Tag Archives: ACA

What the FY 2018 budget resolution means for ACA repeal

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http://www.fiercehealthcare.com/aca/2018-budget-resolution-republicans-aca-repeal?utm_medium=nl&utm_source=internal&mrkid=959610&mkt_tok=eyJpIjoiTTJZNU4yTTNZV05sWm1FNSIsInQiOiJ2OXhPMHVRRk82MmRcL2llaVprUXFYSFJkbDBIS1lTcm1mRzVDSnFQQWRncUR5WmVDaFdFOGdTTkh4RWhIRTNHakR4Nm5Cd1hVYUIyZ1wveVl4ZTBpUXZqbkdYQldPTFpPazJqYlV4UGlNekw0QklMTHNwaEZtZVJGNHRXY2xVbzJPIn0=

The Senate side of the United States Capitol in Washington, D.C.

Senate Republicans’ fiscal year 2018 budget resolution suggests that they have put their goal of broadly unwinding the Affordable Care Act on the back burner—yet they could still use it to repeal key parts of the law.

The budget resolution (PDF), released by Senate Budget Committee Chairman Mike Enzi, R-Wyo., on Friday, contains reconciliation instructions that direct the Senate Finance Committee to “reduce revenues and change outlays to increase the deficit by not more than $1.5 trillion over the next 10 years.”

Since that reconciliation instruction is rather broad, the GOP could potentially use it to repeal some ACA-related taxes and other provisions that make health insurance affordable under the law, argued a post from the left-leaning Center for American Progress (CAP).

With their new budget resolution, Republicans could also still roll back other portions of the ACA, including the individual mandate, a Bloomberg article noted.

But because the budget resolution doesn’t include any instructions for the Senate Health, Education, Labor and Pensions Committee or the House Energy and Commerce Committee to craft reconciliation legislation, that may indicate that broader ACA repeal efforts are on hold, The Hill reported.

In addition to the reconciliation instructions, the budget resolution includes deficit-neutral reserve funds for legislation that would allow Congress to repeal or replace the ACA. This primarily just signals rhetorical support for rolling back the healthcare law, the CAP post noted, but that’s significant since it shows the GOP isn’t giving up on repeal.

Senate Budget Won’t Let GOP Pursue Full Obamacare Repeal

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https://www.bloomberg.com/news/articles/2017-09-29/senate-budget-allows-1-5-trillion-tax-cut-not-full-aca-repeal

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Senate Republicans unveiled a fiscal 2018 budget resolution Friday that they intend to use to push through as much as $1.5 trillion of tax cuts in the coming months, but it won’t allow the GOP to pursue a full repeal of Obamacare.

The budget proposal would still allow Republicans to pursue a much narrower attack on the Affordable Care Act, including repealing the individual mandate to purchase coverage. The resolution also would let the GOP use the fast-track process to open up drilling in the Arctic National Wildlife Refuge.

The budget, authored by Senate Budget Chairman Mike Enzi, forecasts a balance in nine years through $5 trillion in largely unspecified spending cuts. Unlike the House budget proposed in July, Enzi’s blueprint doesn’t call for cuts to Medicaid or a partial privatization of Medicare.

“A pro-growth tax plan will move the U.S. economy forward and help to produce better jobs and bigger paychecks for every American,” Enzi, of Wyoming, said in an emailed statement.

The Senate draft is to be voted on by the Budget Committee next week, with floor votes planned later in October and a conference to resolve differences with the House after that. The House plans a floor vote on its budget plan next week.

Tax Cut

Once in place, the budget resolution would allow Republicans to bring up a tax-cut bill that would increase deficits by as much as $1.5 trillion, compared with a Congressional Budget Office baseline. Under the fast-track process, the GOP-controlled Senate could pass the proposal with no Democratic votes.

The budget sets a target for the Senate Finance to report back with its draft tax bill by Nov. 13.

“The Senate budget resolution drafted by Budget Committee Chairman Mike Enzi is a critical step to advance President Trump’s agenda to provide tax relief for the middle-class and unleash economic prosperity for all Americans,” said White House budget director Mick Mulvaney in a statement. “I urge the Senate to pass this resolution and come to a swift agreement with the House so President Trump can sign America-first tax relief into law this year.”

Senate Democratic leader Chuck Schumer of New York said the GOP plan would “blow a huge hole in the deficit and stack up debt, leading to cuts in programs that middle-class Americans rely on.”

Individual Tax Rate

President Donald Trump and Republican leaders announced a tax-cut plan Wednesday that would cut the top individual rate to 35 percent from the current 39.6 percent. It would let Congress decide whether to create a higher bracket for those at the top of the income scale. The rate on corporations would be set at 20 percent, down from the current 35 percent. Under Senate rules, any tax cuts that increase the deficit would have to expire in 10 years because the budget process can’t be used for long-term deficit increases.

The provision making it easier for Congress to allow oil and gas drilling in part of the Arctic National Wildlife Refuge was sought by Alaska Republican Dan Sullivan. Under the proposal, royalties from oil and gas production in the wildlife refuge would be raise revenue that could help offset at least $1 billion in tax cuts over a decade.

The proposal’s instructions to the Finance Committee could allow a partial repeal of Obamacare, although panel Chairman Orrin Hatch has said he will keep that separate from a tax overhaul. Republican leaders have said they won’t try again on the health-care law until fiscal 2019.

Balanced Budget

When Republicans attempted to use the 2017 budget process to repeal Obamacare earlier this year, they didn’t provide a 10-year plan for reducing the deficit.

The new Senate plan proposes a balanced budget within nine years, while leaving it to other committees to figure out how to achieve that. The proposal calls for $4.8 trillion in spending cuts over 10 years and $1.635 trillion in revenue losses, including the tax cuts. Balance by 2026 is achieved by assuming $1.2 trillion in economic growth, in part due to the tax cuts. Enzi claims to achieve a $197 billion surplus in 2027.

The Republican assumptions of robust economic benefits from the budget were called into question by a separate CBO analysis. CBO predicted that the budget would reduce economic growth in the first two years and slightly increase it in later years.

CBO estimated that annual real GDP growth in the first two years would average 1.3 percent, down from an average of 1.6 percent in CBO’s baseline. In later years, real GDP growth would be 2.0 percent, compared with 1.9 percent in the CBO baseline.

The budget, unlike the one proposed by Trump in May, would hold defense spending at the current budget cap instead of the president’s proposed $489 billion defense increase over 10 years. Non-defense discretionary appropriations — which fund domestic agencies like the Agriculture Department and National Institutes of Health — would be cut by $632 billion over 10 years compared with $1.6 trillion in Trump’s budget request.

While the Trump and House budget proposals contain a number of nonbinding policy suggestions to carry out their spending cuts, Senate Republicans — weary of policy infighting — are keeping things vague.

Medicare, Medicaid

The House budget seeks to make $203 billion in cuts in entitlements such as Medicare, Medicaid and food stamps, and it could be used to fast-track changes to the Dodd-Frank financial law. The Senate plan avoids those options.

The Senate proposal does allow adjustments to increase the defense spending caps. It also urges senators to revise the Children’s Health Insurance Program, improve management of wildfire-prevention funding, prevent private-pension bailouts and improve services to veterans.

The budget resolution doesn’t address Social Security, which will run a trillion-dollar-plus deficit in the coming 10 years. In the past, Republicans have sought to balance a “unified budget” that includes the program. This time, they are keeping it “off-budget.”

CBO says that without the Social Security accounting move, Enzi’s budget would never balance and would show a $424 billion deficit in 2027.

The nonpartisan Committee for a Responsible Federal Budget said in a statement it prefers the House budget. “We encourage the Senate to look to the House Budget Committee, which passed a budget calling for revenue-neutral tax reform and at least $200 billion of mandatory spending cuts on top of that,” it said.

Dynamic Scoring

The Senate plan renews authority for the CBO and Joint Committee on Taxation to use so-called dynamic scoring when evaluating bills — a move allowing lawmakers to assume that tax cuts will cause economic growth that would offset some of the revenue loss.

And it changes several rules to allow senators to rush a tax bill through, including abolishing the need for a CBO analysis at least 28 hours before a vote.

The Senate plan avoids other tricks, though. Enzi included provisions to keep appropriators from using phantom cuts known as “changes to mandatory programs” to offset discretionary spending increases.

The chairman also rejected pressure from some lawmakers to use a baseline number for tax revenue that would allow $450 billion in additional tax cuts. Instead, he stayed with the baseline used by the CBO.

Polling Spotlight: A silver lining for the GOP on Obamacare repeal

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https://www.brookings.edu/blog/fixgov/2017/09/27/polling-spotlight-a-silver-lining-for-the-gop-on-obamacare-repeal/

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There is good reason to question the assumption that by failing once again to pass legislation repealing and replacing the Affordable Care Act, Republicans have shot themselves in the foot. Although the CBO (Congressional Budget Office) could not analyze in its usual detail the consequences of Graham-Cassidy, it was able to determine that the legislation would cut federal funding for Medicaid by more than $1 trillion over the next decade, throwing millions of low-income Americans off the rolls.

This outcome would have generated a huge political problem for Republicans. A Public Religion Research Institute poll released Monday found 69 percent of Americans opposed to cuts in Medicaid, with only 28 percent in favor. The opposition included 78 percent of Democrats, 69 percent of Independents—and 55 percent of Republicans. In a related finding, nearly 45 percent of Americans are worried that they or a member of their family will lose health coverage in the coming year.

No doubt, failing to act on Obamacare will anger a portion of the Republican base, adding fuel to the insurrection against the Republican establishment and depressing turnout in states and districts where Republican incumbents who support the party’s leadership are running for reelection. But in the long run, it would have been more politically damaging to deprive low-income Americans, including millions of Trump supporters in red states, of the Medicaid coverage they would otherwise have enjoyed.

As behavioral economists have shown, the fear of loss is more acute than the hope of gain. Health policy perfectly illustrates this proposition. Whoever moves to change the status quo must convince people that they will not lose what they already have. The larger the share of people who are satisfied with the status quo, the tougher the task. This is why President Obama put his personal credibility on the line to assure Americans that if they liked their current insurance policy, they could keep it under his proposed reform. When this turned out not to be entirely true, he and his party suffered.

But now, after almost eight years of public disapproval, Obamacare has become the new status quo, the baseline from which most people assess gains and losses. While opposition to Obamacare still exists writ larger, individual provisions—some of which have been under threat from Republican alternatives—are wildly popular among Americans. By threatening to take Medicaid away from millions of people, the Republicans poked a hornets’ nest. Whatever they did after this, they would have been hurt. But by running away, they at least minimized the number of stings. Their legislative failure was a blessing, very effectively disguised.

Socialized Medicine Has Won the Health Care Debate

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https://newrepublic.com/article/145067/socialized-medicine-won-health-care-debate

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“It’s coming down to a choice between Federalism vs Socialism,” Senator Lindsey Graham proclaimed on Twitter earlier this week. “I chose Federalism of #GrahamCassidy.” His tweet echoed his words at a press conference days earlier, where he framed his Affordable Care Act repeal bill as the only way “to stop a march toward socialism.”

It’s unclear if the Republican senator realized that he was cribbing from socialist revolutionary Rosa Luxemburg. In a pamphlet composed a century ago while in prison, Luxemburg wrote: “Bourgeois society stands at the crossroads, either transition to socialism or regression into barbarism.” Graham, presumably, didn’t mean to liken his bill to barbarism. But increasingly, those are the terms in which Americans view the health care debate—as a choice between socialism and regression. Republicans have used “socialized medicine” as a bogeyman—and they’ve steadily lost ground on the issue. Despite Graham’s attempts to portray the idea of caring for sick people regardless of their income level as a “nightmare” scenario, just 7 percent of those polled thought Graham-Cassidy would help them.

The repeated rebukes of attempts to undo Obamacare have shown that the average American is no longer moved by the threat of the “S-word.” If we are on a slippery slope toward socialized medicine, it appears that Americans are just fine with that. For the left, there’s a lot to learn from the successful battles against going backward on health care—lessons about how Trump-era politics can be used to push “socialist” policies that move Democrats, and the American public, forward in unexpected ways.

Introduced after the Bernie Sanders Medicare for all bill made its debut with 16 co-sponsors in the Senate, the Graham-Cassidy bill looked all the worse by comparison. Both bills arrived at the end of a summer of activism, a summer that has treated us repeatedly to the sight of people in wheelchairs carted out of the Senate chanting, “No cuts to Medicaid! Save our liberty!” The health care movement has been led by the people directly affected—people with disabilities, in many cases, along with veterans of the AIDS movement. They understood the power of spectacle, initiating those dramatic clashes at the Capitol. They also know better than anyone the inequalities baked into the existing system. Their fighting skills were honed fighting for decades against those who say, implicitly or explicitly, that they don’t deserve care.

Of course, politicians have long been disconnected from the American public on the issue of health care. But the movement to defend Obamacare has drawn into stark relief the difference between what people want and what politicians want to offer. Republicans like Graham banked on the attachment Americans have to the class system we like to pretend doesn’t exist. They played on the idea, honed through decades of dog-whistles, that government programs are always giveaways for the undeserving poor and people of color. As one law professor and conservative columnist complained on Twitter, “Years from now, when your child is denied a liver transplant bc of transplant diversity goals, you’ll be sorry you allowed single-payer.”

In the U.S., we tend to either deny the existence of class or treat it like a set of characteristics divorced from power relations. A Make America Great Again baseball cap, a taste for Budweiser and NASCAR—those, rather than income level or accumulated wealth, are the signifiers of class that we understand. Meritocracy is supposed to be the thing we have instead of class; you can hear it in the endless bipartisan odes to the ability to work hard and achieve anything—including, apparently, a liver transplant if necessary.

Barack Obama and Ben Carson are both heroes of the meritocratic tale, though with a different partisan inflection. Even Sanders falls victim to the meritocratic narrative at times, with his refrain that “No one who works 40 hours a week should be living in poverty.” The implication that comes with Sanders’s qualifier is that there are some people who may, in fact, deserve to be living in poverty. If class is just about some personal preferences rather than structures that maintain inequality, then it’s fine to maintain a healthcare system that treats only those who can afford it. After all, if they just worked harder, they’d have earned that liver.

Graham’s single most tone-deaf argument to sell his bill was drawing an analogy to welfare reform. Welfare reform, of course, was sold to the country by Reagan, Gingrich, and Bill Clinton through fearmongering about undeserving black mothersand “young bucks.” Graham’s rhetoric about the size of the Medicaid budget leaned hard on this analogy, hoping that Americans resented Medicaid as much as they were taught to resent welfare.

Like welfare reform, Graham-Cassidy would have turned Medicaid and the subsidies in the ACA into block grants for the states to manage as they see fit. But the problem with health insurance is that it is designed to be used. The goal of welfare reform was to kick people off of welfare; the goal of healthcare reform was theoretically to get more people onto health insurance plans. Welfare reform increased poverty; Graham and Cassidy didn’t want to admit their bill would do the same. The analogy failed, though it told us a lot about what Republicans think of the people who use Medicaid.

The ham-handed Republican attempts to dismantle the health care system—the “socialism” warnings, the appeals to the selfishness of privileged white folks—have only reinforced the public’s support for government taking care of its citizens. It was telling how, in Monday night’s televised debate between Graham and Cassidy and Senators Sanders and Amy Klobuchar, Graham fell right into a trap, unintentionally proving his opponents’ point about what Americans want. When Sanders asked, “Do you know what the most popular health insurance program in America is? It’s not the private insurance industry,” Graham jumped in like an overeager schoolchild: “It’s Medicare,” he said.

Both Republicans and Democrats have badly misunderstood what makes Obamacare unpopular. What people don’t like are the inequities that still prevail in our health care system, not the fact that “government is too involved.” When Vox’s Sarah Kliff visited Whitley County, Kentucky, to talk to Trump voters who benefited from the ACA, she heard complaints from those buying private insurance with their subsidies that their deductibles were still too high for them to access care. Others, not surprisingly, were angry that the very poor got Medicaid, while they had to pay monthly premiums for care they rarely used. But that anger hasn’t turned them against the program. Medicaid expansion—the “socialized” part of the ACA—remains wildly popular, with 84 percent of those polled by Kaiser Family Foundation saying it’s important to keep the expansion.

The ACA’s means-testing sets up a hierarchy of plans that at times seem calculated to fuel resentment of those getting “free stuff.” It also requires hours of work—I write from personal experience, as a freelancer who has attempted to explain repeatedly that my income varies from month to month and year to year—to prove to the system that you are not getting away with something you haven’t qualified for.

The ways that people have tried to patch the gaps that remain in Obamacare, through charities and crowdfunding, have also highlighted its inequities. As Helaine Olen recently wrote in The Atlantic, charities, too, are often means-testing applicants, while crowdfunding introduces a new kind of means-testing—“means-testing for empathy,” as writer Patrick Blanchfield told me recently. Most GoFundMe or YouCaring campaigns for medical bills don’t go viral; only around 10 percent of them met their stated goals. For those who have a big social media audience, or whose particularly compelling story takes off, crowdfunding might work. But the glut of such campaigns leaves people weighing story against story, deciding who is going to get their donations. It’s health care by popularity contest.

By focusing on the not-good poll numbers for Obamacare, politicians and pundits have missed the whole point: The law didn’t go too far for Americans to get behind. It didn’t go far enough. And while single-payer opponents continue to evoke rationed care, long lines and wait times, and other problems that supposedly plague England or Canada, the public seems well aware that the reality for many Americans is far worse. By their very complaints, the pundits and politicians continually highlight the inequality in the system; the complainers are those who can afford the kind of carethat comes with personal attention, privacy, shorter waits, and avoidance of rubbing elbows with undesirables.

To move forward, then, the single-payer movement should double down on what we learned through this fight: that expanding Medicaid made it harder, not easier, to claim that the program is a “giveaway” to undeserving poor. The willingness of people with disabilities to claim and hold the spotlight—as the New Republic’s Sarah Jones has written—has helped to challenge our preconceptions about who relies on Medicaid ,and to make politicians confront those who will not be served by a market-based program. And the willingness, finally, of politicians to fight publicly for single-payer—rather than mournfully shake their heads and say it will never happen—expands the range of policies that even establishment media is willing to discuss.

Most important, we have learned that the old fearmongering tropes about socialism are no longer enough to whip Republican votes for a major plank of their own platform. If anything, the successful fight should help progressives shed their fears of boldly advocating for what they know is right and working to change public sentiment without endlessly obsessing over potential political pitfalls.

It seems that barbarism, to Graham and his ilk, is the idea that they would lose their right to segregated, high-end care to some undeserving, poor person of color. To the rest of us, however, barbarism is a system that decides who deserves to live or die by the color of their skin, the money in their bank account, the hours that they work, or their ability to work at all. This is now an American consensus. And if socialism is the medicine our system needs, the country is ready to embrace it—even by name.

Five questions on healthcare following Price’s resignation

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Five questions on healthcare following Price’s resignation

Five questions on healthcare following Price's resignation

Tom Price’s resignation as Health and Human Services (HHS) secretary creates a big leadership void at the top of the department tasked with administering a health law Republicans hate.

President Trump accepted the embattled secretary’s resignation Friday on the heels of Politico reports detailing how Price’s travel on military and charter jet flights had cost taxpayers more than $1 million since May.

“I have spent forty years both as a doctor and public servant putting people first,” Price said in his resignation letter. “I regret that the recent events have created a distraction from these important objectives.”

Price’s resignation also follows the GOP’s latest failure to repeal and replace ObamaCare, which Trump had wanted accomplished quickly earlier in the year.

Here are five questions about what comes next:

Who is taking over?

Dr. Don Wright, a career official at HHS,  will serve as acting HHS secretary effective Saturday. Wright has served as the acting assistant secretary for health at HHS since February after joining the agency in 2007, according to HHS’s website.

He’s held a number of positions during his tenure at HHS, including deputy assistant secretary for health and director of the Office of Disease Prevention and Health Promotion.

During his time at HHS, Wright oversaw the national dietary guidelines and the department’s health literacy agenda.

He also represented the U.S. at the World Health Organization executive board.

Prior to joining HHS, Wright worked for the Occupational Safety and Health Administration (OSHA).

Before he started working for the government, he worked for 15 years in the private sector at a clinic and consulting practice in Texas.

What comes next on ObamaCare?

Congressional Republicans won’t be voting to repeal ObamaCare anytime soon. That’s because the vehicle they were using to repeal President Obama’s signature health law without requiring a single Democratic vote expires Saturday.

The focus will now be on how HHS implements the health law.

ObamaCare supporters and local groups tasked with enrolling consumers in the exchanges, known as navigators, are openly frustrated with the administration.

Democrats are arguing that the White House is blatantly sabotaging the law. They point to the administration’s decision to shorten the open enrollment window by half. In late August, HHS announced it was slashing advertising funding by 90 percent and cutting funding for navigator groups by 41 percent.

Open enrollment begins Nov. 1.

Who could replace Price permanently?

Several names have been reported as possibilities for taking over Price’s job.

One is Seema Verma, who heads the Centers for Medicare and Medicaid Services. She was an architect of several state-tailored Medicaid waivers, notably Indiana’s Medicaid expansion program when Vice President Pence was governor. Several Democrats joined Republicans to confirm Verma in a 55 to 43 Senate vote.

Verma was also dispatched to the Hill during the Senate’s ObamaCare repeal bill effort in attempts to smooth over intra-party divisions over how to tackle Medicaid.

Another name being floated is Scott Gottlieb, the Food and Drug Administration commissioner. A handful of Democrats also supported Gottlieb’s nomination.

Politico also noted that Department of Veterans Affairs Secretary David Shulkin was rumored to be a possible replacement, but Shullkin has had questionable travel expense of his own.

Before Trump nominated Price, a short-list of candidates for the HHS job included Housing and Urban Development Secretary Ben Carson, former Speaker Newt Gingrich (R-Ga.), Florida Gov. Rick Scott (R) and former New Jersey state Sen. Rich Bagger, according to a list obtained by Buzzfeed.

What will the confirmation process be like?

It’s unclear when Trump plans to nominate Price’s replacement. But Price’s resignation is setting up a potentially nasty confirmation process in the Senate.

Democrats have accused the Trump administration of trying to sabotage ObamaCare and whomever is nominated will likely be asked about how they would handle the law.

“Throughout his brief time leading the Department of Health and Human Services, Tom Price has repeatedly abused the public trust and betrayed the agency’s mission to improve Americans’ health care,” Sen. Ron Wyden, ranking Democrat on the Senate Finance Committee, said in a statement Friday.

“I hope that his resignation will mark the beginning of a new chapter for the Trump administration’s health care agenda. Tom Price’s replacement needs to be focused on implementing the law as written by Congress and keeping the president’s promise to bring down the high cost of prescription drugs.”

Democrats were opposed to Price’s confirmation, mostly because of questions about his stock trades and investments, which they said were a conflict of interest.

In protest, Democrats didn’t show up to the Finance Committee’s confirmation hearing, and Chairman Orrin Hatch (R-Utah) used a procedural maneuver to push through the nomination. He could likely do that again if Democrats don’t show up.

The whole process took a little less than three months, and it’s unlikely this one will move any faster.

That means HHS is unlikely to have a permanent health secretary in time for ObamaCare’s fifth open enrollment season.

Will Price still pay for his charter seats?

Price said he would pay $52,000 to the U.S. Treasury for the cost of his seats on the private charter planes. That’s a small amount compared to the more than $1 million he reportedly racked up.

But there are also questions about whether he still plans to pay that money back.

“Wait… did we get our money back first?” asked Rep. Linda Sanchez (D-Calif.)

Price, who was worth more than $8 million in January according to his nomination disclosure forms, didn’t mention the money in his resignation letter.

 

 

Obamacare Repeal Bills, Like ‘Game of Thrones’ White Walkers, Are Very Difficult to Kill

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https://www.americanprogress.org/issues/healthcare/news/2017/09/21/439380/obamacare-repeal-bills-like-game-thrones-white-walkers-difficult-kill/

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Michele and Igor speak with Andy Slavitt, former acting administrator at the Centers for Medicare and Medicaid Services under former President Barack Obama—and Twitter hero—about the latest efforts in Congress to repeal the Affordable Care Act in the form of the Graham-Cassidy bill. He reminds listeners why health care is far more personal and significant than partisan politics and how to work toward universal coverage.

 

3 Ways the Senate Budget Reopens the Door for ACA Repeal

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https://www.americanprogress.org/issues/economy/news/2017/09/29/440039/3-ways-senate-budget-reopens-door-aca-repeal/

After the latest failed attempt to repeal the Affordable Care Act (ACA) in the Senate, Sens. Lindsay Graham (R-SC) and Ron Johnson (R-WI) declared that they would only support a new budget resolution that enabled them to keep trying to force through their own health care bill. The Senate has not had to meet the 60-vote standard to pass ACA repeal because of the budget reconciliation process, which lets the Senate pass legislation with a simple majority vote. This process began with reconciliation instructions included in the fiscal year 2017 budget that Congress passed in January 2017, but those instructions expire on September 30.

While the new FY 2018 budget resolution from the Senate Budget Committee retreats from ACA repeal to some extent—after massive public opposition—it would still enable Congress to revive major elements of ACA repeal using reconciliation. Here are three ways the proposed Senate budget supports ACA repeal.

1. An overly broad reconciliation instruction to the Senate Finance Committee

The Senate Finance Committee has jurisdiction over both tax policy and several federal health care programs, including Medicare and Medicaid. If the Senate wanted to limit the scope of a reconciliation bill to tax policy, the budget resolution could give instructions to the Senate Finance Committee that only cover revenues. Instead, the budget instructs the Finance Committee to produce legislation that increases deficits by up to $1.5 trillion over 10 years.

Since deficit changes can be accomplished via changes to both spending and revenues, the Finance Committee could use this reconciliation instruction to repeal ACA-related taxes as well as much of the spending that helps people purchase health insurance under current law. Politico reports that “95 percent of health care policy” goes through the Senate Finance Committee, according to a Republican Congressional staffer discussing ACA repeal. As a result, the staffer said, “it’s not like we couldn’t slip it in anyway.”

Every dollar the Finance Committee cuts from health care could be used to pay for tax cuts for the rich that would be on top of the $1.5 trillion tax cut financed by deficits. This reconciliation instruction could let Congress pass a huge deficit-financed tax cut for the wealthy and corporations, combined with major elements of ACA repeal, in a single omnibus reconciliation bill. If the Finance Committee’s overall bill does not increase deficits by more than $1.5 trillion over 10 years, the Senate could pass it on a party-line vote under reconciliation.

Aside from the Finance Committee, the only other committee involved in ACA repeal in the Senate is the Health, Education, Labor, and Pensions (HELP) Committee. The Senate budget resolution does not give a reconciliation instruction to the HELP Committee, which signals a meaningful retreat from full ACA repeal. Nevertheless, the Finance Committee instruction would still enable the Senate to change major parts of the law, which could include nullifying the ACA mandate for individuals to purchase health insurance, repealing the ACA-related taxes that finance the coverage expansion, and making all of the Medicaid cuts in earlier ACA repeal legislation, such as repealing the Medicaid expansion and making further cuts by turning the program into a block grant.

2. A deficit-neutral reserve fund for ACA repeal

The Senate budget resolution further smooths the path for ACA repeal with a deficit-neutral reserve fund for “repealing or replacing” the ACA. This allows Senate Budget Committee Chairman Mike Enzi (R-WY) to adjust the aggregates that are included in the budget resolution, such as overall spending and revenue levels, to accommodate ACA repeal. This reserve fund helps the Senate majority avoid points of order that could otherwise create hurdles for passing a future health care bill. A similar reserve fund was also included in the FY 2017 budget resolution.

Budget resolutions often include many reserve funds that are mostly designed to signal rhetorical support for an issue. Not only does the reserve fund for health legislation smooth the way for ACA repeal, it also shows that supporters of the Senate budget continue to endorse ACA repeal even after the FY 2017 reconciliation instructions expire on September 30.

3. Deficit-financed tax cuts

Even if Congress does not go after the ACA using reconciliation instructions in the FY 2018 budget, the deficits from the tax cuts the Senate budget enables will be used by the ACA’s opponents to attack the law in the future. Whipping up hysteria about budget deficits is a common tactic to advocate cuts to programs such as Medicare and Medicaid, and it is already being used to justify ACA repeal. When asked a question on CNN from a person who had recovered from substance abuse addiction and who worried about loss of Medicaid coverage for treatment for others suffering from addiction, Sen. Graham responded, “Let’s talk about $20 trillion of debt.”

If lawmakers increase the debt with the very tax cuts that Treasury Secretary Steven Mnuchin says will be “done by the end of the year,” it will add further fuel to their drive to slash programs for low- and middle-income Americans using reconciliation instructions in their next budget resolution for FY 2019. This will not be a long delay—the FY 2019 budget would be passed by April 15, 2018, if Congress follows the schedule for the regular budget process.

Lawmakers can cut taxes, increase deficits, and use those higher deficits to justify a renewed push to repeal the ACA, all before the 2018 midterm elections.

Conclusion

The window is closing for Congress to pass ACA repeal using the FY 2017 reconciliation instructions, but the Senate Budget Committee is reopening it with the FY 2018 budget. The quest to repeal the ACA—thereby cutting taxes for the wealthy, taking health insurance from tens of millions of Americans, eliminating protections for preexisting conditions, and driving up out-of-pocket costs—will continue if Congress passes the Senate budget resolution.

ACA “Bare Counties”: Policy Options to Ensure Access Must Address Longer-Term Stability and Competition

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http://www.commonwealthfund.org/publications/blog/2017/sep/aca-bare-counties

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Continued uncertainty about federal funding for health plans is contributing to higher individual market premiums and insurer withdrawals in 2018. The danger that consumers in some regions wouldn’t have any coverage option next year seemed to subside when insurers in the affected states eventually agreed to broaden their participation. But with the September 27 deadline for deciding to participate in the Affordable Care Act (ACA) marketplaces fast approaching, Virginia officials announced an insurer withdrawal that may leave as many as 63 counties without coverage. At the same time, many more counties appear likely to have just one insurer offering marketplace coverage. The risk that any consumer might be without options for health coverage deserves the right response from policymakers.

Relief for Bare Counties?

The threat of counties without individual market insurers, known as “bare counties,” should be a real concern of policymakers. Even if consumers in all counties have a marketplace plan that gives them access to ACA subsidies, a single plan choice locks consumers into the plan that is available to them, not necessarily the one that best meets their needs. It also fails to foster competition on price and quality, and leaves state officials tasked with approving plans in a difficult position. Two proposals in the Senate would address bare counties, and although both might provide access to federal subsidies, each has significant side effects that are likely to negatively impact market stability and future plan choices.

The Health Care Options Act (S. 761), introduced earlier this year by Senator Lamar Alexander (R–Tenn.), would allow individuals who live in an area without a marketplace plan to qualify for premium tax credits — paid at year-end — to purchase coverage off of the marketplace, including coverage that doesn’t comply with ACA consumer protections. A second bill introduced by Senator Claire McCaskill (D–Mo.), the Health Care Options for All Act (S. 1201), would allow individuals living in a bare county to purchase coverage through the District of Columbia marketplace, where members of Congress and their staff obtain coverage.

By allowing tax credits to be used for coverage that does not meet ACA requirements, the Alexander bill will likely encourage insurers to sell skimpy policies and healthy individuals to enroll in them. Noncompliant policies would have far lower premiums than compliant ones, which, because of the ACA, cannot discriminate based on an individual’s health status. Consequently, insurers that choose to sell in the off-marketplace market likely will hike their premiums for comprehensive coverage to account for the likelihood of enrolling fewer and less healthy individuals. Indeed, they may find that offering such coverage is unsustainable, particularly given that they would still be able to capture healthy, subsidized enrollees through the sale of noncompliant plans.

In contrast, the McCaskill bill would allow consumers to continue to have access to the ACA’s upfront premium and out-of-pocket help and would limit federal financial help to marketplace plans that meet critical consumer protections. However, by requiring insurers selling in the District of Columbia’s small business marketplace to offer individual market coverage to out-of-state consumers, many of whom live in rural areas and are likely to be higher-cost individuals, the proposal may undermine premiums and plan choice for D.C.’s residents and small businesses.

Other potential solutions would offer help to residents of bare counties without the potential harm of the Senate proposals. For example, Congress could allow individuals living in bare counties to use ACA subsidies to buy into other comprehensive coverage — for example, the Federal Employees Health Benefits Program or Medicaid — to ensure access to ACA financial help without undermining market stability.

Policymakers also might consider requiring a fallback plan modeled on the approach taken in the Medicare prescription drug benefit. When that program was enacted, policymakers ensured adequate plan participation in the new market by designating a fallback plan that would provide coverage in any county with two or fewer plans. Such an approach would solve not only the bare counties problem but also would foster competition and ensure adequate plan participation.

Looking Forward

Policymakers looking to stabilize the market and avoid bare counties are right to start by ensuring that payments for cost-sharing reductions continue. Insurers have made clear that guaranteeing federal funding for cost-sharing reductions is a defining factor in their decision to participate in marketplaces next year. In the event there are counties without insurers, it is important that policymakers consider not just the immediate effects of potential policy fixes, but also their longer-term consequences for access to affordable, comprehensive coverage. Solutions for bare counties that allow individuals to use upfront assistance to buy a fallback plan that offers comprehensive coverage would help those individuals who are affected buy and maintain comprehensive coverage while insuring healthy and competitive markets for all.

Down to the Wire: Indecision on ACA Cost-Sharing Reduction Payments Creates Confusion for States

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http://www.commonwealthfund.org/publications/blog/2017/sep/cost-sharing-reduction-payment-indecision

Among the Trump administration’s first promises was to give states more flexibility and control over their health insurance markets than they had had during the Obama years. To date, however, the administration has offered states only uncertainty about what to expect in 2018, which has made it difficult to set premium rates. In particular, state officials are struggling to keep their insurance markets afloat in the face of the Trump administration’s continued indecision over whether to reimburse insurance companies for Affordable Care Act (ACA) cost-sharing reduction (CSR) plans. And time is running out.

No Clarity About Future Payments

Under the ACA, insurers are required to offer plans with reduced cost-sharing for out-of-pocket expenses like copayments and deductibles to eligible low-income enrollees; the government then reimburses insurers for the higher cost of those plans. The Trump administration has threatened to cut off those reimbursements, which for 2018 were projected to reach $8 billion. If these reimbursements do terminate at the end of this year, the Congressional Budget Office has estimated that 2018 premiums will rise by an average of 20 percent. This projection is consistent with similar estimates from the Kaiser Family Foundation and insurers’ own proposed 2018 rates, which were submitted to states this summer.

While the administration has continued to make the monthly CSR reimbursements so far, federal officials have not committed to any future payments. The Trump administration has extended the deadline for finalizing premium rates to September 20, 2017, but even that deadline is fast approaching. Once rates are finalized by states, insurers are locked into them for the full calendar year.

State Decisions Will Drive Insurer Participation and Costs for Consumers and Taxpayers

Whether insurers continue to participate in the ACA marketplaces and what consumers — and federal taxpayers — ultimately pay could depend on the actions of 50 different state insurance commissioners (plus D.C.). Yet, as noted, these state regulators and insurers are in a race against the clock to develop, review, and implement 2018 premium rates that reflect insurers’ likely costs as accurately as possible.

To date, state departments of insurance have given insurers different directives about how to set their premium rates for next year. The variation in these directives will result in different — and potentially significant — consequences for consumers, insurers, and federal taxpayers.

At least one state insurance department, Maryland’s, is currently requiring insurers to submit 2018 premium rates assuming they will be reimbursed for CSR plans throughout 2018. This approach has the advantage of helping to keep rate increases in check for consumers, particularly those not eligible for the tax credit subsidies that shelter low- and moderate-income enrollees from premium hikes. But this directive also carries big risks. If the Trump administration cuts the CSR reimbursements and insurers don’t have sufficient time to submit new rates, then they will face significant financial losses and some (if not all) will likely exit the market, leaving consumers without coverage options.

Other states, such as in New York and Utah, have required or allowed insurers to assume they won’t be reimbursed for CSR plans in 2018. While this means big premium increases for many consumers, it gives insurers more confidence to participate in the market by protecting them from major financial losses. At the same time, if the Trump administration decides to keep the CSR reimbursements going (or if Congress steps in to appropriate the necessary funds), these insurers will reap a windfall, financed largely by federal taxpayers through the ACA’s premium tax credits. Yet more state insurance departments, such as in Arkansas, California, Michigan, and New Mexico, have tried to hedge their bets by asking insurers to submit two sets of rate requests — one assuming CSR reimbursements will be paid, one assuming they won’t.

Still other states have not yet provided directives or reassurances to their insurers, essentially leaving it up to each company to decide how to respond to the uncertainty over CSRs. However, allowing each insurer to decide for themselves could lead to significant market disruption. For example, if one insurer sets premiums assuming they will be paid CSRs, but others in the market increase premiums assuming they will not, it will drive enrollment to the lower-cost plan at the expense of its competitors, placing that insurer at risk of insolvency if the CSRs are not paid.

Looking Ahead

Most observers have hoped that federal policymakers would announce a decision on CSRs one way or another in time for insurers to adjust premium rates for 2018. But as the deadline for finalizing rates looms, it is less and less likely that states will have the clear federal signal they need to decide how to best regulate their insurance markets and review proposed premiums for the upcoming year. Without clarity from federal officials or commitment from Congress to continue funding for CSRs, state insurance departments and insurers will need to make some high stakes bets on the future of these markets by setting premiums that may be too high or too low. Ultimately, the risk of losing these bets will be borne primarily by consumers and federal taxpayers.

Following the ACA Repeal-and-Replace Effort, Where Does the U.S. Stand on Insurance Coverage?

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http://www.commonwealthfund.org/publications/issue-briefs/2017/sep/post-aca-repeal-and-replace-health-insurance-coverage

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Conclusion and Policy Implications

The findings of this study could inform both short- and long-term actions for policymakers seeking to improve the affordability of marketplace plans and reduce the number of uninsured people in the United States.

Short-Term

The most immediate concern for policymakers is ensuring that the 17 million to 18 million people with marketplace and individual market coverage are able to enroll this fall.

Congress could take the following three steps:

  1. The Trump administration has not made a long-term commitment to paying insurers for the cost-sharing reductions for low-income enrollees in the marketplaces, which insurers are required to offer under the ACA. Congress could resolve this by making a permanent appropriation for the payments. Without this commitment, insurers have already announced that they are increasing premiums to hedge against the risk of not receiving payments from the federal government. Since most enrollees receive tax credits, higher premiums also will increase the federal government’s costs.9
  2. While it appears that most counties will have at least one insurer offering plans in the marketplaces this year, Congress could consider a fallback health plan option to protect consumers if they do not have a plan to choose from, with subsidies available to help qualifying enrollees pay premiums.
  3. Reinsurance to help carriers cover unexpectedly high claims costs.10 During the three years in which it was functioning, the ACA’s transitional reinsurance program lowered premiums by as much as 14 percent.

The executive branch can also play an important role in two ways:

  1. Signaling to insurers participating in the marketplaces that it will enforce the individual mandate. Uncertainty over the administration’s commitment to the mandate, like the cost-sharing reductions, is leading to higher-than-expected premiums for next year.
  2. Affirming the commitment to ensuring that all eligible Americans are aware of their options and have the tools they need to enroll in the coverage that is right for them during the 2018 open enrollment period, which begins November 1. The survey findings indicate that large shares of uninsured Americans are unaware of the marketplaces and that enrollment assistance makes a difference in whether people sign up for insurance.

Long-Term

The following longer-term policy changes will likely lead to affordability improvement and reductions in the number of uninsured people.

  1. The 19 states that have not expanded Medicaid could decide to do so.
  2. Alleviate affordability issues for people with incomes above 250 percent of poverty by:
    1. Allowing people earning more than 400 percent of poverty to be eligible for tax credits. This would cover an estimated 1.2 million people at an annual total federal cost of $6 billion, according to a RAND analysis.11
    2. Increasing tax credits for people with incomes above 250 percent of poverty.
    3. Allowing premium contributions to be fully tax deductible for people buying insurance on their own; self-employed people have long been able to do this.
    4. Extending cost-sharing reductions for individuals with incomes above 250 percent of poverty, thus making care more affordable for insured individuals with moderate incomes.
  3. Consider immigration reform and expanding insurance options for undocumented immigrants.

In 2002, the Institute of Medicine concluded that insurance coverage is the most important determinant of access to health care.12 In the ongoing public debate over how to provide insurance to people, the conversation often drifts from this fundamental why of health insurance. At this pivotal moment, more than 30 million people now rely on the ACA’s reforms and expansions. Nearly 30 million more are uninsured — because of the reasons identified in this survey. It is critical that the health of these 60 million people, along with their ability to lead long and productive lives, be the central focus in our debate over how to improve the U.S. health insurance system, regardless of the approach ultimately chosen.