First a little background. Medicare is the primary program for seniors and the disabled. It is paid for by taxes on employers and employees and administered by the federal government.

Medicaid is the primary program for the poor. It is paid for by the federal and state governments with taxes. Each state runs its own program and decides who and what to cover within federal floors and ceilings; 20 states (primarily in the South) have not yet expanded their Medicaid programs to cover all the poor with the funding available under the ACA. 

About half of all Californians under 65 have employment-based coverage. The federal and state governments pay for about a third of the costs with a little understood mechanism known as pre-tax purchasing.

Individual coverage is partially paid for by the federal government with refundable tax credits and for the self employed with tax deductibility. The numbers of people with individual coverage have doubled due to the ACA.

The uninsured are people with none of the above coverage and no VA (Veterans Affairs) coverage. In California the numbers of uninsured have fallen very dramatically (more than half) due to the ACA. Undocumented Californians make up at least half of the remaining uninsured; they are not for the most part eligible for full scope Medicaid or for refundable tax credits.

After two years of 4% increases in health insurance premiums, Covered California premiums increased by 13.2% in 2017. Prices for the lowest cost bronze plans however increased only 3.9% (for a three-year average of 3.9%). Prices for the lowest cost silver plans increased 8.1% (for a three year average of 4.8%). Prices for the 2nd lowest cost silver plans (reference plans) increased 8.1% (for a three year average of 4.1%). Prices for the savvy comparison shoppers (i.e. those switching to the lowest priced plan in the metal tier they selected) declined -1.2%.

Clearly there will be lots of financial incentives for Covered CA customers to shop around in the coming year; this report will provide some information for those inclined to do so.

In a recent JAMA article, the President assesses the progress of health reform and makes his recommendations for next steps. http://jama.jamanetwork.com/article.aspx?articleid=2533698  The article includes some excellent graphs showing the improvements in coverage, cost, and quality.

The Committee for a Responsible Budget recently catalogued the campaign promises and their costs over the next decade from Prospective Presidential Nominees Donald Trump and Hillary Clinton. http://crfb.org/papers/promises-and-price-tags-fiscal-guide-2016-election

The chart below summarizes their most significant findings – important reading before the standard obfuscations of political conventions, debates and campaigns.

In most ways, the new plan is same old, same old. It proposes block grants of the Medicaid program to the states, creates Medicare vouchers, adds in a Cadillac benefits tax for employer plans, repeals most but not all of the Obamacare consumer protections and payment reforms. It adds in a flat refundable tax credit for the uninsured. It keeps some consumer protections for those who maintain continuous and uninterrupted coverage and repeals them for most every one else.

Here are the summaries on the financing provisions. I would urge you to read the full 37 pages of text, so you are well-educated in these times of electoral confusion and potential tumult.

n most ways, the new plan is same old, same old. It proposes block grants of the Medicaid program to the states, creates Medicare vouchers, adds in a Cadillac benefits tax for employer plans, repeals most but not all of the Obamacare consumer protections and payment reforms. It adds in a flat refundable tax credit for the uninsured. It keeps some consumer protections for those who maintain continuous and uninterrupted coverage and repeals them for most every one else.

Here are the summaries on the employer and cost containment provisions. I would urge you to read the full 37 pages of text, so you are well-educated in these times of electoral confusion and potential tumult. I will follow up with a blog on the financing provisions in Part 4 of this series.

In most ways, the new plan is same old, same old. It proposes block grants of the Medicaid program to the states, creates Medicare vouchers, adds in a Cadillac benefits tax for employer plans, repeals most but not all of the Obamacare consumer protections and payment reforms. It adds in a flat refundable tax credit for the uninsured. It keeps some consumer protections for those who maintain continuous and uninterrupted coverage and repeals them for most every one else.

Here are the summaries on the Refundable Tax Credit and Consumer Protection provisions. I would urge you to read the full 37 pages of text, so you are well-educated in these times of electoral confusion and potential tumult. I will follow up with blogs on the cost containment and employer coverage provisions in Part 3 of this series.

In most ways, the new plan is same old, same old. It proposes block grants of the Medicaid program to the states, creates Medicare vouchers, adds in a Cadillac benefits tax for employer plans, repeals most but not all of the Obamacare consumer protections and payment reforms. It adds in a flat refundable tax credit for the uninsured. It keeps some consumer protections for those who maintain continuous and uninterrupted coverage and repeals them for most every one else.

Here are the summaries on the Medicaid and Medicare portions. I would urge you to read the full 37 pages of text, so you are well-educated in these times of electoral confusion and potential tumult. I will follow up with blogs on the refundable tax credits, the cost containment provisions and on the consumer protections.

Hillary Clinton’s tax proposal would raise taxes on the highest income individuals, repeal fossil fuel incentives, increase estate and gift taxes and create tax disincentives for corporations to shelter income overseas for tax avoidance purposes. Over the next 10 years, she would increase federal revenues by $1.1 trillion. Her proposals would decrease the federal debt by $1.2 trillion over the next decade and by $4.3 billion over the next 20 years.

Donald Trump proposes to cut taxes for businesses, individuals and heirs quite dramatically. He would decrease federal tax revenues by $9.5 trillion over the next 10 years. Over the following 10 years federal revenues would be cut by $15 trillion. He would increase the federal debt by $11 trillion over the next decade and by $34 billion over the following 10 years.

The general view of economists from both the left and right is that free trade is an excellent idea that benefits all nations. In other words, if the US is best at producing high quality low cost computers and worst at producing high quality, low cost clothes, the US should specialize in computer production and either leave clothes production to others who can do a better job or redesign its clothing design and manufacturing to make it competitive in world and domestic markets.

In general since the Second World War, the US has espoused and implemented free trade with world training partners, which worked well as long as the US was a manufacturing colossus during the 40s and 50s. However beginning in the 60s and 70s, the American competitive edge began to decline, and Germany and Japan rebuilding after World War Two proved able and often superior competitors in manufacturing. China and Mexico are currently perceived as competitive threats by some.

Donald J. Trump proposes mass deportation of 11 million Mexicans and wholesale exclusion of Muslim immigrants, tourists and visitors. His nativism has deep and disturbing roots in our nation’s past.

This is the title of an excellent article by Eduardo Porter on the business page of the New York Times today (June 8, 2016). http://www.nytimes.com/2016/06/08/business/economy/threatened-by-machines-a-once-stupid-concern-gains-respect.html It raises the questions of how society could evolve as computers and industrial robots displace more and more workers. Are human workers going the way of the working horses now thoroughly displaced by cars, trains, tractors and planes over the last century?

My old law school roommate, Dan Sullivan, has just self published a book, entitled Radical Change: the Death of the American Dream exploring in depth the same fascinating issues. http://www.amazon.com/Radical-Change-Death-American-Dream/dp/0692439145?ie=UTF8&keywords=death%20of%20the%20american%20dream&qid=1465439657&ref_=sr_1_3&sr=8-3

The Federal Reserve Bank of New York researchers recently looked at medical debt collection efforts in communities in those states that supported the Medicaid expansion of Obamacare. Medical debts fell like a rock between 2013 and 2015 in counties that previously had a high rate of uninsured. See http://www.bloomberg.com/news/articles/2016-06-07/u-s-states-that-embraced-healthcare-reform-are-seeing-less-debt-sent-to-collection-agencies

The Urban Institute looked at the rise in premiums of the lowest cost silver plans in the Exchanges. http://www.urban.org/research/publication/increases-2016-marketplace-nongroup-premiums-there-no-meaningful-national-average/view/full_report In California these premiums increased by 1.4% between 2015 and 2016.

California’s 2020 waiver requires an analysis of the financing of uncompensated care to the uninsured in California’s public hospitals. At risk is ongoing federal funding for the safety net care pool (SNCP). The recent report by the Navigant Consulting Group provides excellent insight into financing of care for the remaining uninsured and arguments that can be made both for and against continued federal financing of the SNCP (about $236 million annually). SNCP was funded for one year only pending this report and the continuing negotiations with the federal government based on its findings and conclusions.

Overview – the biggest news in the Proposed May Budget Revise was the Governor’s support of a $2 billion bond for supportive and affordable housing for the homeless.

From 2010 to the first quarter of 2015, the nation’s uninsurance rates fell from 22.3% to 13.0%. The percentage rates of uninsured children fell from 13.9% in 1997 to 4.6% in 2015 due to CHIP and then the ACA. The uninsured rates for adults declined from 22.3% in 2010 to 13.0% in 2015 due to the ACA. Most of the declines for adults happened in only 15 months.

In this blog post I review Republican Presumptive Presidential nominee Donald Trump’s health care reform proposals to make America great again. Mr. Trump has seven key points: 1) completely repeal ObamaCare, 2) permit interstate sale of health insurance, 3) deductibility of individual insurance premiums, 4) broader Health Savings Accounts, 5) price transparency, 6) Medicaid block grant and 7) reduce barriers to market entry for pharmaceuticals. Some are good ideas, some are bad, and two are atrociously bad ideas.

The starting points: Medicare covers seniors and the disabled, is paid for by the federal government and covers very little long term care, no dental or vision care. Medicare comprises four parts: Part A for hospital care, Part B for doctors, Part D for prescription drugs and Part C that combines them all through private insurers (HMOs and PPOs). Just over 5.6 million Californians are enrolled.

Medi-Cal covers the poor; it is paid for by the federal and state governments; it covers a full range of long term care, most dental care and vision care only for children. Almost all subscribers are enrolled in local managed care plans (HMOs). Over 13 million Californians are enrolled.

Employment-based coverage covers about ½ of all Californians; it is paid for by employers and employees assisted by a very large tax subsidy (pre-tax purchasing). Most enrollees are in HMOs; the rest in PPOs. Large and medium sized employers are required to offer coverage to their full time employees, small employers are not so required.

Covered California (Exchanges) cover the uninsured and private individually insured above Medi-Cal levels; individuals pay a share of premiums based on their incomes and the federal government pays a very large share of the premiums, copays and deductibles for those who cannot afford the full cost. Individuals pick their plan, their doctor and their level of coverage. Individuals not otherwise covered by Medicare, Medi-Cal, their employers or the VA are required to enroll in coverage, if affordable. About 1.5 million are enrolled.

The undocumented uninsured (about 1.5 million Californians) are only eligible for emergency care and prenatal care through Medi-Cal if they are low income, but are otherwise ineligible for federally financed coverage. California has just begun to offer full scope Medi-Cal for low income undocumented children (about 170,000 may be eligible). This will be through local HMOs.

The latest count is that 47,000 Los Angelenos are homeless. The growth in the city was 11%; the growth in the county was 5.7%. Meanwhile homeless veterans in Los Angeles declined by a third in the past year due to the recent concerted efforts of the federal Veteran’s Administration.