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5 Ways the Graham-Cassidy Proposal Puts Medicaid Coverage At Risk

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5 Ways the Graham-Cassidy Proposal Puts Medicaid Coverage At Risk

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The Graham-Cassidy proposal to repeal and replace the Affordable Care Act (ACA) is reviving the federal health reform debate and could come up for a vote in the Senate in the next two weeks before the budget reconciliation authority expires on September 30. The Graham-Cassidy proposal goes beyond the American Health Care Act (AHCA) passed by the House in May and the Better Care Reconciliation Act (BCRA) that failed in the Senate in July. The Graham-Cassidy proposal revamps and cuts Medicaid, redistributes federal funds across states, and eliminates coverage for millions of poor Americans as described below:
  1. Ends federal funding for current ACA coverage and partially replaces that funding with a block grant that expires after 2026. The proposal ends both the authority to cover childless adults and funding for the ACA Medicaid expansion that covers 15 million adults. Under Graham-Cassidy, a new block grant, the “Market-Based Health Care Grant Program,” combines federal funds for the ACA Medicaid expansion, premium and cost sharing subsidies in the Marketplace, and states’ Basic Health Plans for 2020-2026. Capped nationally, the block grant would be lower than ACA spending under current law and would end after 2026. States would need to replace federal dollars or roll back coverage. Neither the AHCA nor the BCRA included expiration dates for ACA-related federal funds or eliminated the ability for states to cover childless adults through Medicaid.
  2. Massively redistributes federal funding from Medicaid expansion states to non-expansion states through the block grant program penalizing states that broadened coverage. In 2020, block grant funds would be distributed based on federal spending in states for ACA Medicaid and Marketplace coverage. By 2026, funding would go to states according to the states’ portion of the population with incomes between 50% and 138% of poverty; the new allocation is phased in over the 2021-2025 period. The Secretary has the authority to make other adjustments to the allocation. This allocation would result in a large redistribution of ACA funding by 2026, away from states that adopted the Medicaid expansion and redirecting funding to states that did not. No funding is provided beyond 2026.
  3. Prohibits Medicaid coverage for childless adults and allows states to use limited block grant funds to purchase private coverage for traditional Medicaid populations. States can use funds under the block grant to provide tax credits and/or cost-sharing reductions for individual market coverage, make direct payments to providers, or provide coverage for traditional Medicaid populations through private insurance. The proposal limits the amount of block grant funds that a state could use for traditional Medicaid populations to 15% of its allotment (or 20% under a special waiver). These limits would shift coverage and funds for many low-income adults from Medicaid to individual market coverage. Under current law, 60% of federal ACA coverage funding is currently for the Medicaid expansion (covering parents and childless adults). Medicaid coverage is typically more comprehensive, less expensive and has more financial protections compared to private insurance. The proposal also allows states to roll back individual market protections related to premium pricing, including allowing premium rating based on health status, and benefits currently in the ACA.
  4. Caps and redistributes federal funds to states for the traditional Medicaid program for more than 60 million low-income children, parents, people with disabilities and the elderly. Similar to the BCRA and AHCA, the proposal establishes a Medicaid per enrollee cap as the default for federal financing based on a complicated formula tied to different inflation rates. As a result, federal Medicaid financing would grow more slowly than estimates under current law. In addition to overall spending limits, similar to the BCRA, the proposal would give the HHS Secretary discretion to further redistribute capped federal funds across states by making adjustments to states with high or low per enrollee spending.
  5. Eliminates federal funding for states to cover Medicaid family planning at Planned Parenthood clinics for one year. Additional funding restrictions include limits on states’ ability to use provider tax revenue to finance Medicaid as well as the termination of the enhanced match for the Community First Choice attendant care program for seniors and people with disabilities. Enrollment barriers include the option for states to condition Medicaid eligibility on a work requirement and to conduct more frequent redeterminations.
Much is at stake for low-income Americans and states in the Graham-Cassidy proposal. The recent debate over the AHCA and the BCRA has shown the difficulty of making major changes that affect coverage for over 70 million Americans and reduce federal funding for Medicaid. Medicaid has broad support and majorities across political parties say Medicaid is working well. More than half of the states have a strong stake in continuing the ACA Medicaid expansion as it has provided coverage to millions of low-income residents, reduced the uninsured and produced net fiscal benefits to states. Graham-Cassidy prohibits states from using Medicaid to provide coverage to childless adults. With regard to Medicaid financing changes, caps on federal funding could shift costs to states and result in less fiscal flexibility for states. States with challenging demographics (like an aging population), high health care needs (like those hardest hit by the opioid epidemic), high cost markets or states that operate efficient programs may have the hardest time responding to federal caps on Medicaid spending. Faced with substantially reduced federal funding, states would face difficult choices: raise revenue, reduce spending in other areas, or cut Medicaid provider payments, optional benefits, and/or optional coverage groups.

Like Other ACA Repeal Bills, Cassidy-Graham Plan Would Add Millions to Uninsured, Destabilize Individual Market

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https://www.cbpp.org/research/health/like-other-aca-repeal-bills-cassidy-graham-plan-would-add-millions-to-uninsured

Cassidy-Graham's Large Cuts to Federal Health Care Funding Grow Even Larger Starting in 2027

In releasing a revised version of their legislation to repeal and replace the Affordable Care Act (ACA), Senators Bill Cassidy and Lindsey Graham, along with co-sponsors Dean Heller and Ron Johnson, claimed that their bill isn’t a “partisan” approach and doesn’t include “draconian cuts.” In reality, however, the Cassidy-Graham bill would have the same harmful consequences as those prior bills. IT WOULD CAUSE MANY MILLIONS OF PEOPLE TO LOSE COVERAGE, RADICALLY RESTRUCTURE AND DEEPLY CUT MEDICAID, AND INCREASE OUT-OF-POCKET COSTS FOR INDIVIDUAL MARKET CONSUMERS. It would cause many millions of people to lose coverage, radically restructure and deeply cut Medicaid, eliminate or weaken protections for people with pre-existing conditions, and increase out-of-pocket costs for individual market consumers.

Cassidy-Graham would:

  • Eliminate the ACA’s marketplace subsidies and enhanced matching rate for the Medicaid expansion and replace them with an inadequate block grant. Block grant funding would be well below current law federal funding for coverage, would not adjust based on need, would disappear altogether after 2026, and could be spent on virtually any health care purpose, with no requirement to offer low- and moderate-income people coverage or financial assistance.
  • Convert Medicaid’s current federal-state financial partnership to a per capita cap, which would cap and cut federal Medicaid per-beneficiary funding for seniors, people with disabilities, and families with children.
  • Eliminate or weaken protections for people with pre-existing conditions by allowing states to waive the ACA’s prohibition against charging higher premiums based on health status and the requirement that insurers cover essential health benefits including mental health, substance abuse treatment, and maternity care.
  • Destabilize the individual insurance market in the short run — by eliminating the ACA’s federal subsidies to purchase individual market coverage and eliminating the ACA’s individual mandate to have insurance or pay a penalty —and risk collapse of the individual market in the long run.
  • Eventually result in larger coverage losses than under proposals to repeal ACA’s major coverage provisions without replacement.  The Congressional Budget Office (CBO) has previously estimated that repeal-without-replace would cause 32 million people to lose coverage.  The Cassidy-Graham bill would likely lead to greater numbers of uninsured after 2026, however, because it would not only entirely eliminate its block grant funding — effectively repealing the ACA’s major coverage expansions — but also make increasingly severe federal funding cuts to the rest of the Medicaid program (outside of the expansion) under its per capita cap.

By attempting to push this bill forward now, Senators Cassidy and Graham are reverting to a damaging, partisan approach to repealing the ACA that would reverse the historic coverage gains under health reform and end Medicaid as we know it — even as other members of Congress, with the help of governors and insurance commissioners of both parties, are making progress in crafting bipartisan legislation to strengthen the individual market.

Last-Ditch Effort By Republicans To Replace ACA: What You Need To Know

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http://khn.org/news/last-ditch-gop-effort-to-replace-aca-5-things-you-need-to-know/

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Republican efforts in Congress to “repeal and replace” the federal Affordable Care Act are back from the dead. Again.

While the chances for this last-ditch measure appear iffy, many GOP senators are rallying around a proposal by Sens. Lindsey Graham (R-S.C.) and Bill Cassidy (R-La.), along with Sens. Dean Heller (R-Nev.) and Ron Johnson (R-Wis.)

They are racing the clock to round up the needed 50 votes — and there are 52 Senate Republicans.

An earlier attempt to replace the ACA this summer fell just one vote short when Sens. Susan Collins (R-Maine), Lisa Murkowski (R-Alaska) and John McCain (R-Ariz.) voted against it. The latest push is setting off a massive guessing game on Capitol Hill about where the GOP can pick up the needed vote.

After Sept. 30, the end of the current fiscal year, Republicans would need 60 votes ­— which means eight Democrats — to pass any such legislation because special budget rules allowing approval with a simple majority will expire.

Unlike previous GOP repeal-and-replace packages that passed the House and nearly passed the Senate, the Graham-Cassidy proposal would leave in place most of the ACA taxes that generated funding to expand coverage for millions of Americans. The plan would simply give those funds as lump sums to each state. States could do almost whatever they please with them. And the Congressional Budget Office has yet to weigh in on the potential impact of the bill, although earlier estimates of similar provisions suggest premiums would go up and coverage down.

“If you believe repealing and replacing Obamacare is a good idea, this is your best and only chance to make it happen, because everything else has failed,” said Graham in unveiling the bill last week.

Here are five things to know about the latest GOP bill: 

1. It would repeal most of the structure of the ACA.

The Graham-Cassidy proposal would eliminate the federal insurance exchange, healthcare.gov, along with the subsidies and tax credits that help people with low and moderate incomes — and small businesses — pay for health insurance and associated health costs. It would eliminate penalties for individuals who fail to obtain health insurance and employers who fail to provide it.

It would eliminate the tax on medical devices. 

2. It would eliminate many of the popular insurance protections, including those for people with preexisting conditions, in the health law.

Under the proposal, states could “waive” rules in the law requiring insurers to provide a list of specific “essential health benefits” and mandating that premiums be the same for people regardless of their health status. That would once again expose people with preexisting health conditions to unaffordable or unavailable coverage. Republicans have consistently said they wanted to maintain these protections, which polls have shown to be popular among voters.

3. It would fundamentally restructure the Medicaid program.

Medicaid, the joint-federal health program for low-income people, currently covers more than 70 million Americans. The Graham-Cassidy proposal would end the program’s expansion under the ACA and cap funding overall, and it would redistribute the funds that had provided coverage for millions of new Medicaid enrollees. It seeks to equalize payments among states. States that did not expand Medicaid and were getting fewer federal dollars for the program would receive more money and states that did expand would see large cuts, according to the bill’s own sponsors. For example, Oklahoma would see an 88 percent increase from 2020 to 2026, while Massachusetts would see a 10 percent cut.

The proposal would also bar Planned Parenthood from getting any Medicaid funding for family planning and other reproductive health services for one year, the maximum allowed under budget rules governing this bill. 

4. It’s getting mixed reviews from the states.

Sponsors of the proposal hoped for significant support from the nation’s governors as a way to help push the bill through. But, so far, the governors who are publicly supporting the measure, including Scott Walker (R-Wis.) and Doug Ducey (R-Ariz.), are being offset by opponents including Chris Sununu (R-N.H.), John Kasich (R-Ohio) and Bill Walker (I-Alaska).

On Tuesday 10 governors — five Democrats, four Republicans and Walker — sent a letterto Senate leaders urging them to pursue a more bipartisan approach. “Only open, bipartisan approaches can achieve true, lasting reforms,” said the letter.

Bill sponsor Cassidy was even taken to task publicly by his own state’s health secretary. Dr. Rebekah Gee, who was appointed by Louisiana’s Democratic governor, wrote that the bill “uniquely and disproportionately hurts Louisiana due to our recent [Medicaid] expansion and high burden of extreme poverty.”

5. The measure would come to the Senate floor with the most truncated process imaginable.

The Senate is working on its Republican-only plans under a process called “budget reconciliation,” which limits floor debate to 20 hours and prohibits a filibuster. In fact, all the time for floor debate was used up in July, when Republicans failed to advance any of several proposed overhaul plans. Senate Majority Leader Mitch McConnell (R-Ky.) could bring the bill back up anytime, but senators would immediately proceed to votes. Specifically, the next order of business would be a process called “vote-a-rama,” where votes on the bill and amendments can continue, in theory, as long as senators can stay awake to call for them.

Several senators, most notably John McCain, who cast the deciding vote to stop the process in July, have called for “regular order,” in which the bill would first be considered in the relevant committee before coming to the floor. The Senate Finance Committee, which Democrats used to write most of the ACA, has scheduled a hearing for next week. But there is not enough time for full committee consideration and a vote before the end of next week.

Meanwhile, the Congressional Budget Office said in a statement Tuesday that it could come up with an analysis by next week that would determine whether the proposal meets the requirements to be considered under the reconciliation process. But it said that more complicated questions like how many people would lose insurance under the proposal or what would happen to insurance premiums could not be answered “for at least several weeks.”

That has outraged Democrats, who are united in opposition to the measure.

“I don’t know how any senator could go home to their constituents and explain why they voted for a major bill with major consequences to so many of their people without having specific answers about how it would impact their state,” said Senate Minority Leader Chuck Schumer (D-N.Y.) on the Senate floor Tuesday.

No doubt you’ve been hearing about Cassidy-Graham, the GOP’s last-ditch effort to repeal the ACA. See this informative tweetstorm from Edwin Park of the Center on Budget and Policy Priorities to learn about the bill.

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CHI posts $585M operating loss in FY17

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http://www.healthcaredive.com/news/chi-posts-585m-operating-loss-in-fy17/505184/?utm_source=Sailthru&utm_medium=email&utm_campaign=Issue:%202017-09-19%20Healthcare%20Dive%20%5Bissue:12065%5D&utm_term=Healthcare%20Dive

Click to access CHI%20Annual%20Report%20Period%20Ending%20June%2030%202017.pdf

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Dive Brief:

  • Catholic Health Initiatives reported a $585.2 million operating loss for fiscal year 2017, ended June 30, up from $371.4 million in 2016.
  • Non-operating income was strong, however, reaching $713.6 million, versus a $204.2 million loss the previous year. The performance benefited from investments of nearly $640 million, according to CHI’s 2017 annual report.
  • Overall, CHI saw a net surplus of $128.4 million — a welcome result after last year’s net loss of $575.7 million. Total operating revenue for 2017 totaled $15.5 billion.

Dive Insight:

CHI has made strides toward getting back on sound financial ground, officials said in a statement, but challenges remain, particularly in some markets.

During the year, CHI divested its KentuckyOne facilities, a move expected to bring in $534.9 million. The system also transitioned operations, management and control of University of Louisville Medical Center back to the university and sold nearly all of its Louisville area acute care operations.

The company said it has also found a buyer for Medicare Advantage plans, but added that uncertainty around the future of the Affordable Care Act has delayed the sale of its QualChoice Health commercial insurance segment.

The Denver-based system is in talks with Dignity Health about a possible merger of their organizations. The non-for-profit hospital systems signed a nonbinding letter of intent to explore an affiliation in September 2016. San Francisco Business Times reported in June that the two organizations were in “final stages” of merger discussions.

Senate GOP Has 12 Days to Repeal Obamacare and No Room for Error

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https://www.bloomberg.com/news/articles/2017-09-19/senate-gop-has-12-days-to-repeal-obamacare-and-no-room-for-error

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Senate Republicans making one last-ditch effort to repeal Obamacare have the daunting task of assembling 50 votes for an emotionally charged bill with limited details on how it would work, what it would cost and how it would affect health coverage — all in 12 days.

They need to act by Sept. 30 to use a fast-track procedure that prevents Democrats from blocking it, but the deadline doesn’t leave enough time to get a full analysis of the bill’s effects from the Congressional Budget Office. The measure would face parliamentary challenges that could force leaders to strip out provisions favored by conservatives. Several Republicans are still withholding their support or rejecting it outright.

And even if Republicans manage to get it through the Senate by Sept. 30, the House would have to accept it without changing a single comma.

Most Senate Republicans are still trying to figure out what it’s in the bill, which was authored by Republicans Lindsey Graham of South Carolina and Bill Cassidy of Louisiana. Until the past few days, most assumed that GOP leaders had no interest in reviving the Obamacare repeal effort after their high-profile failure to pass a measure this summer.

Republican Senator Steve Daines of Montana said he’s still trying to figure out how the bill will affect his state and wants to hear what GOP leaders say at a closed-door lunch Tuesday.

‘Active Discussion’

“It will be a very active discussion,” he said.

The new repeal bill would replace the Affordable Care Act’s insurance subsidies with block grants to states, which would decide how to help people get health coverage. The measure would end Obamacare’s requirements that individuals obtain health insurance and that most employers provide it to their workers, and it would give states flexibility to address the needs of people with pre-existing medical conditions.

But lawmakers won’t have much more information about the legislation by the time the Senate would have to vote. The CBO said Monday it will offer a partial assessment of the measure early next week, but that it won’t have estimates of its effects on the deficit, health-insurance coverage or premiums for at least several weeks. That could make it hard to win over several Republicans who opposed previous versions of repeal legislation.

So far, President Donald Trump has suggested he’d support the bill, but he hasn’t thrown his full weight behind it.

Majority Leader Mitch McConnell has told senators he would bring up the bill if it had 50 votes, and under fast-track rules he could do so at any time before Sept. 30. That’s the end of the government’s fiscal year, when the rules expire and the GOP would have to start over.

Several Holdouts

Republicans can only lose two votes in the 52-48 Senate and still pass the measure, with Vice President Mike Pence’s tie-breaker. There are at least four holdouts, and getting any of them to back the measure would require the senators to change their past positions. Pence, who would cast the potentially deciding vote, will return to Washington from New York Tuesday, where he’s been taking part in United Nations General Assembly events, to attend Senate GOP lunches.

Republican Rand Paul of Kentucky said Monday he’s opposed to the Graham-Cassidy bill, saying it doesn’t go far enough. John McCain of Arizona said he’s “not supportive” yet, citing the rushed legislative process.

Two other Republicans — Susan Collins of Maine and Lisa Murkowski of Alaska — have voted against every repeal bill considered this year in the Senate, citing cuts to Medicaid and Planned Parenthood as well as provisions that would erode protections for those with pre-existing conditions. The Graham-Cassidy bill contains similar provisions on those three areas.

“I’m concerned about what the effect would be on coverage, on Medicaid spending in my state, on the fundamental changes in Medicaid that would be made,” Collins told reporters Monday evening.

She said that Maine’s hospital association has calculated the state would lose $1 billion in federal health spending over a decade compared to current law.

“That’s obviously of great concern to me,” she added.

Hard Sell

Murkowski is getting a hard sell from Republican backers of the bill.

“What I’m trying to figure out is the impact to my state,” Murkowski told reporters Monday. “There are some formulas at play with different pots of money with different allocations and different percentages, so it is not clear.”

McCain, who is close friends with Graham, cast the deciding vote to sink an earlier repeal bill in late July when he made a dramatic return to the Senate after a brain cancer diagnosis. At the time, he made an eloquent plea for colleagues to work with Democrats and use regular legislative procedures instead of trying to jam it through on a partisan basis.

John Weaver, a former top adviser to McCain, said supporting Graham-Cassidy would require the Arizona senator to renege on his word.

‘Fair Process’

“I cannot imagine Senator McCain turning his back not only on his word, but also on millions of Americans who would lose health care coverage, despite intense lobbying by his best friend,” Weaver said in an email. “Graham-Cassidy, if truly attempted to pass, will bypass every standard of transparency and inclusion important to people who care about fair process.”

Despite the obstacles, the bill’s backers are putting on a good face about the prospects.

“We’re making progress on it,” said Republican Senator Ron Johnson of Wisconsin. “I’m still cautiously optimistic, but there are a lot of moving parts.” Johnson is planning a Sept. 26 hearing on the measure in the Homeland Security and Governmental Affairs Committee, which he leads. The Senate Finance Committee is planning its own hearing Sept. 25 on the measure.

“There’s a lot of interest,” Senator Pat Toomey of Pennsylvania said Monday. “Those guys have done some very good work.”

A number of Republicans are still pushing for changes to the bill, so the final version may evolve. It’s also subject to parliamentary challenges under the reconciliation process being used to circumvent the 60-vote threshold in the Senate. That could allow Democrats to strike provisions that take aim at Obamacare’s regulatory structure.

Last Chance

If it passed the Senate, the House would have to pass the bill without any changes. House Speaker Paul Ryan said Monday that the measure is Republicans’ last best chance to repeal Obamacare.

“We want them to pass this, we’re encouraging them to pass this,” Ryan told reporters at a news conference in Wisconsin. “It’s our best, last chance of getting repeal and replace done.”

But that won’t be easy either. The measure strives to equalize Medicaid funding between states, which means that some House Republicans from Medicaid expansion states could find it hard to support. That includes states like New York and California, which stand to lose federal funds under Graham-Cassidy. Those states have only Democratic senators, but have some GOP House members.

Another Run

In some ways, it’s remarkable that Republicans are mounting another run at repeal.

Two months ago, Majority Leader Mitch McConnell’s effort to pass a replacement with only Republican support suffered a spectacular defeat in the Senate. When members of the Senate health committee then began working on a bipartisan plan to shore up Obamacare, Graham and Cassidy revved up a new bid to get their GOP-only bill to the Senate floor.

Graham and Cassidy are hoping to channel the GOP’s embarrassment at failing to repeal Obamacare this summer after seven years of promising to do so. But Paul said Monday this legislation shouldn’t be treated like a “kidney stone” you pass “just to get rid of it.”

Despite all the obstacles, Democrats quickly geared up for another campaign against repeal, warning that the latest bill is a serious threat.

“This bill is worse than the last bill,” Senate Democratic leader Chuck Schumer of New York told reporters Monday. “It will slash Medicaid, get rid of pre-existing conditions. It’s very, very bad.”