepared by Republicans to respond to the Supreme Court decision, which is expected within days.

The report by the budget office is sure to be cited by members of both parties as they continue fighting over health care through the 2016 elections. Democrats, defending the law they passed five years ago, can use the report to argue that repealing the law would be a bad move because it would increase the deficit. Republicans can use it to argue that the law itself is bad.

Senator Michael B. Enzi, Republican of Wyoming and the chairman of the Senate Budget Committee, said the report showed that “repealing the president’s health care law will increase economic growth.” But Representative Nancy Pelosi of California, the House minority leader, said it showed that “repeal will explode the deficit.”

The budget office said that repealing the law — with its insurance subsidies and expanded eligibility for Medicaid — would increase federal budget deficits by $353 billion in the coming decade, largely because the government would forgo big savings in Medicare and would lose revenue from new taxes and fees. But after taking account of the positive economic effects of a repeal, it said, the increase in the deficit would be $137 billion.

The law tends to “reduce the supply of labor by reducing some people’s incentives to work,” the report said. Repealing it would reverse those incentives and could increase the output of goods and services, the gross domestic product, by seven-tenths of 1 percent, the study said.

The insurance subsidies, along with expanded eligibility for Medicaid, “generally make it easier for some people to work less or to stop working without losing health insurance coverage,” the report said.

■ The government would lose $167 billion in penalty payments from large employers, who are supposed to offer insurance to full-time employees.

■ It would lose $87 billion from eliminating a new excise tax on certain employment-based health plans with relatively high premiums. Under current law, revenue from this “Cadillac tax” will grow rapidly as more health plans are affected each year, starting in 2018.

■ It would lose $346 billion in new taxes paid by high-income people, $142 billion in fees paid by insurance companies and $54 billion in fees paid by manufacturers of prescription drugs and devices, provisions of the health care law meant to help pay for it.

■ It would save $822 billion because it would no longer subsidize some private insurance bought through the exchanges.

■ It would save $824 billion in Medicaid and the Children’s Health Insurance Program.

But, the budget office said, repealing the health law would accelerate Medicare spending, which has been growing at an exceptionally slow rate.

The law throttled back the growth of Medicare payments to hospitals,nursing homes, health maintenance organizations and other providers. Repealing it would undo those savings, and as a result, Medicare spending would rise by roughly $800 billion over 10 years, the report said.

The report analyzes the economic effects of the health care law and the ways in which those effects may, in turn, influence federal spending and revenues — a technique known as dynamic scoring. Democrats fear that Republicans will use that approach to help justify tax cuts. But at least in the report on Friday, Mr. Hall was cautious in using the new technique and carefully documented the economic assumptions that led to his conclusions.

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Shared Responsibility in the Affordable Care Act

Shared Responsibility in the Affordable Care Act | Healthcare and Technology news |

Recently we wrote that it was well past time to end the employer mandate in the Affordable Care Act.  In light of some commentary, we thought it best to revisit this issue in more detail.  It seems that most of the support for the employer mandate comes from a misguided understanding of why employers are currently the primary source of private health insurance.  It is explicitly not because of a sense of “responsibility” to the employee, at least not any more responsibility than they feel when they pay employee wages for their work.

Here is a basic summary of how labor markets work, based on decades of very widely accepted academic research and practical experience. Employees receive compensation from their employers in return for their work product.  In other words, employers aren’t running charities for their workers, but neither are workers volunteering their time at firms.  Each expects something from the other. Some employee compensation comes in the form of cash wages and some in the form of fringe benefits such as health insurance, pensions, free coffee, parking, etc.

Either explicitly or implicitly, employers and employees negotiate these compensation packages with employers attempting to craft the least expensive package that the employee will accept.  Firms know they can offer employees tax free income in the form of health insurance and they exploit this feature of the tax code to the benefit of both employees and employers.  And for a variety of reasons, prior to the exchanges, it was often much easier for employers to purchase insurance than it was for employees to buy it on their own.  As a result, many Americans get insurance from their employer.  As an added “benefit” of this system, the whole country likely spends more on health insurance than we otherwise would and the federal government provides more tax benefits to the rich than to the poor.

It should be clear from this point that employers are not “giving” their employees health insurance.  We know this because when health insurance gets more expensive, wages don’t grow as quickly.  This is because employers are only interested in the cost of the total compensation package, and if health costs go up, wages must go down.

Failing to understand these basic economic points leads to poor arguments and harmful policies.  For example, in a recent Viewpoint in the Journal of the American Medical Association, John McDonough and Eli Adashi make an impassioned plea in favor of keeping the Section 1513 of the ACA also known as the “Shared Responsibility for Employers.”

Congress’ decision to call the requirement of employers to provide health insurance or pay a fine as a “shared responsibility of employers” is a master stroke of propaganda to which we must tip our hats.  However, we must see through this cute turn of phrase and realize that this section of the ACA simply enshrines some of the worst aspects of our current health insurance system and actively works against many of the actual goals of the ACA.  Unfortunately, McDonough and Adashi have their blinders on.  They state, “[t]he core value undergirding the shared responsibility principle is the realization that all of the major stakeholders of the health care system must contribute something if comprehensive health care reform is to be accomplished. Stated differently, making the ACA work requires a measure of  responsibility from consumers, hospitals, physicians, insurance companies, drug makers, medical device makers, home health agencies, labor, and—because of section 1513—large employers.”  This argument amounts to a bit of a tautology.  Large employers are a stakeholder in the health care system because we mandate them to be a part of it [under section 1513] and because we mandate that they offer insurance they are a stakeholder in the health care system.  McDonough and Adashi never ask the more fundamental question:  Why should employers even be part of the health care system to begin with?  If we are trying to implement health reform, shouldn’t we be looking to end those aspects of the system the create large distortions?

They then go all in by stating that the shared responsibility is a “public good especially for employers who might otherwise be inclined to shift the cost of employer sponsored health insurance onto the federal government and thereby the taxpayers.”  Much like calling the employer mandate a “shared responsibility,” saying that this is also a public good is at best a misapplication of the term. In economics we define a public good as having two characteristics:  you cannot stop another person from using it and its value doesn’t decrease when another person does use it.  Clean air and national defense are quintessential public goods.  But health insurance?  (This is hardly the first time that JAMA has published egregiously incorrect economic arguments.  We note in passing that the American Economic Review has the good sense not to publish medical studies.)

Then there is this question of “shifting the cost” of ESI onto the government.  This notion ignores that the burden of ESI already falls on the government because these benefits are exempt from incomes taxes. According to the White House Office of Management and Budget, in 2012 this cost the federal government approximately $170 billion.  Given the progressive nature of the United States Income Tax Code, this tax break is exceptionally regressive with an estimated five sixths of the benefits of the exemption flowing to the top half of the income distribution.  If employers stop offering health insurance, the competitive market for labor will force them to increase wages.  Because health insurance costs are roughly independent of wages, the resulting wage increase will be larger, in percentage terms, for lower income workers.  At the same time, federal tax receipts will increase and, given the progressive nature of the tax code, more of this money will come from richer Americans than from poorer Americans.  And if Congress could ever get its act together on tax reform, this could be part of a grand bargain resulting in lower overall marginal income tax rates.  This is what happens when you eliminate massive inefficiencies – everyone wins.  (Well, the bloated health sector would lose, as individuals might purchase less generous health insurance.  But isn’t the point of ongoing health policy to relieve us of this bloat?)

Firms that stop offering ESI could shift costs to the federal government to the extent that lower income individuals would now qualify for subsidies on the ACA exchanges.  We find it perplexing that ending the horizontal inequity of the ACA (i.e. the individuals with similar assets, income, and family structure face meaningfully different tax liability based on whether they get insurance from an employer vs. the exchange) would be seen as a negative.  Certainly this aspect of the ACA should be seen as a bug and not a feature.

We should also note that removing the employer mandate is not the same as ending employer provided health insurance. As noted health economist Mark Pauly has said many times, employees may value the services of their employers as a knowledge broker for insurance. In addition, firms with a high percentage of relatively well compensated employees may find it is economically advantageous to give up the subsidies on the exchange in order to retain their tax free insurance (though this seems to be more of an argument in favor of ending the tax exemption).  All we are asking for by ending the mandate is allowing the exchanges to compete on a more even footing with ESI.  Even if we do not eliminate the perversions of the current tax code, ending the mandate would benefit many employees and create a thicker and healthier market for the exchanges which should improve both the options and pricing

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The Supreme Court's Surprise Ruling Saves Obamacare

The Supreme Court's Surprise Ruling Saves Obamacare | Healthcare and Technology news |

The Affordable Care Act survived its second major challenge at the U.S. Supreme Court on Thursday. In a 6-to-3 decision, the justices ruled that the Internal Revenue Service can continue to provide health-insurance subsidies to middle-class people living in all states.

At issue in the case, King v. Burwell, was whether the subsidies should go to residents of the roughly three dozen states that use the federal health-insurance exchange, in addition to those who live in states that run their own exchanges.

It’s a highly technical difference, but had the decision gone the other way, Obamacare might have unraveled. Individuals who receive these subsidies make less than $48,000 per year, and many would struggle to afford health-insurance plans without the government’s financial help. Health-policy analysts feared that, without the subsidies in place, healthy people would withdraw from the health-insurance exchanges in large numbers. That, in turn, would cause premiums to skyrocket, making insurance unaffordable to almost anyone who does not receive insurance coverage through their jobs.

The Affordable Care Act gave states the option to either set up their own exchanges or to rely on the federal government’s marketplace through The part of the law that describes the subsidies said they should only apply to people in the exchanges “established by the state.” The plaintiffs in the King case said that clause meant the IRS was offering subsidies to residents of federal-exchange states illegally.

In the opinion of the Court, Chief Justice John Roberts dismissed the idea that the fate of the entire Obamacare law should hinge on such a technicality.

“In petitioners’ view, Congress made the viability of the entire Affordable Care Act turn on the ultimate ancillary provision: a sub sub-sub section of the Tax Code,” he wrote. “We doubt that is what Congress meant to do.”

Many patient advocates cheered the decision. “It means that millions of people with serious health conditions such as cancer will continue to have access to essential treatment and care, and millions of others at risk for disease will be able to afford preventive screenings and tests that could save their lives,” said Chris Hansen, president of the American Cancer Society’s advocacy arm, in a statement.

Justices Antonin Scalia, Clarence Thomas, and Samuel Alito dissented, writing, “Words no longer have meaning if an Exchange that is not established by a State is ‘established by the State.’”

Roberts concludes by saying that the Court is attempting to respect what Congress hoped to accomplish in passing the law: “Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them.”

There are still a few, more minor, legal challenges to Obamacare remaining. But at least for now, the law lives to see another day.

Jannell Alino's curator insight, August 27, 2015 7:43 PM

Congress passed the Affordable Care Act and the Supreme Court ruled that the IRS will be able to continue to administer health insurance to middle class people to all in the United States. If this did not pull through Obamacare would have left thousands of people without insurance and helpless. Many who are on Obamacare make less than 48K a year and need assistance from the government. If this were to happen a large number of healthy people would withdraw from health insurances causing prices to go up and then no one would be able to afford health insurance! The Affordable Care Act gives states the option to set up their own exchanges or rely on the government. With the passing of this act people suffering from serious illness will be able to care and have access to treatment as well as others who are susceptible to illness. Some conclusions that can be drawn from this article are that by the passing of this act thousands of citizens are still able to have health insurance and do not have to pay with an arm and a leg. Yes this argument is logical because it would be irrational to take away a program that has aided so many Americans in getting the health care they need. This relates because if this act was to fail our health insurance prices would go up and going to get a simple checkup would cost a fortune! I think it is great that the congress passed this act because I would want everyone to be able to have the privilege to seek out help if they were ill. No there is no bias, it is objective to all citizens in the united states.!

ACA's Mandate To Buy Coverage May Be GOP-Friendly

ACA's Mandate To Buy Coverage May Be GOP-Friendly | Healthcare and Technology news |

Whether it’s a penalty to pick a drug plan under Medicare or the new Republican proposal to replace the Affordable Care Act or the President’s health law alone, penalties abound for being uninsured.

A new analysis by the Urban Institute said “individual responsibility” requirements akin to the controversial individual mandate included in the Affordable Care Act requiring individuals to buy coverage or face a tax penalty also exist in other health reform proposals and existing health insurance programs.

Some, like the Medicare Part D drug coverage for seniors and Medicare Part B’s physician services for the elderly, have been in place for years. Another, a new Republican proposal to replace the ACA, also has its penalties.

The so-called “Patient Choice, Affordability, Responsibility, and Empowerment Act” or PCARE, proposed by Republican Rep. Fred Upton of Michigan and GOP Sens. Orrin Hatch of Utah and Richard Burr of North Carolina would “impose strong penalties on the uninsured,” Urban Institute health policy researchers Linda Blumberg and John Holahan wrote in their analysis out this week called, “the New Bipartisan Consensus for an Individual Mandate.”

“Specifically, if individuals fail to maintain continuous coverage, they can be medically underwritten or effectively denied insurance in the nongroup market,” the Urban Institute’s authors wrote of the Hatch-Burr-Upton legislation. “Medicare Parts B and D also have provisions that penalize individuals for failing to promptly enroll in coverage for the same reason, yet this approach to an individual mandate has not been controversial.”

All of the proposals share the common thread that health insurance, particularly coverage that involves the private insurance market, need an individual responsibility component to ensure healthy people are in the insurance risk pool. Without healthy people buying coverage and paying premiums, claims submitted largely by sick policyholders would lead to soaring health care costs.

The individual responsibility provision has long been the stance of health care interests like the American Medical Association and the health insurance lobby, America’s Health Insurance Plans, which represents Aetna (AET), Cigna (CI), Humana (HUM), UnitedHealth Group (UNH) and most Blue Cross and Blue Shield plans.

“If you want to keep a private market-centered approach and prevent discrimination in insurance against those with health problems, you have to have a mechanism that brings in and holds in the healthy,” Blumberg, seniors fellow at the Urban Institute’s health policy center told Forbes in an interview. “You have to have an individual mandate to hold the healthy into the insurance risk pools.”

The GOP’s Obamacare replacement requires individuals to have insurance “continuously for 18 months to be guaranteed access to a private nongroup insurance policy,” the Institute said in a statement accompanying their analysis. Meanwhile, the ACA imposes tax penalties for those individuals who go without insurance for more than three months in any given year. And Medicare Parts B and D have penalties that are much steeper than the ACA’s for those who delay enrolling after they become eligible.

“Under both programs, penalties are assessed on those who enroll, disenroll and then enroll again,” the institute fellows wrote.

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1 In 4 New Doctors Would Change Careers If They Could Start Over

1 In 4 New Doctors Would Change Careers If They Could Start Over | Healthcare and Technology news |

Even as doctors enter a medical field with more paying patients under the Affordable Care Act and unprecedented numbers of job opportunities, 25 percent of “newly trained physicians” would still choose another field if they could, according to a new analysis.

More than 60 percent of doctors-in-training who were in the final year of their medical residency last year received at least 50 job solicitations during their training, according to a survey by physician staffing firm MerrittHawkins. Another 46 percent received at least 100 job solicitations.

“There are simply not enough physicians coming out of training to fill all the available openings,” MerrittHawkins president Mark Smith said.

This comes amid a physician shortage, changing payment structures and new regulations and paying customers under the health law that are creating more opportunities yet anxiety among doctors as they enter this new order.

“The paramount thing on new doctors’ minds is: will I have a life,” said Phil Miller, vice president at MerrittHawkins, a division of AMN Healthcare (AHS). “They are running into a maelstrom and there are all sorts of changes taking place.”

Merritt executives say it shouldn’t be surprising that 25 percent would select another field of study if they had to start over with their education given the turbulent environment they face.

The 2015 survey of residents in their final year of medical residency, which tallied more than 1,200 responses last year from a sampling of 24,000, indicates young doctors are ready to enter a world of “9 to 5” employment rather than launching their own private practice. More than 90 percent said they preferred employment with a salary rather than an “independent practice income guarantee.”

The more predictable hours young doctors want comes after four years of medical school and three to five years of residency, often with long hours and an exhaustive schedule.

Here are some other survey highlights from residents in their final year:

  • 78 percent expect to make at least $176,000 in their first year of practice
  • 39 percent are unprepared to handle the business side of medicine
  • 2 percent preferred a solo setting as their first practice
  • 93 percent preferred to practice in communities of 50,000 or more people

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