I don't think the Affordable Care Act isn't the reason why the Republicans are going to make gains in the mid-terms. What's really driving this is general ennui and uncertainty around the tepid economic recovery and the American people's block-headed tendency to blame whoever's in office and vote for whatever major party is out of office. Oh, and youth apathy (and/or idealistic refusal) for voting in mid-terms. This is a tradition going back decades, and has nothing to do with practical policy issues. At most, the Obamacare roll out will be seen as a symptom of deeper incompetency on other issues from the Obama white house, fair or not.

One of Obama's biggest and most wretched failures to date is his refusal to mount a truly vigorous defense of his own goddamn program—and phoning-it-in comments from Rose Garden photo ops don't count. He ignored the Cutler memo and he didn't take his fucking 747 and competent/articulate key advisors on an extended road trip at any time in the last four years, the only explanation for which that I can think of is to preserve some pathetic back-pedaling space in case the rethugs actually succeed in fatally damaging their ideological two-headed calf.

He could do something if he wanted to; lots of Congressional primaries still to come before the Nov. 4th mid-term election.

Man, the Republican Party minus people of color and women is one thing, but old people? That's really going to hurt.

Why are you always so negative, we got some time between 2014 and don't underestimate the Tea Party and the GOP. GOP was supposed to win the Senate last two times, they did not.

@ 1 I don't think set in stones that they will make gains, and more blame is on the GOP for economy that one reason Obama won in 2012.

Is Medicare Advantage popular? Why? It's always struck me as corporate welfare bullshit.

There are so many factual errors in this story it's hard to know where to begin. First, Medicare Advantage coverage has zero to do with the ACA exchanges except that both of them are risk adjusted populations, and both of them are regulated. There are several differences between MA and ACA (the former uses the CMS-HCC model vs. HHS-HCC model for the exchanges, for example) but these have to do with how providers and payers manage the risk adjustment. They have nothing whatsoever to do with quality of care.

It is a true statement that Medicare Advantage is being cut. I'm currently sitting in the San Diego airport flying back from a Medicare Advantage conference, and the cuts were one of the topics discussed. The ACA called for $156B In cuts over 10 years to pay for the Obamacare. The cuts for this year were only postponed, not eliminated. Originally CMS was planning a 5.9% cut for MA payments in 2015, but the final CMS call letter released a couple of weeks ago reduced the cuts to between 3.0-3.5%. The cuts will hit physicians and healthplans, but probably won't translate into higher premiums for members in the short term because there is a strong movement in the market toward zero-premium MA plans (i.e., they're free.) Instead, the benefits will be cut over time. It's too soon for those cuts to have taken effect.

Washington state will be relatively harder hit, but is by no means the most impacted state. 40 Senators and 218 House members have expressed concerns to CMS and urged it to protect seniors.

For the record: Medicare Advantage covers 15 million seniors, 1 in 5 of whom are minorities. 41% have incomes of $20,000 or less. 90% of
lseniors are satisfied with their MA plan.

Several things are on the table including raising the age of Medicare eligibility above 65, changing the reimbursement rate for physicians, increasing premiums for high income individuals for Medicare Part B and Part D (office visits and drugs, respectively), beneficiary cost sharing, and raising premiums.

Thanks, Dr. Z.

@5 Nate Silver said it and it became Common Knowledge.

Gov. Medicare Fraud oughta understand why people like Medicare. He made enough money ripping off the system, he must be a fan.

@2, I'm not a big Obama fan, but I will admit that his presidency is truly unique. No US president ever has had to deal with a devoutly antagonistic opposition party. Nixon, Johnson, Reagan, the congress accepted their leadership and worked with them. Not so for Obama. The Republicans have completely given up their loyalty to the US & the constitution and only operate on their loyalty to their own party.

I feel Obama's biggest mistake was to refuse to prosecute the extensive crimes of Bush & Cheney, both foreign and domestic betrayals.

@7 - thanks for the lesson on MA! I feel like I never see this kind of analysis anywhere in the media.

The cuts will hit physicians and healthplans, but probably won't translate into higher premiums for members in the short term because there is a strong movement in the market toward zero-premium MA plans (i.e., they're free.) Instead, the benefits will be cut over time. It's too soon for those cuts to have taken effect.

This is fascinating to me - so, in short: MA isn't being elimiinated? Just cuts? Presumably the benefits package(s) is(are) just different than 'regular' medicare (A&B) - a different matrix of services? I'm curious why MA hasn't - with it's greater degree of fine-tuned benefits - slowly captured market share from old-school A&B?

@13: like Social Security, Medicare has accumulated rule and special gotchas for decades. For example, not everyone on Medicare is over the age of 65 (e.g. the disabled and people with end-stage renal disease are covered regardless of age.) Conversely not everyone over 65 is covered (e.g. veterans.)

There are alternatives to MA. Medigap is one. Medigap is sold as a supplement to traditional Medicare to cover things that MPA+MPB doesn't (long term care in nursing homes isn't covered by traditional Medicare, for instance, but it is covered by Medicaid and it may be covered by Medigap.) The difference between the two is that Medigap supplements traditional Medicare, whereas Medicare Advantage replaces traditional Medicare.

It is only in the past year that we're starting to see more zero-premium MA plans being offered, and not surprisingly there's been a big shift in membership towards these plans. That's one reason they are popular, and why cutting them is politically risky. Who wouldn't want to sign up for a plan that significantly improves Medicare benefits and costs nothing to the patient?

As for why MA hasn't supplanted traditional Medicare (at least among people who qualify) - the usual reasons: people don't understand it, they are reluctant to change (seniors doubly so), they can't afford the extra few dollars a month when the premiums aren't free, they aren't aware it exists, etc.

The way the ACA exchanges work can be understood as a game of poker.

Choose your favorite game of poker - the rules for the cards don't matter. The only thing that matters is the rules for the pot.

The players represent insurance companies. The cards are the patients. The higher the card, the sicker the patient (a jack might be someone with chronic diabetes, a queen might be cardiovascular disease, etc.) The way the ACA works is that the sicker your membership is, the more of the exchanges pot you can claim. The player with the best hand gets half the pot. The next best hand claims half of the remainder, and so on.

Anyone who folds is permanently out of the game.

At the end of each round, you don't throw all the cards back. Each player may keep two cards for use in the next round.

For added fun, the player with the biggest hoard can pick a card out of any other player's hand during any game. That card may be kept or discarded. The player who lost a card draws a new one.

Keep playing until just two insurance companies are left. That's ACA poker.