Obamacare turns five

by Rob Cullen on March 27, 2015 - 3:46 PM

obama signature on ACA

This week marked the fifth anniversary of the passage of the Affordable Care Act. For the past five years, its opponents have said that this new law would be a disaster– that people wouldn’t buy coverage on the exchanges, that premiums would double or triple, that it would explode the deficit, that it would wreck our healthcare system.

None of these things has come true. Obamacare hasn’t fixed every problem with our healthcare system, but as the law turns five so far it’s doing exactly what it’s supporters claimed it would: expanding coverage to millions of Americans, bringing down costs, and improving the quality of care.

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Republican Rep. Tom Price, chair of the House Budget Committee.

Republican Rep. Tom Price, chair of the House Budget Committee.

Since the Republicans took over the House in 2011, every budget they’ve proposed has looked more or less the same, especially with respect to healthcare. Each year their budget calls for privatizing Medicare, massive cuts to Medicaid, and repealing Obamacare with no plan to replace it.

We thought this year might be different. After all, it’s the first time since 2011 the House Budget committee has been chaired by someone other than Paul Ryan (he’s moved on to chair the more powerful Ways and Means committee), and it’s the first time in almost a decade that Republicans in the Senate have had to produce a budget of their own.

But nope, it’s pretty much just more of the same: privatizing Medicare, massive cuts to Medicaid, and repealing Obamacare with no plan to replace it. What’s different now are the budget gimmicks. In the past, they’ve been vague on how they would cut other domestic spending, but their healthcare plans were pretty straightforward. This year, both the House and Senate plans call for trillions of dollars in healthcare savings– but where most of that savings comes from is a detail Republicans say they’ll figure out later.  [click to continue reading…]


The latest Obamacare case hinges on these two justices: John Roberts and Anthony Kennedy

The latest Obamacare case hinges on two justices: John Roberts and Anthony Kennedy

After last week’s oral arguments in the latest Obamacare Supreme Court case (over whether the government can provide subsidies on federal exchanges), we have a pretty good idea how most of the justices will rule. The court’s more liberal justices– Ginsburg, Kagan, Breyer, and Sotomayor– will almost certainly uphold the subsidies, and we’re pretty confident that three of the conservatives– Alito, Scalia, and Thomas– will rule against them.

As for Roberts and Kennedy though– the deciding votes– it’s anyone’s guess. Still, their comments during the oral arguments can at least give us a sense of what they’re thinking about. And surprisingly they seem to be considering constitutional questions that even the plaintiffs didn’t bring up– and one of these questions could be a bigger threat to the law than anyone seems to realize.

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supreme court subsidies protest

One odd thing about the Affordable Care Act– given that its passage was a top priority for Democrats, while not a single Republican voted for it– is that it’s actually set up to benefit red states much more than blue ones. As Vox’s Ezra Klein explains:

Health reform spends more in states with more uninsured residents. And red states have higher rates of uninsurance than blue ones. In 2013, of the 25 states with the highest rates of nonelderly uninsured, 18 of them had voted for Mitt Romney in the 2012 election.

So all else equal, a bill that spends its money covering the uninsured is going to spend more money in red states than blue ones. But all else isn’t equal. The way Obamacare pays for itself also favors red states.

One of Obamacare’s major pay-fors is a 3.8 percent tax on investment income earned by richer taxpayers. This hits blue states harder than red states because blue states are, well, richer. Of the 25 states with the highest median income, 19 voted for Obama in 2012.

Another way Obamacare funds itself is through its tax on “Cadillac” health-care plans, which begins in 2018. The tax is really just a levy on very generous employer-provided plans — which are more common in blue states, with their history of unionization, than red ones. That means the Cadillac tax will hit harder in blue states than red ones.

But here’s what’s even weirder: Republicans have been working really hard to reverse that setup so that they pay more to get less.

When the Supreme Court made the law’s Medicaid expansion optional in 2012, it was GOP-controlled states that opted out. This didn’t save them any money– the federal government would have paid the entire cost of expansion until 2016, and those other taxes didn’t go away–all it did was leave millions uninsured in their own states. And if the Supreme Court rules in this latest case that the only states who build their own health exchanges can get subsidies, it will again be residents of red states getting screwed.   [click to continue reading…]


What Steven Brill and 60 Minutes got wrong about Obamacare

by Rob Cullen on February 24, 2015 - 1:52 AM

steven brill and lesley stahl

If you asked us to name the best article on health care we’ve read, near the top of the list would be Steven Brill’s 2013 Time Magazine cover story, “Bitter Pill: Why Medical Bills are Killing Us.” It’s a fascinating (and at 36 pages, thorough) look at a topic that affects all of us: America’s ridiculously high medical costs.

Brill’s follow-up articles were also excellent. His “Hate Obama, Love Obamacare,” published in January of 2014, was one of the best assessments of Obamacare’s successes and shortcomings in providing access to care that we’ve seen; and “Obama’s Trauma Team” was an interesting look at how the healthcare.gov website was fixed so quickly after its disastrous launch.

We expected his new book, America’s Bitter Pill, would be equally great since it combines that previous work with new behind-the-scenes reporting on the passage and launch of the Affordable Care Act. The result, however, is less than the sum of its parts, and one of the book’s main assertions– that there’s almost nothing in Obamacare to control healthcare costs– is wrong.

Unfortunately that was the part of the book that 60 Minutes focused on in a recent segment featuring Brill. The result is a trainwreck of misinformation.   [click to continue reading…]


wolf and corbett

There was big health care news in Pennsylvania this week: as promised, newly elected Democratic governor Tom Wolf has announced the first steps in transitioning the state away from his predecessor’s Healthy PA plan to full Medicaid expansion under Obamacare.   [click to continue reading…]


child getting vaccinated

As a website devoted to explaining complicated topics in healthcare, we haven’t really tackled the vaccination debate before, because, well… it’s not all that complicated. The science is clear: there’s no evidence that vaccines cause autism. End of story.

Or at least it should be. With so many people choosing to opt out of vaccinations, an outbreak of measles– a disease that the Centers for Disease control considers eliminated in the U.S.– recently infected at least 40 people at Disneyland who spread it to at least six states. In the midst of this, some prominent political leaders (most notably Rand Paul) have implied that vaccines actually do cause “profound mental disorders” despite zero credible evidence, while others, like New Jersey Governor Chris Christie, have said that the decision whether or not to get a vaccine is simply a matter of personal choice.

But while vaccines have gotten much more attention in recent weeks, there’s still not that much to say about the issue. According to Aaron Carroll, a professor of pediatrics at the University of Indiana who blogs at The Incidental Economist, all that really needs to be said on the subject are these points:

  1. Measles is a terribly infectious illness that is a public health issue.
  2. There’s a vaccine that is amazingly effective.
  3. The vaccine is very, very safe, and it doesn’t cause autism.
  4. Policies in the United States should try and encourage all children to get immunized, as we need almost everyone to be immune to achieve herd immunity.
  5. We should allow some people to forego vaccination if they absolutely must, but we should try to make sure it’s not for reasons that are scientifically wrong – ie violate (1), (2), or (3).
  6. Unvaccinated people can be restricted from certain public activities (ie school) during emergency situations like outbreaks.

We agree; however, we thought it might be helpful to explain the reasoning and scientific evidence behind each of them.   [click to continue reading…]


CBO director Doug Elmendorf testifies before the House Budget Committee

Current CBO director Doug Elmendorf testifies before the House Budget Committee

The thing that stood out most for us in the Republican response to the State of the Union last week was what was missing. Aside from a call for President Obama to approve the Keystone XL pipeline, Iowa Senator Joni Ernst didn’t mention a single specific policy. She criticized the Washington mindset that “gave us political talking points rather than serious solutions,” shortly before launching into… a list of political talking points:

  • “We’ll propose ideas that aim to cut wasteful spending and balance the budget.”
  • “We’ll advance solutions to prevent the kind of cyberattacks we’ve seen recently.”
  • “We’ll work to confront Iran’s nuclear ambitions.
  • “Let’s simplify America’s outdated and loophole-ridden tax code.”
  • “We must also honor America’s veterans.”

There was however, one substantive part of the speech– a quick mention of something the GOP had already done: “The new Republican majority you elected started by reforming Congress to make it function again.” It’s a vague claim, but since it supposedly already happened, it’s also something we could look into.

We found one helpful reform in the House: scholars from think tanks testifying before the House will now have to disclose whether their organizations have received money from foreign governments. And in the Senate, new majority leader Mitch McConnell has promised to allow members of both parties to offer more amendments to bills than they could under Harry Reid (although it’s not an official rule change– he could easily change his mind and clamp down on amendments when it suits him).

However, as the New York Times reports, rather than “making Congress function again,” many of its new rules are an attempt to game the system for Republicans:

One new rule allows the House to overturn recommendations of an independent panel created by the Affordable Care Act to trim Medicare costs. Another makes it more difficult to shift Social Security money between the program’s different trust funds, increasing the likelihood that deep cuts to disabled workers and their families will be made as the Disability Insurance Trust Fund nears depletion in 2016. That quickly drew condemnation from AARP, the powerful lobby for retired people.

But the most troubling examples of Republican “reforms” are those targeting the Congressional Budget Office: replacing its respected director and changing the way it estimates the costs of bills. If politics were a football game, this would be the equivalent or replacing the ref and rigging the rules to favor your team.   [click to continue reading…]

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The Health of the Union 2015

by Rob Cullen on January 21, 2015 - 9:56 PM

obama sotu 2015

Compared to past President Obama’s past State of the Union addresses, this year’s was an unusual one for health care. The words “Affordable Care Act” weren’t spoken at all, and the only reference to the president’s signature law was a brief sentence mentioning the uninsured who gained coverage and the recent slowdown in the growth of healthcare costs. The omission of the ACA is especially odd considering that (1) so far the law has not just met, but exceeded its goals for expanding coverage and controlling costs; and (2) there’s another month left of open enrollment to buy coverage for 2015– something it seems like the president would want to mention.

On the other hand, a bunch of other health care issues did come up in the speech, including a couple that we haven’t really talked about before on this site. Here’s our annual look at health care in the State of the Union.   [click to continue reading…]


An Obamacare guide for filing your taxes

by Rob Cullen on January 13, 2015 - 6:17 PM

looking at tax form

One of the hardest parts about covering America’s healthcare system is that if someone comes to us with a question– even if it sounds relatively simple– there’s almost never an easy answer.

For example, wondering what the penalty for not having health insurance is in 2015? The short answer is it’s $325 per person or 2% of your household income, whichever is higher. But, if we wanted to be more accurate, the real answer is “it depends”– based on your income, family size, how many months you went without coverage, and whether you qualify for any exemptions. Or want to know whether your income is low enough to qualify for Medicaid? Well it depends on your family size and what state you live in. If your state didn’t expand Medicaid under Obamacare, it also may depend on whether you’re pregnant, disabled, a parent, etc.

You might notice that we answer questions with “it depends” a lot.

So we were somewhat shocked that we recently got a question from a reader that seemed like it would require a complicated answer (it’s about Obamacare and filing taxes), but actually did not require an “it depends”:

When you’re filing your taxes, how do you provide proof that you had insurance in 2014?

Answer: You don’t have to provide proof. If you had coverage all year, you simply check the box that says you had full year coverage (line 61 on the 1040). That’s it. Here’s what it looks like:

1040 health coverage reporting

Unfortunately that turned into a slippery slope of other questions with “it depends” answers. What do owe if you didn’t have coverage, or only had coverage part of the year? If you bought coverage on the exchange, how do you determine whether you got the correct subsidy? If you ended up making more money than you estimated when you applied for Obamacare, how much do you have to pay back?

To help answer these questions (and others) we’ve put together a quick guide to how Obamacare works when you’re filing your taxes.   [click to continue reading…]