Health care consultant and expert Bob Laszewski offers this rather humorous analysis of Mitt Romney’s promise to repeal the Affordable Care Act by issuing waivers to states and pushing a repeal bill through the reconciliation process.

Romney aides claim the former Massachusetts governor will allow states to ignore the requirements of the ACA by trying to expand the scope of the law’s “flexibility” waivers — which allow states that agree to provide health care coverage to their residents to opt out from implementing the individual mandate, the employer penalty for not providing coverage, and the exchange regulations. Romney will attempt to stretch the law to its breaking point by redefining the terms of the waiver:

For example, the Romney camp is suggesting that the requirement to provide coverage to a comparable number of people doesn’t refer to how many people are covered but instead allows them to interpret that as just making a comparable number of health insurance plans available in the market.

Say what?

It is possible that a Romney administration could try to delay implementation of critical parts of the law from the scheduled January 1, 2014 implementation date. With so much of the implementation of the law up in the air waiting for a Supreme Court ruling and the 2012 election results, it is not out of the question that there will have to be delays past 2014, no matter who is president. But if Romney tried any delays intended to derail the law, I would have to believe that about every liberal and progressive group in America would instantly be in front of about every federal judge in the land—likely with success.

The reconciliation bit works no better. Without the necessary 60 votes in the Senate for full repeal, “budget reconciliation bill would have to apply only to the budget-related elements of the new law” and would leave many portions intact. “Romney could end up creating a chaotic environment driven by enormous uncertainty over just which parts of the new health care law would be implemented–for consumers, health care providers, and insurers,” Laszewski argues before asking, “Doesn’t that make you feel better?”

HHS has announced that the annual increases in premiums for seniors in Medicare Part B will be somewhat lower than expected and is attributing the change to “historically low healthcare utilization rates, due in part to the health reform law’s investment in prevention; and the 3.6 percent Social Security cost-of-living hike announced earlier this month.” Washington Post’s Sarah Kliff has the details:

Most seniors will see a $3.50 bump in their monthly premiums in 2012, from $96.40 up to $99.90. That’s lower than the $106 premium that the Medicare Trustees Report had projected in May. About a quarter of Medicare beneficiaries, particularly those who are newer enrollees and have higher income (and had been paying higher premiums), will actually see a reduction in their monthly payments.

This is the third piece of good Medicare news that the administration has rolled out this year. Earlier, the White House announced decreases in the average premiums for Medicare’s prescription drug plan as well as for Medicare Advantage, the managed-care alternative to traditional fee-for-service coverage.

Now recall that premiums in employer-sponsored health insurance market increased more than expected — by 9 percent — despite the historically low utilization rates (a result of the recession). As Austin Frakt has explained, the causes of premium changes are somewhat complex, but it makes one wonder about the wisdom of the GOP’s plan to shift seniors from Medicare into private coverage. At the very least this comparison isn’t very flattering for private insurers or their abilities to control health care spending.

And note one more thing: while the increases in private premiums attract waves of media attention — and no shortage of Republicans happy to blame the spikes on the Affordable Care Act — the small increase in Medicare premiums will likely go underreported and uncredited.

Via Politico’s Pulse, the House Oversight and Government Reform committee is out with a new report arguing that the health care law implements a “marriage penalty tax” that will over time “directly cause fewer individuals to marry”:

1. Because the law links the tax credit to household income, two people who make above a certain combined income will not be able to get a tax credit if they file together (married), but if they get divorced or decided against tying the knot they would, individually, be eligible for a premium credit. Giving people pause about marriage could be a big “unintended consequence” of the law, the report says. (PULSE thought bubble: or provide a convenient excuse to those with commitment issues?)

2. Although the proposed rule on tax credits is somewhat unclear on the issue of affordability for families with employer-sponsored insurance, the GOP report suggests that the rule could be interpreted in a way where families with only one spouse receiving insurance through their employer could encounter a dilemma where they are forced to choose between a.) a divorce and tax credits b.) buying individual insurance without a premium subsidy or c.) paying a penalty and forgoing insurance.

Republicans first raised this concern during the health care reform debate and it’s still as meritless now as it was then. Here’s why: The affordability credits are pegged to the federal poverty guidelines, which treat married people as a unit and view individuals as separate parties filing separate tax returns. These guidelines assume, as Judith Solomon points out, that “people benefit from economies of scale when they’re living together” and recognizes that unmarried individuals have fewer resources (lower incomes, more money spent on basic necessities) than married families. In fact, since the majority of the uninsured are not married and marrying lowers uninsurance rates, providing more subsidies to individuals is a better way of targeting affordability credits to those who need them most.

That’s issue number one. Their second concern about an HHS rule offering insurance subsidies for workers if their employer doesn’t provide affordable individual coverage (as opposed to family coverage) is a worry health care advocates share. But to expand the affordability definition and allow more people to take advantage of the tax credits within the exchanges would cost the government “an extra $50 billion a year” — spending Republicans would surely oppose. The greatest irony of all, however, is that Republican health care prescriptions — look to the Boehner alternative introduced in the House for an example — don’t provide subsidies to anyone — married or unmarried Americans and it’s actually their efforts to repeal the ACA and do little to nothing for health care spending that would significantly strain families and their economic well being.

The individual mandate may not be “essential” to the Affordable Care Act’s successful implementation, a new study published yesterday in Health Affairs has concluded. Researchers John F. Sheils and Randall Haught agree that removing the incentive for younger and healthier people to purchase coverage would increase overall premiums (and create a premium spiral), but argue that “other provisions of the law that would greatly mitigate this effect” resulting in a slightly lower than expected premium increases and smaller coverage loss rates.

“We estimate that if the mandate were lifted, premiums in the individual market would increase by 12.6 percent—somewhat less than other estimates—with 7.8 million people losing coverage, versus other estimates for coverage loss of 16–24 million people,” the study says. “In sum, the Affordable Care Act would still cover 23 million people who would have been uninsured without the law”:

The premium subsidies provided under the act would also serve to restrain a premium spiral by absorbing much of the impact of premium increases. According to the Congressional Budget Office, about two-thirds of people with nongroup coverage under the act would receive premium subsidies. These subsidy amounts are tied to the premium for the second-lowest-cost of the “silver” plans offered by insurers through the health insurance exchanges (one of five plans of different actuarial values that are to be offered in the exchanges). Thus, any increase in the premium for that plan results in increased subsidy amounts, which will cover much or even all of the increase in premiums, depending on the plan a family has selected. [...]

For example, the act also permits plans to limit enrollment to an annual “open enrollment period” of about six weeks beginning in October of each year. Open enrollment periods, which are used by many employer health plans, typically limit enrollment of workers to one month of the year. Limiting this period of enrollment encourages people to take coverage by forcing them to forgo insurance for up to eleven months before they have another opportunity to enroll. The risk of going without coverage over that long a period causes many workers to take up insurance when they can.

There is great uncertainty surrounding these estimates — previous research by Jonathan Gruber, for instance had found that “the number of uninsured people would increase by twenty-four million people in the absence of the mandate” and the Congressional Budget Office (CBO) reported that 16 million could lose coverage.

The problem is that if you take away the mandate, you’re really eliminating any strong incentive for younger individuals who would otherwise forgo coverage to purchase insurance, balance out the risk pool and drive down costs. If you’re not attracting that population in the first place and only enrolling sicker individuals who need coverage (and can take advantage of the tax credit), that doesn’t sound like a terribly sustainable model — and certainly not one that the insurers or tax payers who are footing the tax credit bill will agree to live with.