The Update Desk: The Affordable Care Act

So, there's this court case, Texas vs. United States, that maintained that the Affordable Care Act would be unconstitutional because, as of 2019, the penalty for the individual mandate was $0 under president Trump's Christmas Tax Cut. The thinking of the Texas AG, and the 19 GOP states that joined the lawsuit, is that since the individual mandate penalty no longer exists, and because the tax key to the constitutionality of the ACA according to the Supreme Court, and since the whole shebang is tied up with an inseverability clause, it should be struck down. The lawsuit was filed about a year ago, and in December a conservative judge agreed.

Yesterday, the Justice Department made it officially known that it agrees with the decision of the lower court.

The DOJ said Monday that it agrees the decision should stand as the case works its way through the appeals process in the US Court of Appeals for the 5th Circuit. 

"The Department of Justice has  determined that the district court's judgment should be affirmed," the department said in a short letter to the appeals court. 

So, while Democrats are getting all riled up, and Republicans are getting all excited that a court may do what they were unable to do, with 60 failed votes and $87,000,000 wasted in the process, I thought I'd remind everyone what this could mean to America.

Back in 2017, I talked about what "repeal and replace later" would mean, beyond the elimination of protections for pre-existing conditions, which the DOJ also did not defend in the early days of the Texas suit.  Here are some of the things I thought of pretty quickly, back then:

1. Immediately shut down Healthcare.gov and the 28 federally facilitated marketplaces and the five state-based marketplaces using the federal platform. 
2. Cancel the coverage for individuals and families who were covered under the now-defunct marketplaces.
3. Return any unused premium to them.
4. Immediately repeal the voluminous taxes required under the Affordable Care Act, whether charged to a business, a health insurer, any medical facilities, and so on. This will of course require an immediate rewriting of the tax code just to get us back to where we were before the Affordable Care Act went into effect.
5. Immediately repeal the individual mandate.
6. Immediately kick over-aged dependents off their parents' policies in any location such coverage is not mandated under any other jurisdiction.
7. Immediately remove the Medical Loss Ration (MLR) requirements, which dictate the percentage of health care premium dollars insurers must pay for benefits (base around 80%) and requires insurers to rebate premiums to insureds when they don't meet the MLR percentage.
8. Immediately eliminate the full coverage for pre-existing conditions at no additional premium - let the games begin.
9. Remove no-cost-sharing coverage for preventative care, including things like lead screening, mammograms and paps, prostate screenings, annual physicals, a whole host of lab tests, and countless other benefits - those can all go back to whatever pricing structure was in place before.
10. Remove all subsidies which currently help people pay for coverage - all of them.  
11. Similarly, remove all supports that are paid to insurance companies to help cover the costs of  insuring the people who got coverage under the ACA. 
12. Eliminate requirements for 'essential benefits' including outpatient services; emergency services; hospitalization; pregnancy, maternity and newborn care; mental health and substance abuse, prescription drugs, and more.
13. Immediately end all funding for Medicaid expansion.
14. Immediately reintroduce annual and lifetime limits on benefits.
15. Immediately increase the population of uninsured by the number of people covered under a marketplace (~10 million or so as of February 2017) and the number covered under Medicaid expansion, ~14 million)

And that's not an exhaustive list -- I forgot mental health parity regs which were enfolded into updates of the ACA along the way, for example. 

Now, some of those numbers have likely changed but the gist of this is that the Affordable Care Act was much, much more than just the individual mandate and protections for people with pre-existing conditions.  Sadly, that's something that politicians from both parties have been unwilling or unable to communicate well, and of course they continue to ignore lots of the other provisions, if for different purposes. 

The formal move by the DOJ this week to not defend the law of the land will embolden progressives on the Medicare-for-All bandwagon; sadly, it won't likely embolden anyone else to work to defend the other key provisions that also protected patients.  

As the president would say, SAD.

Quick Takes (v19): Charlie Gard

Quick Takes

I'm not a huge fan of politicians interjecting themselves into healthcare decisions for individual patients or into particular kinds of healthcare decisions, such as contraception or end-of-life care. I've written about this stuff before (here, and here, for example).

Many times, the individual situations are dire, agonizing, and unimaginable for anyone who has not lived it themselves, and that's why (and when) politicians tend to get involved. Other times, it's because of a belief that we can legislate a preferred sense of values (chosen by the involved politicians) via giving or taking away payment for and access to healthcare services.

The cases are far more complicated when, for one reason or another, on behalf of one side or another, courts are involved.  This happens in America, and it happens in other countries - so that automatically qualifies our elected officials to meddle, right?

That's what's happening in the case of Charlie Gard, an 11-month-old British child with a terminal disease and other serious complications necessitating him being on life support. British courts have determined that further treatment for him would be futile but his parents are fighting. American and Italian doctors have gone to England to consult on the case, and the parents want to bring him here for an experimental treatment that will not cure him, but may prolong and possibly improve his life.

It's an ugly mess, as these cases typically are (remember Terri Schiavo?) but it's an ugly mess across the ocean and wildly outside the jurisdiction of the House of Representatives, one would think.

But one would be wrong.

It seems the House of Representatives has passed an amendment granting legal permanent resident status, which would allow them to come to the US for the experimental treatment (the House and Senate need to act before anything becomes official). In the middle of an intense national disagreement on what health care and health insurance will look like for Americans

• millions of whom stand to lose coverage quickly (under the most recent Senate plan) or more slowly (under the House plan), and
• millions of whom struggle to pay for insurance premiums, or face choices between paying for necessities like housing and food or paying for medical treatment, and
• millions of whom may end up in ridiculously high premium risk pools because of preexisting conditions, and
• millions of whom will go back to annual or lifetime limits on treatment of illnesses like Charlie Gard's, and
• millions of whom, even with insurance, have no reasonable access to experimental treatments themselves.

What are we doing? Why is our government meddling in a court case in another country? 

Why are we prioritizing one foreign child over millions of Americans?