Another View   1 comment

Rick shared our write-up on the Patient Freedom Act (Cassidy Collins, if you prefer) with a coworker and she asked if she could write up her impressions and publish under me. As I’ve said, if you’re not in private practice, it’s dangerous for a doctor to say “boo” about Obamacare. I don’t mind being used by doctors to get the message out.


Image result for image of medical careFirst, the PFA would dramatically expand taxpayer funding for abortions, even when compared to Obamacare, something Rick realized he’d missed on our write-up.

The PFA (text available here, and a summary available here) gives states a choice of three options regarding the health care system within their borders. They can either:

  1. keep Obamacare in place
  2. use an allotment, based on 95 percent of a state’s Obamacare spending, to create their own insurance regime (albeit with several federal mandates remaining)
  3. go out on their own and not receive any federal funds.

Section 104 of the bill contains a complicated formula to determine state allotments for option two—the default option for states under the PFA. Section 104(b)(2) provides that states that did not expand Medicaid under Obamacare will receive 95 percent of the amount they would have received had they accepted the Medicaid expansion.

Instead of reducing Obamacare’s spending, the Patient Freedom Act could well increase by giving new Medicaid funds to states that declined to expand.

Medicaid reform should not disadvantage states that did not expand Medicaid under Obamacare, but the proper solution does not lie in adding to nearly $2 trillion in Obamacare spending over the coming decade. Instead, it lies in freezing enrollment in the Medicaid expansion, unwinding that new spending, and transitioning beneficiaries over time off the rolls and into work.

The Patient Freedom Act does not repeal any of Obamacare—the word “repeal” doesn’t appear anywhere in its 73 pages—but, it effectively ends the current HSA regime, making Health Savings Accounts less attractive to individuals.

Current law makes HSAs tax-privileged in two ways. First, contributions to an HSA can be made on a pre-tax basis—either via a payroll deduction through an employer or an above-the-line deduction on one’s annual tax return. Second, HSA distributions are not taxable when used for qualified health expenses under Obamacare.

The Patient Freedom Act would abolish the first tax preference while retaining the second. Individuals must contribute after-tax dollars to an HSA, but their contributions could grow tax-free, and distributions would be tax-free when used for qualified health expenses, as under current law. Section 201(b) prohibits additional contributions to “traditional” HSAs following enactment of the bill, instead diverting new contributions to the Roth HSAs created by the measure. While the bill does not require individuals to convert their existing HSAs to the new Roth HSAs, account administrators at banks and mutual funds could require their customers to do so at some point, which could result in a hefty tax bill .

Health Savings Accounts are a proven vehicle to help control the growth of health costs. In fact, expansion should have been used before Obamacare was ever considered. While Obamacare included new restrictions on HSAs, Democrats did not upend the accounts nearly as much as contemplated by the Patient Freedom Act. Significantly reducing the tax preferences for Health Savings Accounts would not lower health care costs. If anything, it would raise them.

In recent years, some Americans have faced the problem of “surprise” medical bills. These can occur when individuals seek emergency care at an out-of-network hospital, or when some providers at a facility remain outside an insurer’s network (for example, a surgeon and the hospital are in-network, but the anesthesiologist is out-of-network). To address these issues, Section 1001 of Obamacare included new mandates that insurers not impose prior authorization requests on emergency care, and require only in-network cost-sharing for all emergency care, regardless of whether the patient was treated at an in-network hospital or not.

Section 121(a)(2) of the Patient Freedom Act goes further than Obamacare, imposing maximum charges for emergency services: 85 percent of insurers’ usual, customary, and reasonable charges for physician care; 110 percent of Medicare payment rates for inpatient and outpatient hospital care; and acquisition costs plus $250 for drugs and biological pharmaceuticals.

While the issue of “surprise” medical bills does present a policy problem—individuals caught in the middle of stand-offs between providers and insurers regarding payment rates—there are other ways to resolve it short of government price controls.

Sections 105(c) and 107(c) of the PFA create parameters through which states can automatically enroll their residents in health insurance—complete with restrictions on the type of coverage states can auto-enroll individuals in. While individuals can opt out of insurance should they wish to do so, this mandate that doesn’t call itself a mandate could prove even more problematic than Obamacare’s requirement that all individuals purchase health coverage.

Automatic enrollment represents bad policy. Much of it comes down to two questions:

  • With the most recent enrollment estimates in Obamacare’s exchanges from seven months ago (June 30), how will states determine who is insured, and who should be auto-enrolled in coverage, in real time?
  • Even if states could compile all that data, why should individuals have to give their personal insurance details to another government database?

Nearly four years ago, tSen. Bill Cassidy said this about the IRS’ power in enforcing Obamacare:

Obamacare requires thousands of IRS agents to implement the law…They’re going to go through the small businesswoman’s books, to make sure that she actually has the number of employees that she claims, and that she has adequate insurance. That’s a little scary when you see what the IRS has been doing with their political targeting.

Granted, the PFA doesn’t have an employer mandate to enforce, but why is Sen. Cassidy’s “solution” to big government overreach at the federal level allowing states to impose their own intrusive requirements on individuals and businesses…?

Conservatives seeking to repeal Obamacare should be disappointed by the ways in which the Patient Freedom Act exceeds Obamacare in several key respects, while liberals will undoubtedly oppose any attempt to devolve or deregulate health care coverage to the states. Its Senate sponsors notwithstanding, the bill appears to lack a natural constituency and it doesn’t really address the very real problems with Obamacare. It appears just to transfer them to the states. The question is — would making an intrusive, inefficient federal health care coverage system into an intrusive, inefficient state health care coverage somehow make it more palatable?

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