Where does Obamacare's money come from

US Health Care Reform: Dysfunctional Policies

The tussle over US health care reform is over for the time being: Obamacare remains in force. Yet millions fear for their medical care. Interior views from America's divided capital Washington.

Donald Trump has again failed to organize a majority for a bill to replace Obamacare. Even his own ranks were not behind his plans. Photo: dpa

Washington DC, September 6th: While Donald Trump continues to foment everything and everyone in the White House, the Ratio has moved in in the government district around the Capitol. Aside from the debates about hurricanes, North Korea and the debt limit, the Senate Health Committee meets in the Hart Building. It happens what hardly anyone would have thought possible: Republicans and Democrats sit down at a table to talk about health care reform. The aim of the committee is not a big hit, a general overhaul of Obamacare or even a new reform. The aim is to stabilize the individual insurance market that was created under Obamacare. He has problems in some parts of the country. Both the insurers and the insured complain about the high costs of care services (see box on care structures).

The hearing is open to the public and there is great interest. Not only journalists have come, also citizens. The Capitol Police present immediately nipped individual disruptive actions by patients in the bud. The chairman Lamar Alexander, Republican, has proclaimed a clear goal: He wants to ensure calm in a market that is unsettled by the din in and around the White House and help with state funds that the prices for the premiums remain stable. If the Senators fail, Lamar sees Republicans and Democrats alike to be responsible: "The guilt will be on each of us, and deservedly," the Republican says clearly.

The tone in the boardroom is forgiving - a rarity in overheated Washington. As Lamar's colleagues gradually take the floor, they never tire of stressing the importance of this step. Lisa Murkowski, Republican Senator from Alaska, thanks for allowing a "constructive dialogue". Democrat Michael Bennet (Colorado) says a joint exchange is "long overdue". Several senators report from their home regions - of the "relief" of the citizens when they found out that in Washington there is finally non-partisan cooperation on health policy.

The first session is followed by three more. Insurance officers from various states, governors, doctors, insurers, patient representatives are invited. Many guest speakers speak plain language before the committee. Like Mike Kreidler, the insurance commissioner from Washington State, where there is still a stable insurance market: “The government's approach is making us nervous about 2018. Congress needs to act quickly and address these uncertainties. Millions of hard-working families rely on it. The system will collapse if you do nothing. ”Most speakers implore the senators to support Obamacare - for the benefit of the citizens.

Protect patients, stabilize markets

Alexander judged after the meetings: "It is clear that in order to really protect the patients, we have to stabilize the markets, limit the increases in premiums and begin to reduce the premiums in the future." And he emphasizes hopefully: Such a high level He had not seen any non-partisan cooperation in Washington for years.

But by this time it had long been clear: not all of his party friends were of this opinion.

September 13: Republican Senators Lindsey Graham and Bill Cassidy appear in front of the cameras in the government district. In the luggage: A single-handedly worked out draft to finish Obamacare after all. Core contents: The supply of the citizens falls completely into the hands of the federal states, only the money for it comes from Washington, distributed according to a complicated key for each state. There it should be decided individually how the supply should be designed.

The alternative would put more of a burden on the socially weak

The Republican alternative to Obamacare would mean: The general obligation to have health insurance falls. Likewise, the insurers no longer have to offer the basic care introduced under Obama and can ask people with previous illnesses to pay more than healthy people. Medicaid, the state care program for socially disadvantaged citizens that was greatly expanded under Obamacare, will also be massively cut, as will the subsidies that help financially weak citizens to purchase insurance. Overall, there is less money than before for the supply and government spending is limited. Graham made his position clear: “The Republicans have promised for seven years to repeal the Affordable Care Act. (...) We refuse to give up. "

Unsurprisingly, he received applause from the White House. President Trump supports the proposal. He welcomed the fact that Graham and Cassidy were working on a solution to "free the American people from the disastrous Obamacare burden," he said.

All efforts of the rational minds in Washington to introduce a law to stabilize Obamacare are now on hold again.

But that's not all of the political intrigues. Same day, just a few office buildings away. The other side also pours fuel on the fire: The left wing of the Democrats around the former presidential candidate Bernie Sanders (himself independent) presents its own draft law: one and the same health insurance for all Americans, organized by the state. Sander's suggestion: He would like to expand the popular state program Medicare, through which America's senior citizens (65 years and over) and citizens with disabilities are covered.

Sanders not only wants to open Medicare to all US citizens, but also wants to massively expand its services: dentistry, hearing aids, reproductive medicine, maternal care - he believes that health care should include all of this in the future. At the same time, Sanders sees potential for savings through the broad access of all citizens to one and the same supply system, if only by eliminating the immense bureaucracy costs that the complex US system is currently causing. According to Sander's idea, the state becomes the citizens' central partner in health care. The proposal would decouple health insurance and employment. Private providers would be almost completely displaced from the system.

McCain is considered principled and steadfast

For America's Conservatives, Sander's push is "extreme" - just as leftists, conversely, see the Republican push to put all power over health care in the hands of the states. Because of the majority in the US Congress - both chambers are in the hands of the Republicans - Sander's move has no chance of being heard at all. Nevertheless, it has political significance: The initiative is considered a blueprint for what can be expected of democratic candidates in the 2020 presidential election campaign.

September 18: Hope grows in the ranks of the conservatives. The US media reports: The Republicans are on the verge of getting the 50 votes needed to abolish Obamacare. It would be a highlight for the conservatives - and for Trump - if the attempt to revive the anti-Obama care maneuver, believed to be dead, were still successful.

But one core problem remains: As with all other advances, the Republicans don't have much time to grapple with the bill. Because: The time for the vote is pressing. The conservatives can only push through the draft with a simple majority until the end of September, after which the voting modalities in the Senate will change. The Democrats would then have to vote - unimaginable.

Someone who has already got in Trump's way expressed skepticism on US television and appeals for non-partisan cooperation: Political veteran John McCain. “Why did Obamacare fail? Obamacare was only passed through with the votes of the Democrats, "says the Republican in the popular format" Face the Nation "on CBS. "That is not the right way." A law must be discussed intensively. Already at this point the party friends could foresee evil: McCain is considered to be principled and steadfast.

However: The advance of the Graham-Cassidy duo has continued support from above. Both Trump and his Vice Mike Pence are trying in private talks to convince the Senators to approve the bill. There is a good reason for the immense commitment: Trump and the party leadership are not only backing the conservative electorate that has been promised to abolish Obamacare. The Republicans' multimillion dollar donors also complain. According to media reports, they are threatening to turn off the party's money if the conservatives don't finally get something done.

Only a few days later: The mini-euphoria that suddenly appeared in conservative circles evaporates just as quickly as it came. As much as the party leadership tries, the opposition to the Graham-Cassidy draft is growing. Not only the Democrats are at the front. Little by little, important players in the healthcare sector are publicly positioning themselves against “Trumpcare”. Patient organizations. Medicine societies. Eventually even the insurance industry. The draft is one of the "most radical" proposals that have been submitted so far, it is said. And: The supply system could not work as proposed.

Shortly afterwards, the hopes of the Republicans to kill Obamacare after all, finally burst. Again, people from their own ranks refuse to follow Trump. Right-wing hardliner Rand Paul (“still too much Obamacare”), John McCain (“work non-partisan”) and Maine's Senator Susan Collins (law is “flawed”) are gradually opposing the president and their own party leadership. The next day, the renewed failure is official, the Conservatives withdraw: Mitch McConnell, the Republican majority leader in the Senate, announces that there will be no vote. All that remains to him is to emphasize: "We have not given up wanting to change the American health system."

That means: Millions of Americans can - for the time being - breathe a sigh of relief. Not all of them, however. For the 18 million US citizens who take out health insurance through the individual market, the political turmoil of the past weeks and the government's anti-Obamacare policy have consequences: Analysts assume that in some regions with a further drastic increase in Insurance premiums by up to 50 percent can be expected.

After all: Trump has now indicated that he wants to work with the Democrats on health policy in the future. The non-partisan talks between the moderate senators were also resumed. Outcome: uncertain.

Nora Schmitt-Sausen

Obamacare individual market has problems

The Affordable Care Act, called Obamacare, created a new individual insurance market in the United States. 18 million Americans get their health insurance through it, about half of them with financial support from Washington. The problem: In many parts of the country, the young market is not yet very robust. Some providers of health insurance have withdrawn from it after a short time due to a lack of prospect of profit. Uncertainty about Obamacare's future and repeated threats by the Trump administration not to help insurers financially have also impacted the market. The result: In many regions there is only one single provider available. This lack of competition drives up the prices of the policies. The rapidly skyrocketing premiums are a major problem for many of the newly insured. Quite a few are no longer able to pay their insurance premiums.

Complex supply structures

The US healthcare system is highly complex, and care is divided into many different sectors. The majority of Americans - 156 million - are insured through their employers. The quality of care depends, for example, on what insurance policies the employer offers and what costs the employee is willing to pay himself. In the pre-Obamacare era, US citizens were without health insurance if they lost or changed their jobs. Now you can protect yourself in these times via the new individual insurance market.

Other central pillars of the system are the two major state care programs Medicare (for the elderly and people with disabilities) and Medicaid (for the socially disadvantaged). The latter was massively expanded under Obamacare. A total of 130 million Americans are insured through this. 74 million are on Medicaid, 56 million on Medicare.

22 million Americans purchase health insurance for themselves. 18 million of these buy their health insurance through the individual insurance market newly created under Obama, half of them again receive government support. This market is primarily for the self-employed, part-time workers and citizens who are employed in small businesses that do not have to offer insurance.

There are also other government programs such as America’s own care system for America’s soldiers (nine million insured persons) or the Children's Health Insurance Program, which is linked to Medicaid. This covers almost nine million children from families who earn too much to get Medicaid but too little to be able to purchase a policy for the children.

28 million Americans still have no health insurance.