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Men Wrote The Senate Health Care Bill. This Woman Could Stop It.
As Majority Leader Mitch McConnell (R-Ky.) tries to negotiate his way to a health bill that can win at least 50 Republican votes, there is one woman in the Senate who could stop the bill cold.
She isn’t even a senator.
Elizabeth MacDonough is the Senate’s parliamentarian, the first woman to hold that post, which involves advising senators on the chamber’s byzantine rules and procedures. She alone can decide what pieces of the emerging Senate overhaul of the Affordable Care Act can be included under the budget reconciliation process senators are using. That process allows them to pass the measure with a simple majority vote rather than needing the usual 60.
In theory at least, she could reject the very deals McConnell is trying to cut.
By all accounts, MacDonough, who has spent almost her entire career working for the Senate and was appointed to her position in 2012, is scrupulously fair and trusted by both major parties.
“Elizabeth is great,” said Rodney Whitlock, a former Republican staffer on the Senate Finance Committee who has argued tricky legislative points before her numerous times. Democrats agree. “She’s a straight shooter and an honest broker,” said Bill Dauster, a longtime Democratic staff director for the Budget Committee.
It’s good that both sides like her, because if the Senate bill comes to the floor, MacDonough may have to make some tough decisions that will make one side or the other very unhappy.
MacDonough, along with her assistant parliamentarians, are charged with deciding which pieces of the bill violate the rules of budget reconciliation, in particular the “Byrd Rule,” named for its author, the late Sen. Robert Byrd (D-W.Va.). That rule requires that everything in the bill pertain directly to the federal budget. The idea is to prevent senators from loading up the budget bill, which gets fast-track consideration, with unrelated items that belong in the regular, slower Senate process.
The judgments mostly involve parts of the bill that opponents argue don’t add to or subtract from federal spending, or whose budget impact is “merely incidental” to the purpose of the policy. Outside observers say the parts of the Senate measure that are vulnerable under this rule include provisions that would defund Planned Parenthood and those affecting the rules for private insurance plans.
Generally, the “Byrd bath,” as it’s called on Capitol Hill, involves a string of meetings between Senate committee staff and the parliamentarian.
(Photo courtesy of the U.S. Senate)
“The Democrats go in, the Republicans go in, then both of them go in together,” said Dauster. Each side argues whether certain language should or should not be allowed in the bill.
The parliamentarian’s office in the Capitol “is actually a small room,” said Whitlock. “And when they are ready to have you in, you’re standing around and all the assembled in the room have at it.”
MacDonough does not make her rulings immediately after the arguments. “She has, of late, gotten back to people by email” with her decisions, said Dauster.
That has not always been the case. In the past, said Bill Hoagland, a longtime GOP staff director for the Senate Budget Committee, after making their arguments “we would wait until we went to the floor and [a senator] would raise a point of order” against some specific language, and senators and staff would learn the parliamentarian’s decision only then.
MacDonough’s ruling may prompt the bill’s authors to delete language before the bill comes to the Senate floor. Or they may opt to let the drama may play out in front of the C-SPAN cameras. Any senator can raise a point of order against a specific provision claiming it violates the Byrd Rule. It takes 60 votes to overcome such a point of order.
But what if Senate leaders opt not to accept MacDonough’s decision?
“That’s what scares the heck out of me,” said Hoagland. Under the Senate’s rules, the senator who is acting as the presiding officer during the debate does not have to take the parliamentarian’s advice. But if he or she rules against what the parliamentarian has advised, “I would argue that you have basically destroyed the Byrd Rule and you’ve destroyed the purpose of reconciliation at that point,” he said.
That’s because it would allow the majority party, which controls the Senate, to effectively include any provisions it wants in the fast-track budget bill with only a simple majority.
“It’s another way to go nuclear,” said Dauster, referring to efforts to end the Senate filibuster, which requires 60 votes to break.
Will that happen? It depends how MacDonough rules. And how badly the Republicans want their health bill to pass.
McConnell Has About $200B In ‘Candy’ To Make Deals On Obamacare Repeal
http://khn.org/news/mcconnell-has-about-200b-in-candy-to-make-deals-on-obamacare-repeal/
The path to 50 votes for an Obamacare replacement bill seemed to narrow dramatically Thursday as efforts to craft a quick compromise foundered — but Senate Majority Leader Mitch McConnell has $200 billion to build a bridge to victory. His dealmaking may be just beginning.
While many policy experts, lobbyists and senators Kaiser Health News spoke to this week seemed skeptical that the Better Care Reconciliation Act could be saved, they said they could envision a way for McConnell (R-Ky.) to succeed in crafting a bill that would partially replace the Affordable Care Act.
McConnell has significant wiggle room in his repeal bill. Under the budget rules he is using to move the legislation, he needs to reach $133 billion in deficit reduction over 10 years. The Congressional Budget Office estimated that the BCRA would save $321 billion.
That leaves about $200 billion in deficit savings that McConnell can afford to give back and use to make deals with as many as a dozen senators who oppose his draft bill.
“There’s clearly a path to do this,” said Matt Salo, the executive director of the National Association of Medicaid Directors. “McConnell has enough candy to do it, and enough time. It’s still a very real possibility.”
Figuring out exactly how to spread the confectionery around, though, is no simple matter.
ACA Replacement Plans and the Individual Market
Health Care Battle On Hill Has Veterans Defending Obamacare Benefits
Air Force veteran Billy Ramos, from Simi Valley, Calif., is 53 and gets health insurance for himself and for his family from Medicaid — the government insurance program for low-income people. He says he counts on the coverage, especially because of his physically demanding work as a self-employed contractor in the heating and air conditioning business.
“If I were to get hurt on the job or something, I’d have to run to the doctor’s , and if I don’t have any coverage they’re going to charge me an arm and a leg,” he said. “I’d have to work five times as hard just to make the payment on one bill.”
There are about 22 million veterans in the U.S. But fewer than half get their health care through the Veterans Affairs system; some don’t qualify for various reasons or may live too far from a VA facility to easily get primary health care there.
Many vets instead rely on Medicaid for their health insurance. Thirty-one states and the District of Columbia chose to expand Medicaid to cover more people — and many of those who gained coverage are veterans.
The GOP health care bill working its way through the Senate would dramatically reduce federal funding for Medicaid, including rolling back the expansion funding entirely between 2021 and 2024.
Air Force veteran Billy Ramos, now 53, in a 1982 photo from his basic training days as an airman in Texas, at Lackland Air Force Base. Now self-employed, Ramos relies on Medicaid for his family’s health insurance needs. (Courtesy of Billy Ramos)
Medicaid coverage recently has become especially important to Ramos — a routine checkup and blood test this year showed he’s infected with hepatitis C. California was one of the states that chose to expand Medicaid, and the program covers Ramos’ costly treatment to eliminate the virus.
“Right now, I’m just grateful that I do have [coverage],” he said. “If they take it away, I don’t know what I’m going to end up doing.”
The Senate health plan — which proposes deep cuts to federal spending on Medicaid — has veterans and advocates worried. Will Fischer, a Marine who served in Iraq, is with VoteVets.org, a political action group that opposes the Republican health plan.
“If it were to be passed into law, Medicaid would be gutted. And as a result, hundreds of thousands of veterans would lose health insurance,” Fischer said.
It’s too early to know just how many veterans might lose coverage as a result of the Medicaid reductions. First, states would have to make some tough decisions: whether to make up the lost federal funding, to limit benefits or to restrict who would get coverage.
But Dan Caldwell thinks those concerns are overblown. He’s a Marine who served in Iraq and is now policy director for the group Concerned Veterans for America.
“The people who are saying that this is going to harm millions of veterans are not being entirely truthful,” Caldwell said. “They’re leaving out the fact that many of these veterans qualify for VA health care or in some cases already are using VA health care.”
About a half-million veterans today are enrolled in the VA’s health care program as well as in some other source of coverage, such as Medicaid or Medicare. Andrea Callow, with the non-profit group Families USA, wrote a recent report showing that nearly 1 in 10 veterans are enrolled in Medicaid.
“Oftentimes veterans will use their Medicaid coverage to get primary care,” Callow said. “If, for example, they live in an area that doesn’t have a VA facility, they can use their Medicaid coverage to see a doctor in their area.”
Whether a particular veteran qualifies for coverage through the VA depends on a host of variables that she said leaves many with Medicaid as their only option.
But, Caldwell said, rather than fighting to preserve Medicaid access, veterans would be better served by efforts to reform the care the VA provides to those who qualify.
“We believe that giving veterans more health care choice and restructuring the VA so that it can act more like a private health care system will ultimately lead to veterans who use the VA receiving better health care,” he said.
The Urban Institute found that the first two years after the enactment of the Affordable Care Act saw a nearly 44 percent drop in the number of uninsured veterans under age 65 — the total went from 980,000 to 552,000. In large part, that was the result of the law’s expansion of Medicaid.
Medicaid’s Role in Financing Behavioral Health Services for Low-Income Individuals
Medicaid’s Role in Financing Behavioral Health Services for Low-Income Individuals
Behavioral health conditions affect a substantial number of people in the U.S. and are especially common among people with low incomes.1,2,3 Behavioral health conditions include mental illnesses, such as anxiety disorders, major depression, bipolar disorder, schizophrenia, and post-traumatic stress disorder, as well as substance use disorders (SUD), such as opioid addiction. These conditions range in severity, with some being more disabling than others. People with behavioral health needs may require a range of services, from outpatient counseling or prescription drugs to inpatient treatment.
As a major source of insurance coverage for low-income Americans, and as the only source of funding for some specialized behavioral health services, Medicaid plays a key role in covering and financing behavioral health care. In 2015, Medicaid covered 21% of adults with mental illness, 26% of adults with serious mental illness (SMI), and 17% of adults with SUD.4 In comparison, Medicaid covered 14% of the general adult population.5 In total, approximately 9.1 million adults with Medicaid had a mental illness and over 3 million had an SUD in 2015. Nearly 1.8 million of these adults had both a mental illness and an SUD.6,7
Current Medicaid program financing guarantees federal financial support to states with no pre-set limit. The Better Care Reconciliation Act (BCRA), as proposed by the Senate, restructures federal Medicaid financing by changing it to a per capita cap or block grant, which would likely impact states’ ability to provide coverage for and access to behavioral health services for people who need them. This issue brief provides an overview of Medicaid’s role for people with behavioral health needs, including eligibility, benefits, service delivery, access to care, spending, and the potential implications of the BCRA.
Medicaid’s Role in Covering Veterans
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