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Sunday, March 12, 2017

Trumpcare Versus Obama Care-What You Need To Know

How the Republican Healthcare Act Compares to the Affordable Care Act

The Republican plan, euphemistically referred to as Trumpcare addresses insurance and not improvements in healthcare delivery. Insurance is NOT health care. This analysis examines how the proposed healthcare plan in House Bill 277 differs from the Affordable Care Act, known as Obamacare. For information on ACA improvements in health care at the patient level, refer to the link below.[1]  This article cites credible sources from nonprofit entities or government agencies and only facts are used, not false proclamations.


Medicaid Coverage is medical insurance for low-income folks

Eligibility Standards
Expanded eligibility for Medicaid to 138% of the federal poverty level; 32 states opted to expand coverage, increasing access to healthcare for 11 million people.[2]
Beginning in 2020, repeals the Medicaid expansion, allowing existing Medicaid participants to remain, but with the inability to re-enter later if you lose your eligibility; Millions would lose their medical insurance. (Gunja, 2017)
Mental Health Benefit

Expanded to include mental health parity, to increase access to health treatment for mental conditions under the essential benefit provisions of the ACA. (Kirsten Beronio, 2013)
Insurance companies would no longer have to offer mental health benefits under insurance contracts.
Substance Abuse Treatment

Plans were required to offer coverage for substance abuse treatment, comparable to other illnesses and it is estimated 5 million people have used this benefit. (Kirsten Beronio, 2013)
Insurance companies are not required to offer treatment for drug addiction, which is problematic given the national crisis in opioid addiction, currently killing 91 people a day. (Centers for Disease Control and Prevention, 2016)
Employer Insurance

Required employers to offer medical insurance within standardized benefit levels, or pay a fine.
Employers will no longer be required to offer medical insurance for their employees and no fines will be levied. Small business tax credits, to help businesses offer medical insurance are cancelled in 2020.
Impact on Individuals in Insurance Exchanges
Required pooled rates, which were spread across age bands, not individual levels; creating more affordability. (Jost, 2016)
Insurance companies can age rate, to increase pricing toward older participants (those most likely to need more health services). Cost sharing provisions which helped low income people are eliminated.
Taxes to fund the plan
Follow the link to a previous article which detailed the taxes.[3] Most sectors of the healthcare system contributed to taxes to fund the provisions of the Affordable Care Act which is self-funding.

Would eliminate most of the taxes except the “Cadillac Healthplan Tax”, lower capital gains for the top 2.5% of income earners, and charge all employees covered on insurance plans through their employers, a Value-Added Tax (like the Canadians charge on services).
Women’s Healthcare

Mandated insurance plans cover birth control and women’s gynecological exams annually.
Defunds all Planned Parenthood Services and removes the requirement to provide wellness services or birth control.
Financial Impact on Individuals
Older low income people had greater subsidies so they could buy medical insurance.
Older low income folks will pay thousands more per year for medical insurance. Young people will pay less for insurance, but since there are no penalties for not participating enrollment will decline, eroding the overall viability of insurance exchanges.
Employer Provided Medical Plans
Employers can deduct the full cost of their medical and other benefit plans and employees are not taxed on these benefits.
Eliminates the tax advantage for employers which will cause the cancellation of many health plans across the nation because this is a very expensive benefit for employers to offer. Example, your employer pays $12,000 in insurance plan premiums for you, these would now be taxable as income to the employee and nondeductible to the business.
Individual Penalties for Not Participating

Tax Laws
Proof of insurance is required at income tax filing. A tax penalty up to $695 per adult ($2,085 family) is due unless you qualify for one of the many exemptions, which include your inability to afford insurance.
No requirement to have medical insurance, but if your coverage lapses, you will pay a penalty (up to 30%) upon re-enrollment regardless of your income. The penalty would be meted out by the insurance company.
Medicaid Funding
Affordable Care Act provides additional subsidies to states for the expansion of Medicaid, to increase insurance coverage and access to medical care across the nation.
Republican plan wants to cap any federal Medicaid contribution to a flat amount per person, without cost-of-living increases and not based on actual plan costs.

A quick analysis of this doomsday health insurance scheme, eliminates most incentives, especially for the bottom 25%-of-income-households and a swath of the middleclass, to obtain medical insurance. By removing the tax incentive for employers to provide health plans more Americans will lose medical insurance through their employment, throwing more people into the chasm of the uninsured. By removing the tax credits for small firms, fewer of those will be able to offer medical insurance to their workers. And the piece de resistance of this Trump sanctioned health plan is to further destabilize the insurance exchanges, by removing the accountability requirement that residents have medical insurance. Plus, allowing the insurance companies to eliminate or reduce specific medical conditions will harm treatment for public health needs. Older individuals will face steep premium increases as the Republican plan allows insurance companies to charge older Americans up to five times what they charge the younger ones. In other words, back to business as usual for the insurance industry, where they can eliminate an entire “class” of people from their contracts and of course, charging those most in need significantly higher premiums.

Finally, there isn’t one thing about this “plan” that addresses the improvement of health care, lowers the cost of your health care treatment, or encourages transparency and accountability from any of the price gouging suppliers. More to come on the provisions which will impede consumer protections and create road blocks on price and quality transparency for consumers. Of course, can we really expect anything else from an administration which felt ethics classes were unnecessary, and refuses to allow adequate time for public comment on a bill which would be so harmful to people?

For the best interactive tool to see how you would fare under the Republican Health Plan, follow the link below to the nonprofit, Kaiser Family Foundation site and search for your age and county to get your tax credit information. The Republican plan only provides tax credits based on age, not on income, with a phase-out at $75,000.[4]

And this is the healthpolicymaven signing off wishing you fully informed consent for any medical procedure, contract, or act. Roberta E. Winter is a former insurance broker and healthcare consultant,  who has been devoted to healthcare reforms since 2002 and is the author of .


Centers for Disease Control and Prevention. (2016). Drug Overdose Deaths Continued to Increase in 2015. Health and Human Services, Centers for Disease Control and Prevention. Centers for Disease Control and Prevention. Retrieved March 12, 2017, from
Gunja, S. R. (2017, March 7). Why Millions Would Lose Coverage Under the Medicaid Expansion Changes in the House Affordable Care Act Repeal Bill. To the Point-Quick Takes on Health Care Policy and Practice. Retrieved March 12, 2017, from
Jost, T. (2016). Affordability: The Most Urgent Health Reform Issue For Ordinary Americans. Health Health Affairs . Retrieved March 12, 17, from
Kaiser Family (2017). Tax Credits Under the Affordable Care Act Versus the American Health Care Act. The Henry J. Kaiser Family Foundation. The Henry J. Kaiser Family Foundation. Retrieved March 7, 2017, from
Kirsten Beronio, R. P. (2013). AFFORDABLE CARE ACT EXPANDS MENTAL HEALTH AND SUBSTANCE USE DISORDER BENEFITS AND FEDERAL PARITY PROTECTIONS FOR 62 MILLION AMERICANS. Health and Human, Office of the Assistant Secretary for Planning and Evaluation. U.S. Department of Health and Human Services. Retrieved March 12, 2017, from

Wednesday, February 15, 2017

Expected Program Cuts to Affordable Care Act and Federal Budget Impact

Orthopedic surgeon, Dr. Tom Price is now in charge of Health & Human Services and here is an analysis of the laws he may try to dismantle, programs which could lose government support, and the ensuing federal budget implications. This article is based on actual facts, not “alternate facts” which are popular with the Trump Administration.
Budget Implications
The Patient Protection and Affordable Care Act has been a revenue generator, while also providing medical insurance for 20 million low income people and has helped to reduce the federal deficit. (, 2017) According to the Office of Management and Budget (OMB) and the Joint Committee on Taxation (JCT), repeal of the Affordable Care Act would cause the federal deficit to grow by $137,000,000,000 by 2025. (Congressional Budget Office, 2015) That’s right, a repeal of the ACA would increase the deficit by 137 billion dollars.  Here are some of the provisions which have generated money for the government, which are likely to be repealed by the Republican Congress under the Trump Administration.
Pay or Play-Taxes generated from income tax filers who did not have an exemption to the requirement for obtaining medical insurance and are required to pay a tax penalty.
Luxury Plan Tax-This tax is applied to health insurance plans which cost more than twice the national average for an enrollee.
Insurance Company Tax-Insurance companies pay a premium tax which goes into the fund to pay for medical insurance for low-income residents and the provisions of the Affordable Care Act.
Medical Device Tax-Orthopedic and cardiac device manufacturers have been required to pay a 2.9% tax on the cost of the device, which funds provisions under the ACA including healthcare for low-income people.
Estate and Trust Tax-This tax applied to undistributed net income, which affects larger trusts, and is 3.8% of that income.  Again, the money goes toward health insurance subsidies for low income persons.
Employer Tax-Failure to offer minimum essential benefits in a health insurance plan will generate a tax, up to $3,000 per effected employee.
Medicare Payroll Tax Increase-The payroll tax used to fund Medicare, was increased by .90% (less than 1% not 90%, if Sec. of Education DeVos is quoting this). This tax is paid equally by the employee and employer and is used to pay for Medicare programs. Don’t kid yourself, Congress will never reduce your payroll tax as this is necessary to shore up Medicare.
Medicare Changes from the Affordable Care Act
Most of the Centers for Medicare and Medicaid(CMS) changes under the ACA involve improving health quality (clinical quality based on patient results) and transparency (in terms of payment and performance). Will these programs also be terminated under HHS Cabinet Secretary Price?
1.       Subsidies for Medicare Advantage (HMO) payments based on counties with a higher density of low income residents-This benefits rural areas as well as the urban poor.
2.       Health care quality rankings impact how much the facilities receive, as well as the Medicare Advantage enrollment population. This is a pay-for-performance initiative.
3.       Insurance companies selling Medicare Advantage Plans must use 85% of annual collected premiums to pay for enrollee claims and plan services, which caps opportunistic accounting charges which contribute to inflated premiums. Insurance companies should be able to administer their plans for 15% as Medicare does it for 6%.
4.       Designating medical homes for patients, is a patient management tool, and has been shown effective in care management, especially for diabetes and other chronic diseases.
5.       Mandatory 90-day review period before the government will pay for durable medical equipment, which is frequently marketed to senior citizens without regard to efficacy or best fit analysis.
6.       Fraud Detection-A special commission in Health and Human Services was established to compare tax records to aid in identification of criminals who are stealing money from our government through fraudulent claims, etc.
Medicaid Changes from the Affordable Care Act
Under the Trump Administration many programs impacting low-income Americans are likely to be modified, reduced or cut and here is the list:
1.       Expansion of Medicaid to include all low-income people, not just children. This was modified through a court order and now applies to 33 states which opted to expand their Medicaid coverage, thus reducing stress on state health systems. Will these states lose the federal matching money they are currently receiving for providing this coverage for low income residents with incomes within 138% of the federal poverty range?
2.       State employees became eligible to enroll their children on the Children’s Health Plan (CHIP) because of the Affordable Care Act, will this be repealed?
3.       Free standing birth centers, such as midwifery and other women’s health facilities, such as Planned Parenthood, became eligible to receive Medicaid funding for additional services under the ACA. Congress has already indicated a desire to defund Planned Parenthood, but what about the other facilities under this provision? This means program cuts for preventive care for women. I guess Trump expects women to build a wall around the uterus, just like Mexico.
4.       Creation of Medical Home designations for patients with at least two chronic conditions, which provides funding for better care management. Participating medical facilities received additional compensation to assume enhanced care coordination through the medical home provisions. Will community health organizations lose this funding?
5.       Hospital Safety-net Demonstration Project-This is an initiative involving several hospitals to identify vulnerabilities in hospital systems across the nation, which are primarily urban trauma centers, to prevent hospital closures. Tom Price has said he does not favor the Centers for Medicare and Medicaid Demonstration Projects. (Pear, 2016)
6.       Greater mental health treatment funding for hospitals with a significant population of indigent patients (urban trauma centers) was part of the ACA. Will there be funding cuts for vulnerable populations and will the mental health parity insurance mandate be repealed?
7.       Medicaid Waiver or Section 1115 Programs have been around a long time and they are primarily a vehicle to increase cost sharing for recipients and reduce expenses for the states which fund them. The standardization of this process will probably not go away as states continue to seek relief from spiraling Medicaid costs.
8.       Improvement of funding for state Medicaid matching for noninstitutionalized care programs-will this be torpedoed?
Improving Health Quality and Paying for Performance
Accountable Care Organizations
The Accountable Care Organization Act became effective in 2012 and is administered by the Centers for Medicare and Medicaid. This program saved CMS over 700 million in the first five years, through better monitoring of preventable health events. (David Blumenthal, 2015) At present, 15% of all Medicare enrollees are served through Accountable Care Organizations. The ACO program identifies high cost health care events, such as hospital re-admissions and links improved clinical outcomes to performance, by paying health systems more money for achieving these targets. Health systems voluntarily participate in the program. There are 480 participating health care organizations within the U.S. and nine million people benefit from accountable care provisions. (Centers for Medicare Services, 2017)The Centers for Medicare and Medicaid have indicated this program saved the government 466 million in 2015. (Centers for Medicare and Medicaid, n.d.)
Financial and Clinical Efficacy
The Accountable Care Act created the Federal Coordinated Health Care Office whose purpose is to study health programs, gauge results, and seek ways to optimize the government expenditures with patient care. Will this agency be terminated because Dr. Price, who is a member of the Tea Party coalition, thinks doctors and hospitals should have less oversight? Hospitals are now huge corporations, often controlling entire regions, dictating prices, and are not typically subject to anti-trust laws. Shouldn’t some independent government agency be reviewing their programs, the costs, and the impacts on consumers?
Clinical Effectiveness and Research
The Institute for Clinical Effectiveness, known as the Patient Centered Outcomes Research Institute (PCORI), was created to identify and promote best healthcare practices for patient safety and clinical health, based on the following criteria:
1.       Assessment of preventative, diagnostic, and health care treatment options
2.       Improving health systems
3.       Improving health care decision making and patient communications
4.       Addressing health disparities (why patients in different demographic groups have different health outcomes/services)
5.       Accelerating patient centered research to identify ways to economically and clinically improve health
Funding for the PCORI agency was provided through the American Recovery and Rehabilitation Act in 2009, which taxes insurance companies $1 to $2 per enrollee. PCORI is taxed with identifying ways to cut waste, reduce unnecessary procedures, and improve disease surveillance to improve health outcomes.  The oversight organization has put a spotlight on medical suppliers, pharmaceutical companies, insurers, and other agents in the national healthcare landscape. For more information on this, read Chapter 3, pages 27-29 in my 2013 book, Unraveling U.S. Healthcare-A Personal Guide. (Winter, 2013)
 Of course, medical lobbyists have been deluging Congress with appeals to remove the “onerous taxes” which impact their businesses adversely (hardly at all) resulting in higher costs for American consumers. These companies simply want more money to reward their shareholders and enrich their stock option plans. No one in Congress is exempt from the influence of healthcare industry lobbyists, because even stalwart Democrats, Elizabeth Warren (MA) and Al Franken (MN) have lobbied to get the 3% medical device tax removed, because Boston Scientific, St. Jude Medical, and Medtronic are big employers located in their respective states. Removal of this tax would not result in lower costs for any patient or health system which buys any of their devices.  Increasing pricing transparency for cardiac and orthopedic devices would potentially result in savings for health systems and patients, but you don’t hear any lobbying for that. If anything, this scenario illustrates more acutely why we need independent government agency oversight for our healthcare system.

Returning to the 1950’s model for healthcare will not lower costs across the health system and it is important for consumers to understand that your insurance premiums are but one aspect of the healthcare system. We all need to be concerned about that for which we pay for our health care, the conflicts of interest inherent in the system, and that which is negotiable. Isn’t this how we would handle any other significant purchase? Keep reading this column for up-to-date information on healthcare concerns, actions, and facts. And this is the healthpolicymaven signing off wishing you fully informed consent for your next vote, purchase, or procedure. Read the fine print and do use “actual facts” from vetted sources for decision-making.

Roberta E. Winter, MHA, MPA is a freelance journalist and consultant, with analytical experience in the insurance industry, hospital systems, regulatory analysis, healthcare research, and patient advocacy.


Centers for Medicare and Medicaid. (n.d.). 2016 Fact Sheets Medicare Shared Savings Program. Retrieved February 15, 2017, from Centers for Medicare and
Centers for Medicare Services. (2017, February 15). CMS Medicare Shared Savings Programs. Retrieved from
Congressional Budget Office. (2015). Budgetary and Economic Effects of Repealing the Affordable Care Act. United States Congress. Washington, D.C.: Congressional Budget Office. Retrieved February 15, 2017, from
David Blumenthal, M. M. (2015, June 18). The Afforable Care Act at 5 Years. (M. Mary Beth Hamel, Ed.) The New England Journal of Medicine, 372, pp. 2451-2458. doi:10.1056/NEJMhpr1503614 (2017, February 15). Retrieved February 15, 2017, from
Pear, R. (2016, November 28). Tom Price, Obama Care Critic is Trump's Choice for Health Secretary. Retrieved from The New York Times:
Winter, R. E. (2013). Evidence-Based Planning-What It Means and Why You Should Care. In R. E. Winter, Unraveling U.S. Healthcare-A Personal Guide (pp. 27-29). Lanham, Maryland: Rowman & Littlefield.

Sunday, January 22, 2017

World Unites in Opposition to Trump Presidency

Seattle and the World March in Opposition to Trump
Yesterday, I awoke at 5:40AM energized and ready to participate in my democracy with the fullness of my mind, body, and spirit, by marching in the Seattle Women’s March against the Trump Administration. Cycling onto the ferry for my commute into the city, I expected to see a few dozen other women like me, the outliers in society. Instead I was greeted by an armada of pink-pussy-hatted faces, representing almost the entire ferry population. There were so many women protestors, the ferry had to open the men’s restroom on the ferry for women, because the lines were too long in the women’s facilities. An air of friendship, comradery, and generosity permeated the air as people walked through the boat giving signs, stickers, and other protest materials to wear. Upon exiting the boat at the Coleman Dock, I parked my bicycle and decided to walk with the group, two miles to the start of the march, in Judkins Park. A sea of people, from all walks of life, black, brown, caramel colored, purple haired, red haired, and everything in between made their way to the start of this historical occasion. The Pacific Northwest weather even managed to grant us one of the rare sunny warm days of the past two months.

As a lifelong political activist and someone who marched for the ill-fated Equal Rights Amendment in the 70’s, I am no stranger to demonstrations, marches, and expressions of free speech. This demonstration, originally designed as a women’s march to protest the policy positions of the Trump Administration, was expected to draw 75,000 people, and there were 130,000 souls marching shoulder to shoulder in Seattle. Aside from the sheer size of the group, I was awestruck by octogenarians with walkers, canes, and wheel chairs who were going to march up to eight miles in protest to the new presidential administration! As we rounded the corner past Judkins Park onto Jackson Street, looking down the hill toward Elliott Bay there was a continuous sea of people for blocks. A massive wall of humanity, shoulder-to-shoulder, consumed four traffic lanes, and spilled over onto the sidewalks unbroken for the four miles to Seattle Center. The creativity of the protest signs was museum worthy and I was gifted a hand-painted one with a single image about reproductive rights, which I am preserving. Though viewpoints varied from the environment, healthcare, reproductive rights, education, immigration, and fair treatment for all people regardless of race or social orientation, everyone was peaceful, kind, and engaged. There were many children in the march, with their parents and grandparents, holding handmade signs. I spoke to as many children as I could, thanking them for participating in the march and telling them about their 1st amendment rights. One little girl, who was eight-years-old, said, “Oh, I thought that was going away.” I told her, well with Trump and some of the Republicans, they would like to make some of our 1st amendment rights go away (freedom of the press) and that is why we need to be here. It is so important that you stand up for your free speech, because that is what makes a true democracy. She said “Oh, I see, with a solemnity rare in someone her age.”
 The extensive presence of the Millennials, bodes well for the future of this nation, for they will be paying the price for our mistakes in stewardship. These young people are our future and it was a revelation to see them in full force. And the young parents, figuring out the logistics to bring not just one, but often two children, including infants and toddlers to the event was inspiring. Throughout the entire day, I never heard a single parent berating their children. Which, if you travel in the U.S. you will find that public displays of repudiation and disciplining children are common fare.
Recognizing the “Women’s March” was not a local event, but a national one, and globally represented in hundreds of cities throughout the world, from Paris, to Brasilia, millions marched against the Trump dogma. The sanctity and preservation of our world depends on cooperation among peoples and nations which are vastly disparate and hope is realized through the millions who dedicated their time to the belief in democracy on this day.  This march best represented our America, inclusive, engaged, peace-loving, and generous.

And this is the healthpolicymaven signing off a bit more encouraged than on November 8, 2016. Please continue to read this column for critical information on healthcare under the Trump Administration.

Healthpolicymaven is a trademark of Roberta E. Winter and Praevalere Inc, in continuous use since 2007.