Tag Archives: ACA Repeal

The massive Senate GOP shift on pre-existing conditions

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https://www.axios.com/the-massive-senate-gop-shift-on-pre-existing-conditions-2458798705.html

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Over the past several weeks, senior GOP aides have repeatedly said that if the Senate bill touches pre-existing conditions in any way, it will lose around a third of the caucus. Today, a provision that could cause sick people to pay much higher premiums than they currently do has not caused any Republicans to say they’ll vote against the GOP health bill.

  • When Senate GOP leaders first presented their plan to the caucus in a PowerPoint presentation, it explicitly said that pre-existing conditions wouldn’t be touched, aides say.
  • As recently as two weeks ago, aides said members were surprised and angry to learn that Sen. Ted Cruz’s Consumer Freedom Option would allow plans that didn’t include the Affordable Care Act’s pre-existing conditions protections. (They could only be sold by insurers that also offered plans with the protections.)
  • Sen. Bob Corker: “I think people understand that’s got to be protected, and people understand what happened when the House dealt with it and opened it up, and it’s just not something that senators are wishing to do.”
  • Sen. Shelley Moore Capito over recess: “I think that reopens an issue that I can’t support, that it would make it too difficult for people with pre-existing conditions to get coverage.”
  • Sen. Chuck Grassley last week: “There’s a real feeling that that’s subterfuge to get around pre-existing conditions.”

Now, that resistance is “melting away,” as one Senate Republican aide put it today. “No one wants to be bad guy.”

Indeed, almost seven hours after the revised bill — including the Cruz provision — had been released, no Republican senator had threatened to vote against the bill unless the provision is removed. In fact, Republicans had surprisingly little to say about it.

What the Consumer Freedom Option does: 

  • It allows insurers that offer ACA-compliant plans to also sell plans that do not comply with ACA regulations, including the law’s essential health benefits and its pre-existing conditions protections.
  • Advocates of the bill say that while this could sort sick and healthy people into two different marketplaces, causing premiums to skyrocket for sick people, they’ll be insulated from these costs by premium subsidies and the bill’s stabilization fund.
  • Members “don’t realize we are basically creating single payer for sick people,” the GOP aide told me, saying that Republicans’ support is growing because people with pre-existing conditions can still get exchange plans.
  • The problem: “If there were hearings, everyone would have a lot more information about Cruz. Right now, Cruz is the only seller of the amendment and he’s the only one with information about the amendment,” said one well-connected GOP lobbyist, who said Cruz’s sales pitch seems to be convincing members to support his idea.
What insurers and experts are saying: 
  • America’s Health Insurance Plans: “Patients with pre-existing conditions … would potentially lose access to comprehensive coverage and/or have plans that were far more expensive.”
  • Scott Serota, president and CEO of the Blue Cross Blue Shield Association: “The ‘Consumer Freedom Option’ is unworkable as it would undermine pre-existing condition protections, increase premiums and destabilize the market.”
  • Kaiser Family Foundation: 1.5 million people with pre-existing conditions could have higher premiums under the Cruz amendment.
Yes, but: The conservative groups love it, as it addresses the ACA regulations that weren’t fully addressed in the previous version of the bill. They believe those regulations are driving up the cost of insurance. Stripping the provision could lose these groups’ support.

And Michael Cannon of the libertarian Cato Institute says the provision “would make access to healthcare more secure for patients who develop expensive conditions” — because it would free insurers to introduce a wider variety of health plans and make them less likely to leave the markets.

 

Why a Bipartisan Health Care Compromise Is Simply a Delusion

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https://www.thefiscaltimes.com/Columns/2017/07/13/Why-Bipartisan-Health-Care-Compromise-Simply-Delusion

Senate Republicans bought themselves a little more time this week to deliver on their top agenda item, repealing and replacing Obamacare. Majority Leader Mitch McConnell agreed to trim two weeks off the August recess, responding to a number of calls within his caucus to expand the legislative calendar. The big question, however, is whether it will help and whether there are any options left if it doesn’t.

McConnell has called a meeting Thursday morning  with the entire GOP caucus, presumably to roll out the new version of the Better Care Reconciliation Act (BCRA). Sen. Pat Toomey first mentioned the new effort on Monday, predicting that it would bridge the gap between moderates and conservatives within Republican ranks. “There’s still a shot at getting to 50 [votes],” Toomey said on CNBC’s Squawk Box.

It got off to a bad start even before the big reveal. Sen. Rand Paul wrote a blistering op-ed at Breitbart on Wednesday to announce his rejection of the new version of the BCRA, calling it “worse than Obamacare-lite.” Paul accused Republicans of bolstering federal authority over health insurance, retaining too much of the Affordable Care Act’s taxes and regulations, and “creating a giant insurance bailout superfund.” Paul decried the lost opportunity to fulfill pledges made during the past seven years to repeal Obamacare “root and branch.”

Unfortunately, the opportunity to repeal Obamacare “root and branch” came and went five years ago when Republicans failed to beat Barack Obama’s re-election bid. Too much of Obamacare has already been implemented, which has distorted the markets considerably and recast political incentives. Donald Trump himself recognized this in his presidential campaign, promising that the repeal of Obamacare would come with a replacement program that ensured the least amount of disruption possible.

Republican Senators from rural states worry that a flat-out repeal without any transitional support would hit hard in the very areas where they won elections. A straight repeal would require 60 votes as it goes beyond merely budgetary issues, but it would be unlikely to get close to 50 even if it qualified for the reconciliation process.

Trump made it clear in an interview with CBN’s Pat Robertson on Wednesday that he expects the Senate to act on Obamacare. “Mitch has to pull it off,” Trump said, noting that Obamacare was “a failed experiment,” and that Congress had to act. When Pat Robertson asked what would happen if McConnell failed to deliver a repeal bill, the president replied, “I think it would be very bad. I will be very angry about it, and a lot of people will be upset.”

That may be a rare case of understatement from President Trump. A new poll from Politico and Morning Consult shows that two-thirds of Republican voters expect the GOP to honor their promises and repeal Obamacare. Forty percent of voters overall want a repeal bill passed (with 47 percent opposed, it should be noted), which makes for considerable pressure on Senate Republicans. Interestingly, though, the poll also shows that a majority of GOP voters (54 percent) want Republicans to work with Democrats on a bipartisan reform of the system.

It’s not the first time that’s been suggested. Mitch McConnell warned last week that a failure of Republicans to coalesce around a solution would force him to work with Democrats on temporary fixes for Obamacare exchanges. John McCain and Bill Cassidy both called for negotiations across the aisle last week, with McCain saying, “That’s what democracy is supposed to be all about.”

Don’t expect to find any escape hatch in that direction, though. Toomey called this option “grim” on Monday for a reason; Democrats are fighting to protect Obamacare. They could get Senate Minority Leader Chuck Schumer to work with them “as long as nothing gets repealed, the mandates don’t go away, taxes remain in place, and Medicaid stays on a completely unsustainable fiscal train wreck,” Toomey told CNBC.

Even renegade Democratic centrists don’t offer much hope for peeling off enough for a bipartisan compromise. A handful of House Democrats issued a proposal called, “Solutions over Politics” (SoP) to redirect the debate over health-care reform. “We are proposing real, concrete solutions that will stabilize and improve the individual market,” Rep. Kurt Shrader (D-OR) declared, “making Obamacare work better for everyone, and getting us closer to universal coverage for all Americans.”

Unfortunately, this agenda looks very close to the same laundry list Schumer has pushed in the Senate. Shrader wants a permanent subsidy for insurance companies to make up for the losses they incur, guaranteeing a perpetual river of red ink from Obamacare. The original reinsurance funds were time-limited because Democrats insisted that markets would stabilize after the first few years and would become self-sufficient. This “solution” concedes the Republican argument that Obamacare is unsustainable without heavy government spending, and is structurally unsound.

Even where it differs from the official Democratic Party line, the SoP proposal doesn’t stray very far. It endorses health-savings accounts (HSAs), but only for “plans compliant with the ACA,” where Republicans want to expand the use of HSAs to allow for non-compliant innovation. The SoP proposal retains all of the mandates while allowing for “catastrophic health insurance plans … for younger enrollees,” without acknowledging that Obamacare’s high-deductible plans already act in practical terms as catastrophic coverage at high premium levels. Their solution for poor enrollment figures is not to repeal the unsound structure of mandates and narrow choice of coverages that creates it, but “robust marketing around open enrollment periods.”

Simply put, there is no basis for compromise between one side that sees Obamacare as an abject failure in need of repeal, and another that sees a lack of government funding and a better PR campaign as the only problems in need of solutions.

No, Republicans must do this on their own if it is to be done at all. That is the Hobson’s choice that faces Senate Republicans, and the sooner they realize it, the quicker they will find a way to move forward on a solution. If they don’t, Trump will almost certainly be proven prescient when voters weigh in on seven years of broken promises.

AHIP: Cruz proposal would destabilize the ACA exchanges

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http://www.fiercehealthcare.com/aca/ahip-cruz-proposal-would-destabilize-individual-marketplaces?utm_medium=nl&utm_source=internal&mrkid=959610&mkt_tok=eyJpIjoiT1RFeFl6QTBOalV4WlRsayIsInQiOiJ2ZkV5eXJiTVp5ZGZQYk5NRlozSzYwdEdoVTduQW1SMDkyVVdqR0lPbXVGMDNJUjJEN0U3b2dDcmp1NlNncSthUStTeFordHNGcVwvMFRtNnFGXC9mczBpa3NDU0NkZHBSa003NkQ4bjVcL3krTkZ1R2ZNb3R4MGtWYWo3UVwvcjkwZVIifQ%3D%3D

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The health insurance industry’s largest trade group is warning that a proposed amendment to the Senate’s healthcare bill could not only destabilize the individual marketplaces, but also harm patients with pre-existing conditions.

The amendment, introduced by Sen. Ted Cruz, R-Texas, would allow insurers to sell health plans that aren’t compliant with the Affordable Care Act’s rules in any given state as long as they sell at least one ACA-compliant plan on that state’s exchange.

Cruz and the amendment’s other supporters in the Senate said the concept would allow insurers to offer a wider variety of coverage options and help lower premiums. Senate Majority Leader even reportedly went so far as to ask the Congressional Budget Office to score the proposal.

But the idea also has plenty of critics, including America’s Health Insurance Plans (AHIP).

In a document (PDF) posted on its website, the trade group said that allowing health insurance products to be governed by different rules would effectively “fracture and segment insurance markets into separate risk pools and create an un-level playing field that would lead to widespread adverse selection and unstable health insurance markets.”

The trade group pointed out that part of the exchanges’ current woes stemmed from the Obama administration’s transitional policy, which allowed individuals to renew their non-ACA-compliant plans. In states that opted to adopt this policy, actuaries estimated that exchange market premiums were an average of 10% higher.

Cruz’s amendment, which would essentially make that transitional policy permanent, “would create even greater instability,” AHIP said.

The fact that the proposal would require insurers to also offer an ACA-compliant plan, the group said, is not enough to protect consumers with pre-existing conditions or higher-than-average healthcare costs. The ACA’s consumer protection provisions, such as guaranteed issue and community rating, AHIP notes, “only work if there is broad participation to assure stable markets and affordable premiums,” which wouldn’t be the case under Cruz’s proposal.

In fact, a newly released analysis from the Kaiser Family Foundation estimated that the amendment could result in 1.5 million people with pre-existing conditions facing higher premiums.

Finally, it’s simply not practical to maintain a single risk pool if all health plans don’t have to provide coverage for the same benefits, AHIP stated, adding that the Cruz amendment also would make programs like risk adjustment “unworkable.”

Revised Senate healthcare bill includes version of Ted Cruz’s controversial amendment

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http://www.fiercehealthcare.com/aca/revised-senate-healthcare-bill-includes-version-ted-cruz-s-controversial-amendment?mkt_tok=eyJpIjoiT1RFeFl6QTBOalV4WlRsayIsInQiOiJ2ZkV5eXJiTVp5ZGZQYk5NRlozSzYwdEdoVTduQW1SMDkyVVdqR0lPbXVGMDNJUjJEN0U3b2dDcmp1NlNncSthUStTeFordHNGcVwvMFRtNnFGXC9mczBpa3NDU0NkZHBSa003NkQ4bjVcL3krTkZ1R2ZNb3R4MGtWYWo3UVwvcjkwZVIifQ%3D%3D&mrkid=959610&utm_medium=nl&utm_source=internal

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Despite opposition from the health insurance industry, Senate Republicans’ revised healthcare bill includes a version of a proposal that would allow the sale of slimmed-down individual market plans.

A new discussion draft (PDF) of the Better Care Reconciliation Act includes a provision based on an amendment proposed by Sen. Ted Cruz, R-Texas. The provision would allow insurers to sell plans that don’t comply with the Affordable Care Act’s benefits requirements as long as they sell at least one plan in that state that does comply.

America’s Health Insurance Plans, which has largely avoided passing judgement on the GOP’s ACA repeal measures, said this week the Cruz amendment would “would create even greater instability” in the individual marketplaces. A separate report estimated that it could result in 1.5 million people with pre-existing conditions facing higher premiums.

Perhaps in a nod to these concerns, the Senate’s revised measure includes an additional $70 billion to help states lower insurance premiums. States with exceptionally high premiums would also get some assistance, as the Kaiser Family Foundation’s Larry Levitt points out:

The reworked Senate bill also maintains the ACA’s taxes on wealthy individuals, and it adds $45 billion in funding to fight the opioid crisis.

Though the cuts to Medicaid that have concerned moderates are left largely intact in the revised bill, the new version does offer some Medicaid funding flexibility for states in the event of a public health crisis. States would also be able to add the newly eligible Medicaid population to coverage under the block grant funding option.

The new Senate bill: Better for the healthy, worse for the sick

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https://www.axios.com/the-new-senate-bill-better-for-the-healthy-worse-for-the-sick-2458657128.html

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The most significant revisions Senate Republicans have made to their health care bill, taken together, point largely in the same direction: They would make the individual insurance market even better for healthy people — and thus worse for sick people.

And they aim to soften the blow to health insurance markets by spending more money on sick customers, rather than trying to prevent disruptions from happening in the first place.

Ted Cruz’s “consumer choice” option: As the insurance industry has explained, if Cruz’s proposal becomes law, healthier people would likely gravitate toward a new set of insurance plans with lower premiums, less coverage, and fewer benefit mandates/consumer protections. If people with pre-existing conditions are the only ones buying policies that have to cover pre-existing conditions, those policies will get pretty expensive — maybe prohibitively expensive.

Catastrophic coverage: The revised bill would let people use their premium subsidies to buy the most bare-bones policies on the market today — those that only cover catastrophic care. And it would let anyone buy those policies through the exchanges; the ACA limited them to people younger than 30. That would, again, nudge more people into plans with less coverage, lower premiums and higher deductibles — a great option for people who don’t need much health care.

This was already the underlying dynamic of the initial Senate bill. The new version turns up the volume:

  • It still repeals the individual mandate.
  • It eventually repeals the ACA’s subsidies for co-pays, deductibles and other cost-sharing — expenses people only incur when they go to the doctor.
  • It retains the ACA’s subsidies for insurance premiums, but pins the value of those subsidies to plans with less coverage and higher deductibles (again — a better deal for people who don’t need much health care).
  • It adjusts those subsidies based on age, giving some young people (who tend to be healthier) more help than they’re getting now, while many older people (who tend to use more health care) would get less.
  • The main solution to the problems those changes would create for sick people: more money. Republicans added another $70 billion to help fund temporary stabilization programs — mainly, direct payments to insurance companies that end up with especially expensive customers.

Bottom line: Health care for sick people is wildly expensive. Within the individual market, the ACA tried to offset those costs in two ways: with direct federal spending; and by heightening the “subsidy” healthy people’s premiums provide for sick people’s expenses. With each revision, Republicans’ bills increasingly accept the first half of that equation while dismantling the second.

Providence plans aggressive cost-cutting, layoffs, amid health care high anxiety

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http://www.oregonlive.com/business/index.ssf/2017/07/providence_plans_aggressive_co.html

Providence Health & Services, Oregon’s largest private-sector employer, is preparing an aggressive cost-cutting campaign that will include layoffs.

The move is clearest sign to date that hospitals face a difficult, uncertain future.

Providence saw its financial position deteriorate markedly in 2016, posting an operating loss of more than $255 million, filings show. Though its annual revenue topped $22 billion and, as a non-profit, it pays no income taxes, Providence is looking to cut costs across its seven-state network, multiple sources say. David Underriner, chief executive of the medical provider’s Oregon operation, would not disclose numbers or locations, but did say, “there will be an impact on people.”

Providence has already cut back in Oregon. Last year, it closed its open-heart surgery program at Providence Portland Medical Center and consolidated that work at St. Vincent’s Medical Center on the city’s westside, Underriner said.

Providence is not alone. St. Charles Health System in Bend has also scaled back spending as its own bottom line suffered in 2016. Oregon Health & Sciences University in Southwest Portland announced a hiring freeze in March.

The new financial weakness comes at a time of high anxiety in health care. A bill to foist a new multi-million-dollar provider tax on hospitals—which would help fund the state’s contribution to Medicaid — was signed into law this week. In Washington, D.C., meanwhile, Senate Republicans continue their efforts to repeal the Affordable Care Act, a move that Providence’s Underriner and many other hospital executives oppose.

Death spiral? Obamacare insurers may be having ‘best year’ yet under ACA

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http://www.charlotteobserver.com/news/politics-government/article160601814.html

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New data on the improving finances of the nation’s individual insurers are calling into question repeated Republican claims that Obamacare marketplaces are collapsing under the Affordable Care Act.

For months, Republican leaders from President Donald Trump and Health and Human Services Secretary Tom Price to House Speaker Paul Ryan have said Obamacare was crumbling under its own weight and could not be saved. And this week, when HHS announced a 38 percent decline in the number of insurers that want to offer coverage next year in states that use the federal marketplace, Price said, “The situation has never been more dire.”

But new research released Monday by the Kaiser Family Foundation shows that profitability and other financial measures for individual insurers have dramatically improved over the last year.

“Now it looks like they’re on track to be profitable and that they’re actually having the best year that they’ve had since the ACA began,” said Cynthia Cox, associate director of health reform at Kaiser.

The share of premiums paid out as medical claims by individual insurers fell to 75 percent in the first quarter of 2017, down from 86 percent in the first three months of 2016 and 88 percent in the first quarter of 2015.

In addition, average monthly premium income exceeded monthly per-enrollee medical claims by roughly $100 in the first quarter of 2017, Kaiser reported. That’s up from about $48 in the first quarter of 2016 and just over $36 in the first quarter of 2015.

Throughout their push to repeal the Affordable Care Act, Republicans have said the market troubles in some areas were proof that Obamacare was unraveling and legislative change was needed. In a pair of tweets on May 4, Trump declared that ObamaCare was “dead” and the individual market was in a “Death spiral!,” in which insurance offerings disappear as premium hikes force all but the sickest to drop coverage.

Cox disputed that assessment: “There’s not really signs of a death spiral here,” she said.

The report, based on insurers’ first-quarter financial reports filed with the National Association of Insurance Commissioners and compiled by Mark Farrah Associates, comes as Senate Majority Leader Mitch McConnell struggles to find 50 votes to pass his Obamacare repeal legislation. Facing opposition from some conservatives, he has expressed a willingness to negotiate with Democrats on a legislative fix of the ACA as Republicans try to re-draft their legislation and move forward next week.

But Monday’s report could make across-the-aisle appeals more difficult, as the data indicates insurers could be on the verge of righting their financial ship.

In a letter to McConnell on Monday, four Democratic senators — Charles Schumer of New York, Debbie Stabenow of Michigan, Richard Durbin of Illinois and Patty Murray of Washington — urged McConnell make “common sense reforms” such as guaranteeing the cost-sharing payments, creating a permanent reinsurance program and finding solutions for areas without insurers.

Certainly, some marketplaces remain under enormous pressure. Far fewer people than originally expected enrolled into marketplace coverage and those who did were sicker, older and more costly than insurers expected. As losses mounted, insurers sharply increased premiums in 2017, making coverage unaffordable for many as enrollment slipped. Some insurers exited unprofitable markets altogether, leaving 38 rural counties in Ohio, Indiana and Nevada with the possibility of no coverage options next year, according to Kaiser. Five states — Alabama, Alaska, Oklahoma, South Carolina and Wyoming — have only one insurer offering marketplace coverage this year.

The Trump administration added to insurers’ problems by relaxing enforcement of Obamacare’s individual mandate and refusing to reimburse insurers for billions of dollars of financial assistance, known as cost-saving reductions, that go to low-income plan members.

An analysis by the Oliver Wyman consulting firm estimated that up to two-thirds of insurer rate increases for 2018 “will be due to the uncertainty surrounding these two market influences” and the Congressional Budget Office estimates premiums will increase 20 percent next year if the individual mandate is not enforced.

Blue Cross Blue Shield of North Carolina, which has more than 500,000 individual policy holders, wants to increase rates on their Obamacare plans by an average of 23 percent next year.

Speaking in Washington, DC at a recent Bipartisan Policy Center panel discussion, J. Brad Wilson, President and CEO of BCBS North Carolina said, “Over 50 percent of that increase is attributable to the uncertainty of CSRs.”

The industry trade group America’s Health Insurance Plans would not comment on the report.

 

Obamacare 101: Is there a smaller fix for the Affordable Care Act?

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http://www.latimes.com/politics/la-na-pol-obamacare-101-marketplace-fixes-20170712-story.html?utm_campaign=KHN%3A%20First%20Edition&utm_source=hs_email&utm_medium=email&utm_content=54139610&_hsenc=p2ANqtz-_oK9ym4MAYbgjGTqJrtwWnYS7JczHHbl_O85RanUGaeiUnTcx9hvcqv7rFbgtEigUowQiiD8dTN5J0Reyhnc3D456E0Q&_hsmi=54139610

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With Senate Republicans struggling to find votes for sweeping legislation to roll back the Affordable Care Act, several GOP lawmakers have raised the prospect of a more limited bill — passed with help from Democrats — to stabilize health insurance markets around the country.

That may be heresy for conservative Republicans who’ve spent seven years demanding the full repeal of Obamacare, as the law is often called.

But most patient advocates, physician groups, hospitals and even many health insurers say more-targeted fixes to insurance marketplaces make more sense than the kind of far-reaching overhaul of government health programs that Republicans have been discussing.

Why do a more limited Obamacare ‘fix’?

For one thing, it would be politically easier. More-targeted legislation also wouldn’t threaten insurance protections for tens of millions of Americans.

The political debate over the 2010 healthcare law has focused for years on what has been happening to insurance marketplaces like HealthCare.gov, which were created by the law for Americans who don’t get health insurance through work.

For a variety of reasons, the marketplaces’ first several years have been rocky.

Insurers in many states struggled to figure out how much to charge for their plans and then raised premiums substantially when customers turned out to be sicker than they expected.

And as uncertainty over the future of the markets has intensified since President Trump’s election last year, several leading national insurers have decided to stop selling plans in some states, leaving consumers in some places with few if any health plans to choose from. Trump has called Obamacare a “disaster” and “dead.”

But the marketplaces — where about 10 million Americans currently get coverage — represent a very small fraction of the U.S. healthcare system.

By contrast, more than 70 million Americans rely on Medicaid and the related Children’s Health Insurance Plan, the government safety net plans for the poor.

Altering Medicaid, as proposed under the GOP plan, would be far more disruptive. And, as congressional Republicans are learning, it is much more controversial.

But isn’t Medicaid a big problem, too?

Many conservatives have long argued the federal government can’t afford to provide so much healthcare assistance to the poor.

But Medicaid has become a vital lifeline for tens of millions of Americans. Medicaid provides assistance to more than one in three U.S. children, protects millions of Americans with disabilities and is the largest funder of nursing home care for elderly Americans, in large part because Medicare does not cover nursing homes.

Obamacare’s Medicaid expansion, which made coverage available to working-age adults in many states, is credited with driving down the nation’s uninsured rate to the lowest levels ever recorded.

And a growing body of evidence shows it is improving low-income Americans’ access to needed medical care, reducing financial strains on families and improving health.

That is why Medicaid has been fiercely defended by patient groups, doctors, nurses, educators and even some Republican governors.

What would it take to stabilize insurance markets?

Probably not that much, actually.

There is widespread agreement that the federal government must first continue funding assistance through Obamacare to low-income consumers to help offset their co-pays and deductibles.

This aid — known as cost-sharing reduction, or CSR, payments – was included in the original law.

But the payments have become a political football as Republicans argued the aid can’t be provided without an appropriation by Congress. And Trump administration officials keep threatening to cut off the payments.

Many insurers say that would be devastating, forcing them to raise premiums by double digits.

Congress could simply put an end to that uncertainty by voting to appropriate the CSR money.

Secondly, most insurance industry officials and independent experts say the federal government must create a better system to protect insurers from big losses if they are hit with very costly patients.

Such reinsurance systems are used in other insurance marketplaces such as the Medicare Part D prescription drug program and are seen as critical to stabilizing markets.

Thirdly, current and former marketplace officials say, the federal government should aggressively market and advertise to get younger, healthier people to buy health plans on the marketplaces.

This strategy has helped Covered California, that state’s marketplace, which has not been beset by some of the problems in other markets.

Finally, many experts say, federal officials likely will have to come up with additional incentives to convince health insurers to offer plans in remote, rural areas.

Some Republicans have suggested that consumers in these areas could be allowed to buy health plans that don’t meet standards set out in the current law.

Would these steps cost more money?

Yes.

But both the House and Senate GOP bills to roll back Obamacare included billions of dollars to stabilize markets over the next several years.

So could Congress put that aid in a smaller healthcare bill?

That’s still unclear.

Many congressional Republicans are reluctant to spend any more money on healthcare aid, especially for a law that most have sworn to repeal.

But polls indicate that Americans now hold congressional Republicans and the Trump administration responsible for the fate of the nation’s healthcare system, including the insurance marketplaces.

That suggests that there could be a political price to pay for the GOP if the markets are not stabilized.

At the same time, Senate Democrats have signaled a willingness to work with Republicans on marketplaces fixes if GOP lawmakers agree to drop their repeal campaign.

But major hurdles remain, including demands from many GOP lawmakers that at least some of Obamacare’s provisions be repealed, such as the highly unpopular mandate requiring Americans to have health insurance.

Rather than stabilizing markets, however, eliminating the insurance requirement could lead to even more turmoil, experts say.

Sounding The Alarms On Children’s Health Coverage

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http://healthaffairs.org/blog/2017/06/26/sounding-the-alarms-on-childrens-health-coverage/

Amari Carter, 5, protests the U.S. House passage of the plan to repeal and replace the Affordable Care Act at the south gate of the Capitol in Austin, Texas, on Friday May 5, 2017. (Jay Janner/Austin American-Statesman via AP)

Buried beneath a very intense discussion on the future of adult coverage in this country has been a far more serious issue in children’s coverage many years in the making.

The American Health Care Act (AHCA) and the president’s recent budget proposal certainly have those who care for children concerned about the future of children’s insurance. The AHCA’s proposed changes to Medicaid would undo a half century of health care standards that were designed to maximize child development and well-being outcomes, such as guaranteed comprehensive health care coverage that includes access to mental health services, dental care, and school-based assistance for children with special health care needs. For special needs children, they have also insured that children with autism have aides to assist them in school, or that a child with cerebral palsy has access to appropriate transportation for themselves and their durable medical equipment to and from school, as well as the assisted nursing to support them while they are there.

But it’s not just the direct impact to children that is concerning. To the extent the AHCA rolls back the Affordable Care Act’s (ACA) Medicaid expansion, it would strip health insurance coverage from many low-income parents, whose own health is critical to that of their children.

There have also been proposed cuts to Medicaid that are at a magnitude never seen before: the president’s budget recommends reducing Medicaid funding by more than $600 billion dollars over 10 years, above and beyond the more than $800 billion in Medicaid cuts written into the AHCA.

These changes to Medicaid would not be trivial: more than 36 million children and adolescents in this country are insured through Medicaid, a number that grows every day. These are not simply children living in poverty; most hail from working families. Many of these children have complex medical or behavioral health concerns, intellectual disabilities, or are in foster care. Medicaid’s reach among children is huge.

The Risk To Families Is A Perfect Storm That’s Been Brewing For Some Time

Although the dramatic changes proposed by the AHCA and the president’s budget are more immediate, the truth is that their impact would negate the gains made in reducing the uninsured rate in children and leave families with fewer options for their children’s health care. When the ACA became law in 2010, children’s uninsurance rates in this country were much lower among children than adults (and continued to decline to only 5 percent by 2015). Lawmakers, therefore, designed the ACA principally to address uninsurance among adults, but nonetheless, added regulations that guaranteed a set of essential benefits to families who purchased coverage through the exchanges, including maternity, pediatric, mental health, and substance abuse benefits.

Optimism abounded and many hoped that the exchanges’ success might one day eliminate the need for the Children’s Health Insurance Program (CHIP). CHIP is a federally subsidized state program, which, at its peak, has insured an additional 8 million children in low- and moderate-income families who were not offered affordable coverage through their employers and could not qualify for Medicaid because their families were just above the federal poverty line.

From that high point, there has been a steady erosion of children’s coverage under their parents’ employer-sponsored plans that has gone largely unseen. Even as we’ve climbed out of recession and more low-income individuals are gaining employment, they’re not being provided affordable family coverage by their employers. Facing soaring benefits costs, many employers are dropping dependent coverage for their employees, or offering ever-more-expensive coverage. Escalating family deductibles and premiums have far outpaced those for single-adult enrollees, making such coverage unaffordable for many families.

Lacking affordable options to cover their children, it’s not surprising that many low- and moderate-income families have responded by flocking to public insurance. We reported on this trend in a recent Health Affairs article, in which we found that in 2013, nearly one-third of children in low-income working families above the poverty line got their health coverage through Medicaid or CHIP, up 8 percent from just six years earlier.

Today, more than 40 percent of children and adolescents in this country are now covered by Medicaid and CHIP, second only to employer-sponsored insurance. As a result, children are disproportionately vulnerable to health care reforms that cut public programs. In making any changes, caution is needed, as is an awareness of the many factors leading to families’ heavy reliance on public programs, if we are to improve, or at least maintain, children’s health.

Potential Solutions To Weather The Storm

Children largely remain on the outside of the ongoing health care debate, yet they have the most to lose. Beyond protecting Medicaid as an entitlement with certain guaranteed benefits there are other potential solutions that could help mitigate this risk.

CHIP Reauthorization

While the AHCA works its way through Congress, some may not have noticed that CHIP funding expires this fall. Without re-appropriation, more than 8 million children may lose coverage immediately. States are already sounding alarms; they have been unable to project their CHIP budgets for next year. The immediacy of the CHIP re-appropriation debate in Congress offers a “NOW” opportunity to stake a new way forward and present pragmatic solutions to strengthen children’s insurance, embracing the realities that have reshaped the family insurance market.

Guarantee Of Essential Health Benefits

The most critical issue arising from any children’s insurance plan today, whether in the employer-sponsored or public insurance market, is the promise of a set of health standards to all children regardless of their insurance. The House-passed AHCA proposes removing the requirement of federally guaranteed essential health benefits from all plans. Should this become law, states will have the choice of whether or not to provide these benefits. So, one solution for protecting children is to require these states to provide families access to a CHIP plan that meets a comprehensive and standard set of federally legislated and guaranteed essential benefits, such as vision, developmental, and behavioral health screenings.

Private Market Reforms

Beyond essential benefits, it may be time to address the affordability and quality of dependent coverage on the employer-sponsored and exchange markets. We may need stronger caps on deductibles as a proportion of income, and limits to exorbitant cost-sharing for child dependents. Furthermore, prohibitions of narrow networks—or the increase of cost-sharing for enrollees who seek out-of-network services—in the pediatric market would go a long way to ensuring that families have critical access to pediatric subspecialty care should their children develop cancer, diabetes, or other debilitating illnesses. While narrow networks may work in the adult health care arena, they are not nimble for families whose children have special health care needs and require specialists based solely in children’s hospital networks that may be tiered out in such plans. All told, the private market is not working for families, and if Congress wishes to halt the migration of families onto public insurance, they may need to hold employers and commercial insurers responsible for their own contributions to crowding families out of that market.

We are at an inflection point in the historic success we’ve had at providing near- universal children’s coverage in this country. While our leaders get mired in discussions around the future of adult coverage, they need to be mindful of immediate vulnerability within the children’s market that could threaten their coverage. It’s time we uncover this threat and make it a bigger part of the mainstream conversation.

Senate health bill a ‘death sentence’ for rural hospitals

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The Senate’s healthcare bill, if passed, could spell doom for some cash-strapped rural hospitals, many of which are already vulnerable to closure, experts say.

Much of the concern is centered on cuts to Medicaid in the bill—a proposal that is also worrying to large hospitals and health systems—which could leave millions more uninsured and significantly increase uncompensated care costs.

“These hospitals are hanging on by their fingernails,” Maggie Elehwany, vice president of government affairs for the National Rural Health Association, told CNN. “If you leave this legislation as is, it’s a death sentence for individuals in rural America.”

The cuts wouldn’t only hurt patients, according to a new report. Some of the bill’s proposals could also lead to thousands of rural healthcare workers losing their jobs. The Chartis Center for Rural Health, a part of strategic planning firm The Chartis Group, estimated that the BCRA, if passed as is, could cause 34,000 rural healthcare jobs to be eliminated.

Under the Senate’s bill, the cuts could cost rural hospitals $1.3 billion in lost revenue. Much of this would be felt in reduced Medicaid payments; expansion states, this would be about $442,000 lost each year per facility, while it would equal about $224,000 in lost revenue. It would likely push nearly 150 more rural facilities into the red, according to the analysis.

One such vulnerable facility is Lincoln Community Hospital, the small, regional hospital in Hugo, Colorado. The 50-bed hospital serves the the town of about 825, according to an article from National Public Radio, with many of its patients on either Medicare or Medicaid.

The funding cuts proposed in the Better Care Reconciliation Act have given leaders at Lincoln pause, and if the hospital were to close it would leave local residents in a “medical desert,” as it’s more than 100 miles to the next nearest hospital.

The facility was nearly shut down several decades ago, and former board member Ted Lyons said that, though the Affordable Care Act is far from perfect, he hopes that members of Congress work to protect rural hospitals if they intend to move forward with a repeal.

“You don’t drown the duck to get the feather out of him,” Lyons told NPR.

Rural healthcare leaders in Pennsylvania expressed similar concerns. Washington Health System operates two hospitals, one with 260 beds and one with 49 beds, in the western part of the state. CEO Gary Weinstein told WESA that if its smaller Waynesburg hospital closed, patients would have to travel at least 30 minutes for care.

The Waynesburg facility is located in Greene County, which is ranked 60th out of 67 Pennsylvania counties in per capita income, so many of its patients are Medicaid recipients. If a patient without insurance comes into the hospital, it recoups just 5% of its costs, Weinstein said.

“We don’t make money when somebody is insured by Medicaid, but at least we get something,” Weinstein said. “But when somebody has no insurance at all, a lot of times they just aren’t able to pay any part of the bill.”

Weinstein said he has spoken to Sen. Pat Toomey, R-Pennsylvania, one of the 13 senators involved in crafting the Senate’s bill, about that possibility, asking him to make additional changes to the legislation.