Posted: September 20th, 2022
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The reflection paper is based on three videos and several journal articles and has its own Assignments and due date.
The videos to watch are Sicko (available on Vimeo and other sites for free viewing), and two more on PBS Frontline entitled ‘
Sick Around America
‘ and ‘
Sick Around the World
‘, also free viewing. Links are in D2L contents. These videos document healthcare in the U.S. before the Affordable Care Act and contrasts the U.S to other developed countries.
Also read the three journal articles in contents Module 5 authored by Dr. Moore. They are entitled:
a. ‘Determining the Effects of the Trump Administration’s Erosion of the Affordable Care Act on Americans Needing Healthcare’ (2020)
b. ‘Why Universal Healthcare is a Trend in the U.S.’ (2018); and
c. ‘Teaching the Affordable Care Act to Aspiring Healthcare Administrators’ (2016).
Two other links in Module 5 lead to other articles available on the Kaiser Family Foundation website. These offer additional background regarding current constitutional threats to the Affordable Care Act from the Trump administration.
Your assignment is to write a paper documenting your reflections on healthcare reform in the U.S. after viewing the videos and reading the articles. What is your assessment of healthcare in America relative to other developed nations? What trends do you see in the U.S. healthcare system? What would you like to see happen? What policy or legal changes would facilitate your vision becoming reality? Use and cite the articles and videos to support your assessment and observations. Be sure to title your paper and state in the beginning its purpose and the questions you will address. The paper should be about 3-5 pages, double spaced, and be submitted into the Assignments designated ‘Module 5 Reflections on Healthcare Reform Paper’ by its due date
Sicko: the movie
Sick Around America
Sick Around the World
Determining the Effect of the Trump Administration’s Erosion of the Affordable Care Act on Americans Needing Healthcare
Gregory A. Moore
Professor, Health and Human Performance
Austin Peay State University
Clarksville, TN 37040
March 8, 2020
The purpose of this paper is to determine the legal and economic effects on the Affordable Care Act (ACA) from recent attempts by the Trump administration to undermine the law. After failing to repeal the law and seeming to lack the patience to see if it will unravel on its own, the Trump administration has used executive orders and administrative agency rules to take steps designed to reduce consumers’ ability to benefit from the law. The enrollment period was cut in half and the marketing budget to promote enrollment cut 90%. Trump cancelled Cost-Sharing Reduction subsidies for those lower-income buyers in the healthcare insurance exchanges. Insurers are being allowed to sell short-term and Association policies that do not meet the ACA regulations for minimum benefits. The Republican controlled Congress repealed the tax penalty for those not having insurance beginning 2019. (Center for American Progress, 2018). The projected net effect of these acts means millions will forego or not be able to afford insurance (Beaton, 2018: Levitz, 2018). Insurers can circumvent ACA rules regarding pre-existing conditions and sell plans without minimum benefits. The young and healthy will leave the insurance market, causing premium prices and costs to rise for those needing insurance and healthcare. (Beezley-Smith, 2018) All but the repeal of the tax penalty mandate can be changed immediately by the next presidential administration and its administrative agencies. Those states that did not support the ACA will find this administration helpful in undermining the law. Those states that have supported the ACA, can exercise their state powers to promote the law at their level. The ACA was operating soundly at the time Trump took office. The damage these recent acts might have will depend in part on how long they are in place. One also finds that the acts lack any ideology, appearing to be more disruptive and malicious than attempting to achieve any policy purpose (Dickinson, 2018). Upon learning Trump dismissed a bi-partisan effort Senator Lamar Alexander (R-TN) was working on to fund the subsidies for the exchanges, the Senator asked, “What’s conservative about creating chaos so millions cannot buy health insurance.” (Williams, 2017) Ultimately the effects of the sabotage are not uniform across all states and some consumers will benefit from the continued operation of the ACA.
Introduction, Focus, and Research Question
Although failing to repeal the Affordable Care Act (ACA) the Trump administration and Republican controlled Congress have continued their efforts to undermine the law. The full frontal attack to repeal the ACA failed, so with the exception of Congressional legislation repealing the tax penalty for not having insurance, the activities being used are executive orders and administrative agency rule changes. The purpose of this paper is to identify what actions have been taken to attempt to undermine or erode the ACA. Next an analysis will be done to determine what damage or benefits there have been to the ACA and those needing healthcare. Finally, we will assess what those needing healthcare can expect from the ACA in the future. The focus will be on the legal, policy, and economic issues. Political and ideological issues will be addressed only as they tangentially relate to our primary focus.
The Trump Administration’s Efforts to Undermine the ACA
The Health of the ACA When Assumed by Trump in 2017
When Trump assumed office the Affordable Care Act (ACA) was operating soundly. Abelson (2017) observed that in the early months of 2017 the insurance markets had been stabilizing and insurers were becoming more profitable. However, in August of 2017 insurance company representatives began to worry about the threats and unknowns from the Trump administration (Abelson, 2017). Sperling and Jennings (2017) reported that the healthcare industry expected to be stable and the Congressional Budget Office agreed. Juan Williams (2017), an author and political analyst for Fox News Channel, remembers Trump promised, “Were going to have insurance for everybody. We’re going to have healthcare that is far less expensive and far better.” Williams says he is still waiting. Williams also notes that a Kaiser Family Foundation survey said 77% of Americans wanted Trump to make the ACA better. Sam Berger, Senior Policy Advisor for the Center for American Progress stated the ACA was not unraveling, as Trump claimed at the time, but was quite strong (Holland, 2017). Holland (2017) said the law was working very well when Trump took office despite Trump’s mantra that the ACA was imploding. Medicaid expansion under the ACA took effect in 2014 and the numbers of uninsured dropped from 18% down to 10.9%, an all time low (Holland, 2017). Since Trump took office, the number of uninsured has risen to 12.3%. The trend to greater coverage and fewer uninsured under Obama has reversed (Holland, 2017). Dickinson (2017) observed that Trump’s self-fulfilling prophecy was that the ACA would fail and Trump has done whatever he can to ensure that.
The Acts of Erosion by the Trump Administration
Holland (2017) says the core of undermining the ACA has been a concerted effort by political appointees in the White House and the Department of Health and Human Services to ensure the ACA doesn’t work. The Center for American Progress (2018) has identified a number of acts that are the essence of the effort. The enrollment period to sign up for insurance plans in the healthcare exchanges has been cut in half. The advertising and marketing budget to promote open enrollment has been cut 90%. Other sources have confirmed these acts and listed others. Levitz (2017) cites the fact the Trump Administration openly encouraged Americans not to enroll in exchanges for health insurance as convincing evidence Trump is trying to undermine the ACA.
Other more serious acts of sabotage have been cited by other sources (Benen, 2017; Caldwell, 2017; Copeland, 2018; Holland, 2017; Kaiser Family Foundation, 2018; Levitz, 2018; Levitz, 2017; Norris, 2017; Sperling and Jennings, 2017; Vartorella, 2018; Williams, 2017.) These acts have been implemented by executive order or through changing rules in administrative agencies. The ACA was designed to operate state level health insurance exchanges in order to create a market where insurance plans could be competitively bought and sold at low cost premiums. Insurers who participate are required to offer only approved plans that guarantee to the consumer a standard set essential benefits like free annual physicals and other preventive care exams. Depending on one’s income a buyer may be eligible for government subsidies that offset the cost of the insurance. These Cost-Sharing Reductions (CSR’s) are for the benefit of consumers and paid to insurers by the government. They typically are for those not eligible for Medicaid, but not able to afford the full cost of insurance.
The Trump administration has begun to erode the exchanges at two levels. The Trump administration has approved states who request them, the ability to offer on a regular basis the sale of plans outside the healthcare exchanges, referred to as short term and Association plans. Normally short-term plans are sold only for short duration until open enrollment, but now Trump is allowing these to replace the approved ACA plans that meet minimum benefits. Association plans are stripped down versions also sold with less than ACA approved benefits. The second level of attack on the exchanges has been stopping the Cost-Sharing Reductions (CSR’s). Mistakenly claiming these were illegal and only benefitting insurers, Trump stopped the subsidies. When the Obama administration began the subsidies, Congress had not yet authorized the funding for the CSR’s and Republicans sued claiming they were unconstitutional. While still in appeal, Trump withdrew from the suit. Trump gave no consideration to a bi-partisan legislative effort by Senators Lamar Alexander (R-TN) and Patty Murray (D-WA) who were arranging the funding for the subsidies. This prompted Senator Alexander to say, “I would ask what’s conservative about unaffordable premiums. What’s conservative about creating chaos so millions can’t buy health insurance?” (Holland, 2017). The only act of erosion involving the Republican controlled Congress has been inserting into a tax bill the removal of the ACA penalty tax for not having health insurance. These acts are being tracked by several sources (Beaton, 2018; Center for American Progress, 2018; Norris, 2017).
Analysis of the Sabotage on Healthcare and the ACA
The Congressional Budget Office and Joint Committee on Taxation predicts repeal of the tax penalty for not having health insurance will discourage 13 million Americans from participating in the insurance market by 2022. Premiums will grow 20% as insurers hike premiums to offset their losses. Consumer purchases of short-term and Association plans will rise (Beaton, 2018). Copeland (2018) explains consumers will find these plans will not cover the essential benefits an ACA minimum benefits plan covers like mental health coverage, maternity care, drugs, and preventive care. Additionally insurers selling these plans can drop or refuse to cover consumers for pre-existing conditions, as commonly practiced before the ACA. The Center for American Progress (2018) argues the administrative agency policy changes under the Trump administration will interfere with the operation of the healthcare exchanges, scaring insurers away and driving up prices. Cancelling the CSR’s is expected to reduce participation in the exchanges. (Holland, 2017). Hospital admissions will decline (Japsen, 2017).
Republican controlled states will have support from the federal Trump administration working against the survival of the health insurance exchanges and driving up premiums on those who need the exchanges for insurance. Williams (2017) reminds us Steve Bannon, formerly an advisor of Trump’s in the White House had said, “We are going to blow up those exchanges.” Pennsylvania had predicted a hike of only 7.6% in premiums in its exchanges, but now will go to 30% due to Trump’s undermining the marketplace exchanges, especially ending the subsidies for the poor (Williams, 2017). Levitz (2018) projects 5 million will be uninsured by 2019. Analyses by Benen (2017) and Levitz (2018) see the federal government will be paying out more money after discontinuing the subsidies. By ending payments to insurance companies in the exchanges, insurers will be driven from the market, spiking premium costs, and increase the deficit, according to the Congressional Budget Office (Dickinson 2018). The deficit may go as high as $6 billion (Williams, 2017). The young and healthy will leave the health care insurance market with no mandate penalty, leaving premiums to increase for those needing insurance the most (Benen, 2017; Levitz, 2018).
Conclusions Regarding the ACA and Americans Needing Healthcare
Effect on ACA Functions
Others have reached conclusions regarding the ACA following Trump’s sabotage attempts. Senator Orrin Hatch (R-UT) has suggested the removal of the tax penalty on the mandate is the beginning of the end of the ACA. On the other hand Jonathan Gruber observes the law is fundamentally in place. The ACA is a shrunken version of what it could be. While having the force of law now, the executive orders and administrative rules can be overturned easily by the next administration and its administrative agencies. Larry Levitt of Kaiser Family Foundation says protection for pre-existing conditions for most insurance plans are still in place. (Beezley-Smith, 2018).
Trump’s assertions the ACA is effectively repealed (Center for American Progress, 2018) is more likely an attempt to convince his supporters he has fulfilled a campaign promise than truly and accurately characterizing the operational status of the ACA. Yet some states that did not support the ACA prior to the Trump administration will cooperate and even facilitate its demise in that state. On the other hand other states have taken steps to promote and support the ACA. States supporting the ACA are running their own exchanges, expanded Medicaid with federal dollars, and are operating soundly. Nine of those states are considering replacing the repealed mandate tax with their own mandate at the state level. The ACA is on the books and operating, but not uniformly across states.
Effect on Americans Needing Healthcare
States control what kind of insurance is sold in that state. Some will avoid allowing proliferation of the short-term and Association plans as not good for consumers. Once the removal of the tax penalty for not having insurance goes into effect in 2019, these alternative plans may not be that appealing, even in states that allow them. A state can offer its own subsidies to replace the loss of federal subsidies in the exchanges, but no state has done that to date. Even without subsidies exchanges promoted by that state may still offer to consumers the best place to find competitively priced plans with essential benefits. On the other hand some consumers in states not supporting the ACA may be confronted with few if any choices in the exchanges. Alternative short-term and Association plans may be available, but will lack essential benefits. These may be the only option for those with pre-existing conditions, but these plans could be exempt from that ACA requirement.
Acts of Erosion and Improving Healthcare
The consequence of Trump’s open rhetoric undermining the ACA and the acts of erosion seem to be more disruptive than uniformly ending the ACA or eliminating all benefits to consumers. However, the long-term effect of these disruptions is unknown. That effect is dependent in part on how the states and consumers respond to the disruption. Further disruptions or promises for better healthcare would be coming from a President who Juan Williams (2017) reminds us once said, “Who knew healthcare could be so complicated.” Some have questioned the purpose of the attacks on the ACA. After close examination it is difficult to see how any of the acts of erosion move our nation any closer to a policy like insuring as many as possible or even reducing expenditures or the deficit. These acts take us no closer to any of those goals. So why was it necessary to attempt to undermine the ACA and move so many away from their affordable insurance coverage? Dickinson (2018) has very direct concerns: “He (Trump) is willing to disrupt businesses, hurt millions of Americans and cost the federal government hundreds of billions of dollars not to achieve any policy purpose but simply out of a malicious drive to avenge the legacy of the first black man to hold the oval office.”
Whatever the intent or motive behind them, Trump’s efforts to undermine the ACA have not had uniformly negatively effect across all states or applicability to all consumers. In summary we have identified the acts of erosion and analyzed the effects of these acts. We determined that while the ACA has been disrupted, it is still in operation. The exchanges function better in some more supportive states than others. We conclude that the reasoning behind the acts is not obvious. Benefits to consumers are limited, but still available. How long is still a question.
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Why Universal Healthcare is a Trend in the U.S.
Gregory A. Moore
Department of Health and Human Performance
Austin Peay State University
Clarksville, TN 37044
Is the recent Congressional House of Representatives repeal and replacement of the Affordable Care Act a significant event in America’s healthcare? Is this a hiccup in a trend for one nation that lacks universal healthcare or the end of a movement? The purpose of this research is to determine if there is a movement to developing universal healthcare in the United States. If there is one, what influences are promoting and supporting that effort, and what influences are slowing or prohibiting that effort? This paper will examine the possibility universal healthcare is a trend over time.
Why might the recent Congressional House of Representatives’ repeal and replacement of the Affordable Care Act with the American Healthcare Act not be a significant event in America’s future in healthcare? Is this action only a hiccup in a far more significant trend for the one modern nation that still lacks having implemented universal healthcare for its citizens? The purpose of this research is to determine if there is a movement to developing universal healthcare in the United States. If there is a trend, what influences are promoting and supporting that trend? What influences are slowing or prohibiting that effort? This paper will examine the possibility universal healthcare is a trend over time. It will also examine recent events that indicate support for and against a movement toward universal healthcare.
Analysis of Influences
ACA Shifts Attitudes
The U.S. spends about twice as much of its Gross Domestic Product (GDP) for healthcare than do other developed nations, but the U.S. only achieves mediocre outcomes in care to its citizens (Teitelbaum and Wilensky, 2017). The more Americans learn about healthcare, it seems they are more willing to expand their options in what healthcare Americans should have. When the Affordable Care Act was introduced in 2010 opponents seemed sufficiently successful in convincing more than half the country to object to the Affordable Care Act (The Daily Signal, 2010). The Kaiser Family Foundation has found some change in those original views about the ACA (Kaiser Family Foundation, Health Tracking Poll, n.d.) Other recent polls have shown higher favorability. Gallup (Norman, 2017) reported the popularity of the ACA had reached 55% favorability. The argument can be made that as the elements of the law are learned and experienced, acceptability of the ACA and its provisions grow among rank and file citizens. The guaranteed coverage of those with pre-existing conditions and coverage of children up to age 26 on their parents’ insurance plans are examples of positively accepted elements. (Feldstein, 2011a) Other elements that were initially unacceptable, like a mandate to be insured or pay a tax, were better explained and proved not to be as invasive or intrusive, or as big a burden as opponents claimed. How the mandate or be taxed brings down costs in the overall market by including the young and healthy has not been a big positive, regardless how true it may be. Other clearly false claims, like the ACA implementing death panels, misleadingly derived from the cost saving and family stress reducing ideas like reimbursing doctors for discussing end of life decisions, were debunked (Talking Points Memo, n.d.).
Attitude toward Government Role in Healthcare
The ACA has as a government program both revealed flaws in a market provided system and at the same time, demonstrated the value of government interventions. The reality is that a market system will provide healthcare to those with the means to purchase it, and one must have dollars to “vote.” Those without or with limited dollars, like the aged, disabled, unemployed, and low income, will not be full participants in a market driven system. Economists find that not to be a market failure, as the market can efficiently do its job meeting the demands of those with means to participate. It is not the job of the market to ensure all can participate in purchasing healthcare or insurance (Feldstein, 2011b)
In 1965 Medicaid and Medicare were approved to address this market problem. The ACA today is an indicator how the market may not be meeting the needs of some. Some insurers have limited their participation in the healthcare.com health insurance markets in each state. As private parties some of these private insurers can elect to opt out of selling plans not considered profitable, even when some members of society with government subsidies cannot purchase care. Hence, the ACA has demonstrated how the market will not necessarily result in what citizens deem needed. Only additional government intervention may address the social outcomes sought. (Feldstein, 2011b; Lee, 2015)
During the 2016 Presidential campaign the left wing of the Democratic Party represented by Senator Bernie Sanders openly promoted universal healthcare. (On the Issues, n.d.) The moderate Democrats avoided that position, but supported continuation of the ACA. Republicans who began the original position to repeal the ACA outright, moved to a repeal but replace the ACA position. An open position for universal healthcare was relatively new even by some of the Democratic Party that promotes government involvement in healthcare. Furthermore, the party that has for six years voted in the one area they controlled, the House of Representatives, to repeal the ACA over 50 times, (Walsh, 2012) now with the potential to take real action on that symbolic vote, has elected not to just repeal the ACA, but to repeal and replace it. A current version of the bill, still not scored by the Congressional Budget Office to date, retains elements of the ACA, but adds some politically ideologically more acceptable components to facilitate passage in one arm of government they control.
John Boehner, a Republican who was until recently the former Speaker of the House of Representative, scoffed that any repeal and replacement of the ACA by his party would occur. Rather, Boehner suggested, the change would be the ACA with a new name and a “box” around it. Some elected Republicans argue they are fulfilling a longstanding six-year commitment to their voting constituents to repeal the ACA. (Tahir, 2017)
As suggested, the repeal has now included replacement. Can we now connect the lack of a total repeal to the preferences of these same constituents? Have these constituents changed their view on government involvement in healthcare and convinced these elected officials to promote more government intervention to provide better healthcare? The political party that has ideologically fought and resisted any or limited government involvement in healthcare has seemed to have loosened its limits on allowing government in healthcare. The narrative now seems to be less concern about government in healthcare and more about which government. Now it seems the state government should be leading the involvement, they argue, not the federal government. Republicans now in charge of the House of Representatives seem to be including the more popular elements of the ACA supported by the public into more ideologically acceptable legal interventions. Those elected officials that opposed the ACA, the only significant law filling a void in government healthcare activity since 1965, will not repeal it, but replace it. This seems to be a step in the direction of accepting greater government involvement in healthcare.
Another factor that seems to have influence on the promotion of universal healthcare is the age of those who supported Senator Bernie Sanders. To the extent that group presents a younger generation of American, the more likely universal healthcare will become reality. This group does not fear the “isms” like their parents and grandparents. This group is not concerned that universal healthcare might be socialized medicine, as their parents and grandparents were told. They seem to be aware of the comparisons of the GDP spending and outcomes of healthcare realized by the U.S. and other nations.
At the other end of the age continuum you would expect to finder older Americans actually needing and using more of the healthcare government programs than their younger fellow citizens. To the extent this group is using the ACA or benefiting from its protection or services, like encouraging states to expand Medicaid, the more likely this group will resist removal of healthcare benefits and popular ACA provisions like guarantees to insure citizens with pre-existing conditions.
When President Obama and the Democratically controlled Congress negotiated the ACA, provider groups were included in the bill’s development. Insurance companies and physician groups were visibly involved, but pharmaceuticals were omitted. These included provider groups have begun voicing concerns over the repeal and replacement of the ACA. Medical providers and insurance companies are experiencing reimbursement due to increased demand in healthcare by newly insured patients. (DuBois, 2014) To the extent a movement toward universal healthcare includes these groups as private partners, their support for universal healthcare may be maintained. Universal healthcare may be achieved by a single payer system. Some use a coordinated private insurer or a mix of private services and government providers. To the extent existing providers and insurers are assured a role in the future system, the more likely they will support a move to universal healthcare.
The ACA will cost the federal government a third of what the Congressional Budget Office projected. (Talking Points Memo, 2017) The ACA over a period of ten years will reduce the deficit and its repeal would increase the deficit. (Congressional Budget Office, 2012, 2012) This comes as a surprising fact as opponents tend to refer to the costs of the ACA, but omit the revenues counted by the Congressional Budget Office. If the ACA can reduce the deficit, what opportunities to reduce our deficit even more do we have with universal healthcare? The financial achievement of the ACA could form a basis for those promoting universal healthcare to move another step farther in financial savings.
A number of factors form a basis of forces to potentially delay or prohibit universal healthcare. The Republican right wing Freedom Caucus would prefer to prohibit or limit any government involvement in healthcare, unless initiated by the states. While the Tea Party seems less covered by the media, to the extent it exists, the government role in healthcare for them would also be limited.
Pharmaceutical and Pharma were not included in the ACA development. One has to only look at the high cost of drugs to see an indication of that. Congress has done little more than hold hearings with some elements of the drug industry when their prices reach exorbitant levels. Any movement toward universal health would likely be seen as a potential threat to the drug industry. Unless an effort is made to reach an agreement with this lobby to guarantee some future participation or neutralize it, it would be a factor that limits efforts to move to universal healthcare.
About half the state legislators and governors refused to expand Medicaid, having obtained a Supreme Court ruling backing their position that it was unconstitutional for the federal government to remove all Medicaid if it was not expanded (Liptak, 2012). The irony is that neither the mandate or pay a tax, nor the required Medicaid expansion by the states would be needed in a system of the federal government offering universal healthcare as an option to its citizens. However the fact these states are controlled by the groups who refused to offer healthcare to its citizens at little or no cost to the states, represents a block of potential resistance to universal healthcare, regardless of their economic self-interest.
On balance, will the forces of promoting universal healthcare prevail over the forces that resist it? The ACA has been a catalyst in changing attitudes toward healthcare. Healthcare is being seen as a human right. It may require the necessity of government involvement. A political candidate can use the phrase ‘universal healthcare’ and be taken seriously. In the long run, the younger age groups will replace older persons and their ideas. This should not be construed that this group is more political, however. Providers have expectations to be involved in the future of healthcare delivery. Fear of financial disaster has not occurred. A Republican controlled House, Senate, and President did not easily repeal the ACA. This suggests the pendulum is not just going to swing one way and then swing back. If repeal had quickly occurred, the best forecast would be healthcare continues just to swing back and forth, going nowhere in particular. The fact the opposition to the ACA has moved to retain elements of the ACA, even as they are carefully trying to fulfill a campaign promise to repeal, is significant. These elected officials seem constrained by their perception of the public interest that more healthcare needs to be offered, not just swing the pendulum back to no care as before the ACA.
How soon universal healthcare will happen is another question. In the area of civil rights in America, the Dred Scott decision upholding slavery was made prior to the Civil War. The Thirteenth Amendment was also legislated. Then Plessey v Ferguson supported racial segregation, making separate but equal the law of the land. However this was overruled fifty years later in Brown v Board of Education. One might observe that this trend has been ongoing for 150 years and continues.
Healthcare had its first event in 1965 with Medicaid and Medicare and a second with the ACA in 2010. How and when a third step occurs is a question. Is this repeal and replace of the ACA a hiccup or an end in the trend toward universal healthcare? As one examines the forces that promote healthcare by government, and those that limit it, the promotion of a movement toward universal healthcare seems to have a significant edge. The age of those who support it combined with the changes in perceived attitudes by those who have opposed it, are indicators a trend is in process toward universal healthcare, although the speed of its acceptance requires further study.
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