Reprinted with permission from ProPublica
This story was co-published with Kaiser Health News, Stat and Vox.
When Louisiana resident Andrea Mongler wrote to her senator, Bill Cassidy, in support of the Affordable Care Act, she wasn’t surprised to get an email back detailing the law’s faults. Cassidy, a Republican who is also a physician, has been a vocal critic.
“Obamacare” he wrote in January, “does not lower costs or improve quality, but rather it raises taxes and allows a presidentially handpicked ‘Health Choices Commissioner’ to determine what coverage and treatments are available to you.”
There’s one problem with Cassidy’s ominous-sounding assertion: It’s false.
The Affordable Care Act, commonly called Obamacare, includes no “Health Choices Commissioner.” Another bill introduced in Congress in 2009 did include such a position, but the bill died — and besides, the job as outlined in that legislation didn’t have the powers Cassidy ascribed to it.
As the debate to repeal the law heats up in Congress, constituents are flooding their representatives with notes of support or concern, and the lawmakers are responding, sometimes with form letters that are misleading. A review of more than 200 such letters by ProPublica and its partners at Kaiser Health News, Stat and Vox, found dozens of errors and mischaracterizations about the ACA and its proposed replacement. The legislators have cited wrong statistics, conflated health care terms and made statements that don’t stand up to verification.
It’s not clear if this is intentional or if the lawmakers and their staffs don’t understand the current law or the proposals to alter it. Either way, the issue of what is wrong — and right — about the current system has become critical as the House prepares to vote on the GOP’s replacement bill Thursday.
“If you get something like that in writing from your U.S. senator, you should be able to just believe that,” said Mongler, 34, a freelance writer and editor who is pursuing a master’s degree in public health. “I hate that people are being fed falsehoods, and a lot of people are buying it and not questioning it. It’s far beyond politics as usual.”
Cassidy’s staff did not respond to questions about his letter.
Political debates about complex policy issues are prone to hyperbole and health care is no exception. And to be sure, many of the assertions in the lawmakers’ letters are at least partially based in fact.
Democrats, for instance, have been emphasizing to their constituents that millions of previously uninsured people now have medical coverage thanks to the law. They say insurance companies can no longer discriminate against millions of patients with pre-existing conditions. And they credit the law with allowing adults under age 26 to stay on their parents’ health plans. All true.
For their part, Republicans criticize the law for not living up to its promises. They say former President Obama pledged that people could keep their health plans and doctors and premiums would go down. Neither has happened. They also say that insurers are dropping out of the market and that monthly premiums and deductibles (the amount people must pay before their coverage kicks in) have gone up. All true.
But elected officials in both parties have incorrectly cited statistics and left out important context. We decided to take a closer look after finding misleading statements in an email Sen. Roy Blunt, R-Mo., sent to his constituents. We solicited letters from the public and found a wealth of misinformation, from statements that were simply misleading to whoppers. More Republicans fudged than Democrats, though both had their moments.
An aide to Rep. Dana Rohrabacher, R-Calif., defended his hyperbole as “within the range of respected interpretations.”
“Do most people pay that much attention to what their congressman says? Probably not,” said Sherry Glied, dean of New York University’s Robert F. Wagner Graduate School of Public Service, who served as an assistant Health and Human Services secretary from 2010 to 2012. “But I think misinformation or inaccurate information is a bad thing and not knowing what you’re voting on is a really bad thing.”
We reviewed the emails and letters sent by 51 senators and 134 members of the House within the past few months. Here are some of the most glaring errors and omissions:
Rep. Pat Tiberi, R-Ohio, incorrectly cited the number of Ohio counties that had only one insurer on the Affordable Care Act insurance exchange.
What he wrote: “In Ohio, almost one third of counties will have only one insurer participating in the exchange.”
What’s misleading: In fact, only 23 percent (less than one quarter) had only one option, according to an analysis by the Kaiser Family Foundation.
His response: A Tiberi spokesperson defended the statement. “The letter says ‘almost’ because only 9 more counties in Ohio need to start offering only 1 plan on the exchanges to be one third.”
Why his response is misleading: Ohio has 88 counties. A 10 percent difference is not “almost.”
Rep. Kevin Yoder, R-Kan., said that the quality of health care in the country has declined because of the ACA, offering no proof.
What he wrote: “Quality of care has decreased as doctors have been burdened with increased regulations on their profession.”
Why it’s misleading: Some data shows that health care has improved after the passage of the ACA. Patients are less likely to be readmitted to a hospital within 30 days after they have been discharged, for instance. Also, payments have been increasingly linked to patients’ outcomes rather than just the quantity of services delivered. A 2016 report by the Commonwealth Fund, a health care nonprofit think tank, found that the quality care has improved in many communities following the ACA.
His response: None.
Rep. Anna Eshoo, D-Calif., misstated the percentage of Medicaid spending that covers the cost of long-term care, such as nursing home stays.
What she wrote: “It’s important to note that 60 percent of Medicaid goes to long-term care and with the evisceration of it in the bill, this critical coverage is severely compromised.”
What’s misleading: Medicaid does not spend 60 percent of its budget on long-term care. The figure is closer to a quarter, according to the Center on Budget and Policy Priorities, a liberal think tank. Medicaid does, however, cover more than 60 percent of all nursing home residents.
Her response: Eshoo’s office said the statistic was based on a subset of enrollees who are dually enrolled in Medicaid and Medicare. For this smaller group, 62 percent of Medicaid expenditures were for long-term support services, according to the Kaiser Family Foundation.
What’s misleading about the response: Eshoo’s letter makes no reference to this population, but instead refers to the 75 million Americans on Medicaid.
Rep. Chuck Fleischmann, R-Tenn., pointed to the number of uninsured Americans as a failure of the ACA, without noting that the law had dramatically reduced the number of uninsured.
What he wrote: “According to the U.S. Census Bureau, approximately thirty-three million Americans are still living without health care coverage and many more have coverage that does not adequately meet their health care needs.”
Why it’s misleading: The actual number of uninsured in 2015 was about 29 million, a drop of 4 million from the prior year, the Census Bureau reported in September. Fleischmann’s number was from the previous year.
Beyond that, reducing the number of uninsured by more than 12 million people from 2013 to 2015 has been seen as a success of Obamacare. And the Republican repeal-and-replace bill is projected to increase the number of uninsured.
His response: None.
Rep. Joseph P. Kennedy III, D-Mass., overstated the number of young adults who were able to stay on their parents’ health plan as a result of the law.
What he wrote: The ACA “allowed 6.1 million young adults to remain covered by their parents’ insurance plans.”
What’s misleading: A 2016 report by the U.S. Department of Health and Human Services, released during the Obama administration, however, pegged the number at 2.3 million.
Kennedy may have gotten to 6.1 million by including 3.8 million young adults who gained health insurance coverage through insurance marketplaces from October 2013 through early 2016.
His response: A spokeswoman for Kennedy said the office had indeed added those two numbers together and would fix future letters.
Rep. Blaine Luetkemeyer, R-Mo., said that 75 percent of health insurance marketplaces run by states have failed. They have not.
What he said: “Nearly 75 percent of state-run exchanges have already collapsed, forcing more than 800,000 Americans to find new coverage.”
What’s misleading: When the ACA first launched, 16 states and the District of Columbia opted to set up their own exchanges for residents to purchase insurance, instead of using the federal marketplace, known as Healthcare.gov.
Of the 16, four state exchanges, in Oregon, Hawaii, New Mexico and Nevada, failed, and Kentucky plans to close its exchange this year, according to a report by the House Energy and Commerce Committee. While the report casts doubt on the viability of other state exchanges, it is clear that 3/4 have not failed.
His response: None.
Rep. Dana Rohrabacher, R-Calif., overstated that the ACA “distorted labor markets,” prompting employers to shift workers from full-time jobs to part-time jobs.
What he said: “It has also, through the requirement that employees that work thirty hours or more be considered full time and thus be offered health insurance by their employer, distorted the labor market.”
What’s misleading: A number of studies have found little to back up that assertion. A 2016 study published by the journal Health Affairs examined data on hours worked, reason for working part time, age, education and health insurance status. “We found only limited evidence to support this speculation” that the law led to an increase in part-time employment, the authors wrote. Another study found much the same.
In addition, PolitiFact labeled as false a statement last June by President Donald Trump in which he said, “Because of Obamacare, you have so many part-time jobs.”
His response: Rohrabacher spokesman Ken Grubbs said the congressman’s statement was based on an article that said, “Are Republicans right that employers are capping workers’ hours to avoid offering health insurance? The evidence suggests the answer is ‘yes,’ although the number of workers affected is fairly small.”
We pointed out that “fairly small” was hardly akin to distorting the labor market. To which Grubbs replied, “The congressman’s letter is well within the range of respected interpretations. That employers would react to Obamacare’s impact in such way is so obvious, so nearly axiomatic, that it is pointless to get lost in the weeds,” Grubbs said.
Rep. Mike Bishop, R-Mich., appears to have cited a speculative 2013 report by a GOP-led House committee as evidence of current and future premium increases under the ACA.
What he wrote: “Health insurance premiums are slated to increase significantly. Existing customers can expect an average increase of 73 percent, while the average change due to Obamacare for those purchasing a new plan will be a 96 percent increase in premiums. The average cost for a new customer in the individual market is expected to rise $1,812 per year.”
What’s misleading: The figures seem to have come from a report issued before the Obamacare insurance marketplaces launched and before 2014 premiums had been announced. The letter implies these figures are current. In fact, premium increases by and large have been moderate under Obamacare. The average monthly premium for a benchmark plan, upon which federal subsidies are calculated, increased about 2 percent from 2014 to 2015; 7 percent from 2015 to 2016; and 25 percent this year, for states that take part in the federal insurance marketplace.
His response: None
Rep. Dan Newhouse, R-Wash., misstated the reasons why Medicaid costs per person were higher than expected in 2015.
What he wrote: “A Medicaid actuarial report from August 2016 found that the average cost per enrollee was 49 percent higher than estimated just a year prior — in large part due to beneficiaries seeking care at more expensive hospital emergency rooms due to difficulty finding a doctor and long waits for appointments.”
What’s misleading: The report did not blame the higher costs on the difficulty patients had finding doctors. Among the reasons the report did cite: patients who were sicker than anticipated and required a raft of services after being previously uninsured. The report also noted that costs are expected to decrease in the future.
His response: None
Sen. Dick Durbin, D-Ill., wrongly stated that family premiums are declining under Obamacare.
What he wrote: “Families are seeing lower premiums on their insurance, seniors are saving money on prescription drug costs, and hospital readmission rates are dropping.”
What’s misleading: Durbin’s second and third points are true. The first, however, is misleading. Family insurance premiums have increased in recent years, although with government subsidies, some low- and middle-income families may be paying less for their health coverage than they once did.
His response: Durbin’s office said it based its statement on an analysis published in the journal Health Affairs that said that individual health insurance premiums dropped between 2013 and 2014, the year that Obamacare insurance marketplaces began. It also pointed to a Washington Post opinion piece that said that premiums under the law are lower than they would have been without the law.
Why his response is misleading: The Post piece his office cites states clearly, “Yes, insurance premiums are going up, both in the health care exchanges and in the employer-based insurance market.”
Rep. Susan Brooks, R-Ind., told constituents that premiums nationwide were slated to jump from 2016 to 2017, but failed to mention that premiums for some plans in her home state actually decreased.
What she wrote: “Since the enactment of the ACA, deductibles are up, on average, 63 percent. To make matters worse, monthly premiums for the “bronze plan” rose 21 percent from 2016 to 2017. … Families and individuals covered through their employer are forced to make the difficult choice: pay their premium each month or pay their bills.”
What’s misleading: Brooks accurately cited national data from the website HealthPocket, but her statement is misleading. Indiana was one of two states in which the premium for a benchmark health plan — the plan used to calculate federal subsidies — actually went down between 2016 and 2017. Moreover, more than 80 percent of marketplace consumers in Indiana receive subsidies that lowered their premium costs. The HealthPocket figures refer to people who do not qualify for those subsidies.
Her response: Brooks’ office referred to a press release from Indiana’s Department of Insurance, which took issue with an Indianapolis Star story about premiums going down. The release, from October, when Vice President Mike Pence was Indiana’s governor, said that the average premiums would go up more than 18 percent over 2016 rates based on enrollment at that time. In addition, the release noted, 68,000 Indiana residents lost their health plans when their insurers withdrew from the market.
Why her response is misleading: For Indiana consumers who shopped around, which many did, there was an opportunity to find a cheaper plan.
Sen. Ron Wyden, D-Ore., incorrectly said that the Republican bill to repeal Obamacare would cut funding for seniors in nursing homes.
What he wrote: “It’s terrible for seniors. Trumpcare forces older Americans to pay 5 times the amount younger Americans will — an age tax — and slashes Medicaid benefits for nursing home care that two out of three Americans in nursing homes rely on.”
What’s misleading: Wyden is correct that the GOP bill, known as the American Health Care Act, would allow insurance companies to charge older adults five times higher premiums than younger ones, compared to three times higher premiums under the existing law. However, it does not directly slash Medicaid benefits for nursing home residents. It proposes cutting Medicaid funding and giving states a greater say in setting their own priorities. States may, as a result, end up cutting services, jeopardizing nursing home care for poor seniors, advocates say, because it is one of the most expensive parts of the program.
His response: Taylor Harvey, a spokesman for Wyden, defended the statement, noting that the GOP health bill cuts Medicaid funding by $880 billion over 10 years and places a cap on spending. “Cuts to Medicaid would force states to nickel and dime nursing homes, restricting access to care for older Americans and making it a benefit in name only,” he wrote.
Why his response is misleading: The GOP bill does not spell out how states make such cuts.
Rep. Derek Kilmer, D-Wash., misleadingly said premiums would rise under the Obamacare replacement bill now being considered by the House.
What he wrote: “It’s about the 24 million Americans expected to lose their insurance under the Trumpcare plan and for every person who will see their insurance premiums rise — on average 10-15 percent.”
Why it’s misleading: First, the Congressional Budget Office did estimate that the GOP legislation would cover 24 million fewer Americans by 2026. But not all of those people would “lose their insurance.” Some would choose to drop coverage because the bill would no longer make it mandatory to have health insurance, as is the case now.
Second, the budget office did say that in 2018 and 2019, premiums under the GOP bill would be 15-20 percent higher than they would have been under Obamacare because the share of unhealthy patients would increase as some of those who are healthy drop out. But it noted that after that, premiums would be lower than under the ACA.
His response: None.