We had a whole other video planned for today but we have to talk about the Cassidy-Graham bill, which is getting closer to passing despite our predictions last week.
Tag Archives: Block Grant Medicaid
What Graham-Cassidy means for pre-existing conditions
https://www.axios.com/what-graham-cassidy-really-means-for-pre-existing-conditions-2487720743.html
Jimmy Kimmel’s takedown of Sen. Bill Cassidy, and Cassidy’s response, ripped open the question of whether the GOP’s latest health reform bill protects people with pre-existing conditions. Cassidy and co-sponsor Sen. Lindsey Graham insist it does — as did President Trump in a tweet last night — but experts say that’s not really the case.
The bottom line: The bill’s funding cuts could pressure states — even blue states — to waive protections for sick people, as a way to keep premium increases in check. Older, sicker people in every state could end up paying more as states try to make up for a funding shortfall.
What the bill does: The bill wouldn’t repeal the Affordable Care Act’s rules about pre-existing conditions. But they might end up only existing on paper, the Kaiser Family Foundation’s Larry Levitt said.
Graham-Cassidy doesn’t let states waive the part of the Affordable Care Act that says insurers have to cover sick people. But it does allow states to opt out of several other ACA rules that can cause people with pre-existing conditions to pay more for their health care. Those provisions include:
- The ban on charging sick people higher premiums than healthy people.
- The requirement that insurers cover “essential health benefits,” including prescription drugs. People who need expensive drugs might not have access to a plan that covers those drugs, requiring them to pay out of pocket.
- Services that aren’t “essential” benefits aren’t subject to the ACA’s ban on annual and lifetime limits.
- The bill also would also loosen rules about how much insurers can raise their premiums because of a customer’s age. (Older people are more likely to have pre-existing conditions.)
What supporters will argue: The bill requires states to say how their waivers would provide affordable and accessible coverage for people with pre-existing conditions. But there’s no definition of what that means, and there’s also no enforcement mechanism.
- “The bottom line is these protections are much more at risk under this bill than they are now,” said Cori Uccello, a senior health fellow with the American Academy of Actuaries.
Another level: At least theoretically, because the bill gives states so much control, a more liberal state like California might choose to preserve more of the ACA’s regulations than, say, Alabama. But this bill would radically redistribute federal health care funding — generally away from blue and purple states and toward red states. Those cuts could back blue states into seeking more expansive waivers.
- Caroline Pearson of Avalere told me: “if you have less money, you either cover fewer people, or you cover the same amount of people with less generous coverage. People with pre existing conditions are very reliant on having access to affordable insurance and need insurance that is comprehensive. So if a bill reduces the availability of comprehensive insurance, people with chronic conditions are going to be disproportionately harmed.”
Cassidy-Graham’s Waiver Authority Would Gut Protections for People with Pre-Existing Conditions
The revised Affordable Care Act (ACA) repeal plan from Senators Bill Cassidy and Lindsey Graham, which is also backed by Senators Dean Heller and Ron Johnson, would give states broad waiver authority to eliminate the ACA’s core protections for people with pre-existing health conditions. These waivers would come on top of the proposal’s elimination of the ACA’s marketplace subsidies and Medicaid expansion, its radical restructuring of the rest of the Medicaid program, and its large cuts to total federal funding for health insurance coverage.
Specifically, a little-noticed provision of the block grant funding states would receive under the plan would let them obtain waivers of ACA pre-existing conditions protections and benefit standards for any insurance plan subsidized by block grant funding. For example, a state that used a small portion of its block grant funding to provide even tiny subsidies to all individual market plans could then waive these protections for its entire individual market. Likewise, states that used block grant funding to offer or subsidize coverage for low-income people could offer plans with large gaps in benefits. States seeking waivers would have to explain how they “intend” to maintain access to coverage for people with pre-existing conditions, but they wouldn’t have to prove that their waivers would actually do so.
In particular, states could waive the ACA’s:
- Prohibitions against insurance companies charging people higher premiums based on their health status. While insurers would still be required to offer coverage to people with pre-existing conditions, they could offer them plans with unaffordable premiums of thousands or tens of thousands of dollars per month. For consumers, an offer like that is no different than a coverage denial.
- Requirements that plans cover “essential health benefits.” Before the ACA introduced the requirement that all plans cover a defined set of basic services, 75 percent of individual market plans excluded maternity coverage, 45 percent excluded substance use treatment, and 38 percent excluded mental health care, according to analysis by the Kaiser Family Foundation. Under the Cassidy-Graham proposal, states could let insurers restore these exclusions, leaving many people — especially those with pre-existing conditions — without access to the health services they need.
The waiver authority included in the Cassidy-Graham plan is similar to the so-called “MacArthur amendment” waivers that were included in the House-passed ACA repeal bill. Analyzing those waivers, the Congressional Budget Office concluded:
- States accounting for one-sixth of the nation’s population would choose to let insurers charge higher premiums based on health status. In those states, “less healthy individuals (including those with preexisting or newly acquired medical conditions) would be unable to purchase comprehensive coverage with premiums close to those under current law and might not be able to purchase coverage at all [emphasis added].”
- States accounting for half of the nation’s population would choose to let insurers exclude essential health benefits. In those states, “services or benefits likely to be excluded … include maternity care, mental health and substance abuse benefits, rehabilitative and habilitative services, and pediatric dental benefits.” People needing these services “would face increases in their out-of-pocket costs. Some people would have increases of thousands of dollars in a year.”
Announcing their revised plan, Senators Cassidy and Graham explained that they sought to revise their prior legislation to accomplish the goal of letting states waive the ACA’s core consumer protections. Apparently, they largely succeeded: if their bill were adopted, millions of people with pre-existing conditions would lose access to these protections, and, as a result, would lose access to needed coverage and care.
5 Ways the Graham-Cassidy Proposal Puts Medicaid Coverage At Risk
5 Ways the Graham-Cassidy Proposal Puts Medicaid Coverage At Risk
The Graham-Cassidy proposal to repeal and replace the Affordable Care Act (ACA) is reviving the federal health reform debate and could come up for a vote in the Senate in the next two weeks before the budget reconciliation authority expires on September 30. The Graham-Cassidy proposal goes beyond the American Health Care Act (AHCA) passed by the House in May and the Better Care Reconciliation Act (BCRA) that failed in the Senate in July. The Graham-Cassidy proposal revamps and cuts Medicaid, redistributes federal funds across states, and eliminates coverage for millions of poor Americans as described below:
- Ends federal funding for current ACA coverage and partially replaces that funding with a block grant that expires after 2026. The proposal ends both the authority to cover childless adults and funding for the ACA Medicaid expansion that covers 15 million adults. Under Graham-Cassidy, a new block grant, the “Market-Based Health Care Grant Program,” combines federal funds for the ACA Medicaid expansion, premium and cost sharing subsidies in the Marketplace, and states’ Basic Health Plans for 2020-2026. Capped nationally, the block grant would be lower than ACA spending under current law and would end after 2026. States would need to replace federal dollars or roll back coverage. Neither the AHCA nor the BCRA included expiration dates for ACA-related federal funds or eliminated the ability for states to cover childless adults through Medicaid.
- Massively redistributes federal funding from Medicaid expansion states to non-expansion states through the block grant program penalizing states that broadened coverage. In 2020, block grant funds would be distributed based on federal spending in states for ACA Medicaid and Marketplace coverage. By 2026, funding would go to states according to the states’ portion of the population with incomes between 50% and 138% of poverty; the new allocation is phased in over the 2021-2025 period. The Secretary has the authority to make other adjustments to the allocation. This allocation would result in a large redistribution of ACA funding by 2026, away from states that adopted the Medicaid expansion and redirecting funding to states that did not. No funding is provided beyond 2026.
- Prohibits Medicaid coverage for childless adults and allows states to use limited block grant funds to purchase private coverage for traditional Medicaid populations. States can use funds under the block grant to provide tax credits and/or cost-sharing reductions for individual market coverage, make direct payments to providers, or provide coverage for traditional Medicaid populations through private insurance. The proposal limits the amount of block grant funds that a state could use for traditional Medicaid populations to 15% of its allotment (or 20% under a special waiver). These limits would shift coverage and funds for many low-income adults from Medicaid to individual market coverage. Under current law, 60% of federal ACA coverage funding is currently for the Medicaid expansion (covering parents and childless adults). Medicaid coverage is typically more comprehensive, less expensive and has more financial protections compared to private insurance. The proposal also allows states to roll back individual market protections related to premium pricing, including allowing premium rating based on health status, and benefits currently in the ACA.
- Caps and redistributes federal funds to states for the traditional Medicaid program for more than 60 million low-income children, parents, people with disabilities and the elderly. Similar to the BCRA and AHCA, the proposal establishes a Medicaid per enrollee cap as the default for federal financing based on a complicated formula tied to different inflation rates. As a result, federal Medicaid financing would grow more slowly than estimates under current law. In addition to overall spending limits, similar to the BCRA, the proposal would give the HHS Secretary discretion to further redistribute capped federal funds across states by making adjustments to states with high or low per enrollee spending.
- Eliminates federal funding for states to cover Medicaid family planning at Planned Parenthood clinics for one year. Additional funding restrictions include limits on states’ ability to use provider tax revenue to finance Medicaid as well as the termination of the enhanced match for the Community First Choice attendant care program for seniors and people with disabilities. Enrollment barriers include the option for states to condition Medicaid eligibility on a work requirement and to conduct more frequent redeterminations.
Much is at stake for low-income Americans and states in the Graham-Cassidy proposal. The recent debate over the AHCA and the BCRA has shown the difficulty of making major changes that affect coverage for over 70 million Americans and reduce federal funding for Medicaid. Medicaid has broad support and majorities across political parties say Medicaid is working well. More than half of the states have a strong stake in continuing the ACA Medicaid expansion as it has provided coverage to millions of low-income residents, reduced the uninsured and produced net fiscal benefits to states. Graham-Cassidy prohibits states from using Medicaid to provide coverage to childless adults. With regard to Medicaid financing changes, caps on federal funding could shift costs to states and result in less fiscal flexibility for states. States with challenging demographics (like an aging population), high health care needs (like those hardest hit by the opioid epidemic), high cost markets or states that operate efficient programs may have the hardest time responding to federal caps on Medicaid spending. Faced with substantially reduced federal funding, states would face difficult choices: raise revenue, reduce spending in other areas, or cut Medicaid provider payments, optional benefits, and/or optional coverage groups.
Last-Ditch Effort By Republicans To Replace ACA: What You Need To Know
http://khn.org/news/last-ditch-gop-effort-to-replace-aca-5-things-you-need-to-know/
Republican efforts in Congress to “repeal and replace” the federal Affordable Care Act are back from the dead. Again.
While the chances for this last-ditch measure appear iffy, many GOP senators are rallying around a proposal by Sens. Lindsey Graham (R-S.C.) and Bill Cassidy (R-La.), along with Sens. Dean Heller (R-Nev.) and Ron Johnson (R-Wis.)
They are racing the clock to round up the needed 50 votes — and there are 52 Senate Republicans.
An earlier attempt to replace the ACA this summer fell just one vote short when Sens. Susan Collins (R-Maine), Lisa Murkowski (R-Alaska) and John McCain (R-Ariz.) voted against it. The latest push is setting off a massive guessing game on Capitol Hill about where the GOP can pick up the needed vote.
After Sept. 30, the end of the current fiscal year, Republicans would need 60 votes — which means eight Democrats — to pass any such legislation because special budget rules allowing approval with a simple majority will expire.
Unlike previous GOP repeal-and-replace packages that passed the House and nearly passed the Senate, the Graham-Cassidy proposal would leave in place most of the ACA taxes that generated funding to expand coverage for millions of Americans. The plan would simply give those funds as lump sums to each state. States could do almost whatever they please with them. And the Congressional Budget Office has yet to weigh in on the potential impact of the bill, although earlier estimates of similar provisions suggest premiums would go up and coverage down.
“If you believe repealing and replacing Obamacare is a good idea, this is your best and only chance to make it happen, because everything else has failed,” said Graham in unveiling the bill last week.
Here are five things to know about the latest GOP bill:
1. It would repeal most of the structure of the ACA.
The Graham-Cassidy proposal would eliminate the federal insurance exchange, healthcare.gov, along with the subsidies and tax credits that help people with low and moderate incomes — and small businesses — pay for health insurance and associated health costs. It would eliminate penalties for individuals who fail to obtain health insurance and employers who fail to provide it.
It would eliminate the tax on medical devices.
2. It would eliminate many of the popular insurance protections, including those for people with preexisting conditions, in the health law.
Under the proposal, states could “waive” rules in the law requiring insurers to provide a list of specific “essential health benefits” and mandating that premiums be the same for people regardless of their health status. That would once again expose people with preexisting health conditions to unaffordable or unavailable coverage. Republicans have consistently said they wanted to maintain these protections, which polls have shown to be popular among voters.
3. It would fundamentally restructure the Medicaid program.
Medicaid, the joint-federal health program for low-income people, currently covers more than 70 million Americans. The Graham-Cassidy proposal would end the program’s expansion under the ACA and cap funding overall, and it would redistribute the funds that had provided coverage for millions of new Medicaid enrollees. It seeks to equalize payments among states. States that did not expand Medicaid and were getting fewer federal dollars for the program would receive more money and states that did expand would see large cuts, according to the bill’s own sponsors. For example, Oklahoma would see an 88 percent increase from 2020 to 2026, while Massachusetts would see a 10 percent cut.
The proposal would also bar Planned Parenthood from getting any Medicaid funding for family planning and other reproductive health services for one year, the maximum allowed under budget rules governing this bill.
4. It’s getting mixed reviews from the states.
Sponsors of the proposal hoped for significant support from the nation’s governors as a way to help push the bill through. But, so far, the governors who are publicly supporting the measure, including Scott Walker (R-Wis.) and Doug Ducey (R-Ariz.), are being offset by opponents including Chris Sununu (R-N.H.), John Kasich (R-Ohio) and Bill Walker (I-Alaska).
On Tuesday 10 governors — five Democrats, four Republicans and Walker — sent a letterto Senate leaders urging them to pursue a more bipartisan approach. “Only open, bipartisan approaches can achieve true, lasting reforms,” said the letter.
Bill sponsor Cassidy was even taken to task publicly by his own state’s health secretary. Dr. Rebekah Gee, who was appointed by Louisiana’s Democratic governor, wrote that the bill “uniquely and disproportionately hurts Louisiana due to our recent [Medicaid] expansion and high burden of extreme poverty.”
5. The measure would come to the Senate floor with the most truncated process imaginable.
The Senate is working on its Republican-only plans under a process called “budget reconciliation,” which limits floor debate to 20 hours and prohibits a filibuster. In fact, all the time for floor debate was used up in July, when Republicans failed to advance any of several proposed overhaul plans. Senate Majority Leader Mitch McConnell (R-Ky.) could bring the bill back up anytime, but senators would immediately proceed to votes. Specifically, the next order of business would be a process called “vote-a-rama,” where votes on the bill and amendments can continue, in theory, as long as senators can stay awake to call for them.
Several senators, most notably John McCain, who cast the deciding vote to stop the process in July, have called for “regular order,” in which the bill would first be considered in the relevant committee before coming to the floor. The Senate Finance Committee, which Democrats used to write most of the ACA, has scheduled a hearing for next week. But there is not enough time for full committee consideration and a vote before the end of next week.
Meanwhile, the Congressional Budget Office said in a statement Tuesday that it could come up with an analysis by next week that would determine whether the proposal meets the requirements to be considered under the reconciliation process. But it said that more complicated questions like how many people would lose insurance under the proposal or what would happen to insurance premiums could not be answered “for at least several weeks.”
That has outraged Democrats, who are united in opposition to the measure.
“I don’t know how any senator could go home to their constituents and explain why they voted for a major bill with major consequences to so many of their people without having specific answers about how it would impact their state,” said Senate Minority Leader Chuck Schumer (D-N.Y.) on the Senate floor Tuesday.
Senate GOP Has 12 Days to Repeal Obamacare and No Room for Error
Senate Republicans making one last-ditch effort to repeal Obamacare have the daunting task of assembling 50 votes for an emotionally charged bill with limited details on how it would work, what it would cost and how it would affect health coverage — all in 12 days.
They need to act by Sept. 30 to use a fast-track procedure that prevents Democrats from blocking it, but the deadline doesn’t leave enough time to get a full analysis of the bill’s effects from the Congressional Budget Office. The measure would face parliamentary challenges that could force leaders to strip out provisions favored by conservatives. Several Republicans are still withholding their support or rejecting it outright.
And even if Republicans manage to get it through the Senate by Sept. 30, the House would have to accept it without changing a single comma.
Most Senate Republicans are still trying to figure out what it’s in the bill, which was authored by Republicans Lindsey Graham of South Carolina and Bill Cassidy of Louisiana. Until the past few days, most assumed that GOP leaders had no interest in reviving the Obamacare repeal effort after their high-profile failure to pass a measure this summer.
Republican Senator Steve Daines of Montana said he’s still trying to figure out how the bill will affect his state and wants to hear what GOP leaders say at a closed-door lunch Tuesday.
‘Active Discussion’
“It will be a very active discussion,” he said.
The new repeal bill would replace the Affordable Care Act’s insurance subsidies with block grants to states, which would decide how to help people get health coverage. The measure would end Obamacare’s requirements that individuals obtain health insurance and that most employers provide it to their workers, and it would give states flexibility to address the needs of people with pre-existing medical conditions.
But lawmakers won’t have much more information about the legislation by the time the Senate would have to vote. The CBO said Monday it will offer a partial assessment of the measure early next week, but that it won’t have estimates of its effects on the deficit, health-insurance coverage or premiums for at least several weeks. That could make it hard to win over several Republicans who opposed previous versions of repeal legislation.
So far, President Donald Trump has suggested he’d support the bill, but he hasn’t thrown his full weight behind it.
Majority Leader Mitch McConnell has told senators he would bring up the bill if it had 50 votes, and under fast-track rules he could do so at any time before Sept. 30. That’s the end of the government’s fiscal year, when the rules expire and the GOP would have to start over.
Several Holdouts
Republicans can only lose two votes in the 52-48 Senate and still pass the measure, with Vice President Mike Pence’s tie-breaker. There are at least four holdouts, and getting any of them to back the measure would require the senators to change their past positions. Pence, who would cast the potentially deciding vote, will return to Washington from New York Tuesday, where he’s been taking part in United Nations General Assembly events, to attend Senate GOP lunches.
Republican Rand Paul of Kentucky said Monday he’s opposed to the Graham-Cassidy bill, saying it doesn’t go far enough. John McCain of Arizona said he’s “not supportive” yet, citing the rushed legislative process.
Two other Republicans — Susan Collins of Maine and Lisa Murkowski of Alaska — have voted against every repeal bill considered this year in the Senate, citing cuts to Medicaid and Planned Parenthood as well as provisions that would erode protections for those with pre-existing conditions. The Graham-Cassidy bill contains similar provisions on those three areas.
“I’m concerned about what the effect would be on coverage, on Medicaid spending in my state, on the fundamental changes in Medicaid that would be made,” Collins told reporters Monday evening.
She said that Maine’s hospital association has calculated the state would lose $1 billion in federal health spending over a decade compared to current law.
“That’s obviously of great concern to me,” she added.
Hard Sell
Murkowski is getting a hard sell from Republican backers of the bill.
“What I’m trying to figure out is the impact to my state,” Murkowski told reporters Monday. “There are some formulas at play with different pots of money with different allocations and different percentages, so it is not clear.”
McCain, who is close friends with Graham, cast the deciding vote to sink an earlier repeal bill in late July when he made a dramatic return to the Senate after a brain cancer diagnosis. At the time, he made an eloquent plea for colleagues to work with Democrats and use regular legislative procedures instead of trying to jam it through on a partisan basis.
John Weaver, a former top adviser to McCain, said supporting Graham-Cassidy would require the Arizona senator to renege on his word.
‘Fair Process’
“I cannot imagine Senator McCain turning his back not only on his word, but also on millions of Americans who would lose health care coverage, despite intense lobbying by his best friend,” Weaver said in an email. “Graham-Cassidy, if truly attempted to pass, will bypass every standard of transparency and inclusion important to people who care about fair process.”
Despite the obstacles, the bill’s backers are putting on a good face about the prospects.
“We’re making progress on it,” said Republican Senator Ron Johnson of Wisconsin. “I’m still cautiously optimistic, but there are a lot of moving parts.” Johnson is planning a Sept. 26 hearing on the measure in the Homeland Security and Governmental Affairs Committee, which he leads. The Senate Finance Committee is planning its own hearing Sept. 25 on the measure.
“There’s a lot of interest,” Senator Pat Toomey of Pennsylvania said Monday. “Those guys have done some very good work.”
A number of Republicans are still pushing for changes to the bill, so the final version may evolve. It’s also subject to parliamentary challenges under the reconciliation process being used to circumvent the 60-vote threshold in the Senate. That could allow Democrats to strike provisions that take aim at Obamacare’s regulatory structure.
Last Chance
If it passed the Senate, the House would have to pass the bill without any changes. House Speaker Paul Ryan said Monday that the measure is Republicans’ last best chance to repeal Obamacare.
“We want them to pass this, we’re encouraging them to pass this,” Ryan told reporters at a news conference in Wisconsin. “It’s our best, last chance of getting repeal and replace done.”
But that won’t be easy either. The measure strives to equalize Medicaid funding between states, which means that some House Republicans from Medicaid expansion states could find it hard to support. That includes states like New York and California, which stand to lose federal funds under Graham-Cassidy. Those states have only Democratic senators, but have some GOP House members.
Another Run
In some ways, it’s remarkable that Republicans are mounting another run at repeal.
Two months ago, Majority Leader Mitch McConnell’s effort to pass a replacement with only Republican support suffered a spectacular defeat in the Senate. When members of the Senate health committee then began working on a bipartisan plan to shore up Obamacare, Graham and Cassidy revved up a new bid to get their GOP-only bill to the Senate floor.
Graham and Cassidy are hoping to channel the GOP’s embarrassment at failing to repeal Obamacare this summer after seven years of promising to do so. But Paul said Monday this legislation shouldn’t be treated like a “kidney stone” you pass “just to get rid of it.”
Despite all the obstacles, Democrats quickly geared up for another campaign against repeal, warning that the latest bill is a serious threat.
“This bill is worse than the last bill,” Senate Democratic leader Chuck Schumer of New York told reporters Monday. “It will slash Medicaid, get rid of pre-existing conditions. It’s very, very bad.”
Hospital group comes out against new ObamaCare repeal effort
Hospital group comes out against new ObamaCare repeal effort
America’s Essential Hospitals announced its opposition to a new ObamaCare repeal and replace bill, warning of cuts and coverage losses.
The group, which represents hospitals that treat a high share of low-income people, said it is opposed to a last-ditch bill to repeal ObamaCare from Sens. Bill Cassidy (R-La.), Lindsey Graham (R-S.C.), Dean Heller (R-Nev.) and Ron Johnson (R-Wis.).
Dr. Bruce Siegel, the group’s president and CEO, said in a statement the bill “would shift costs to states, patients, providers, and taxpayers.”
“Further, by taking an approach so close to that of the earlier House and Senate plans, it’s reasonable to conclude it would have a similar result: millions of Americans losing coverage,” he added.
America’s Essential Hospitals is one of the first major health groups to come out in opposition to the bill. Most have not yet weighed in on the measure, which was only introduced on Wednesday.
Many are also skeptical of the bill’s chances, but it appears to be gaining at least some momentum.
Cassidy told reporters Friday that he thought the bill had the support of 48-49 senators, just shy of the needed 50. Still, the effort faces long odds and a fast-approaching procedural deadline of Sept. 30.
America’s Essential Hospitals was one of the most outspoken opponents of the earlier repeal bills, along with other hospital groups. Many doctors groups were also opposed and many insurers eventually weighed in against provisions to change ObamaCare pre-existing condition rules.
There’s one Obamacare repeal bill left standing. Here’s what’s in it.
After a dramatic series of failed Senate votes in July, there’s one repeal-and-replace plan for the Affordable Care Act left standing. Trump is pushing for a vote, per Politico, and John McCain has announced his support, but the bill has yet to gain significant traction.
The proposal, crafted by Sens. Bill Cassidy (R-La.), Lindsey O. Graham (R-S.C.) and Dean Heller (R-Nev.), essentially turns control of the health-care markets over to the states. Rather than funding Medicaid and subsidies directly, that money would be put into a block grant that a state could use to develop any health-care system it wants. It also allows states to opt out of many ACA regulations. “If you like Obamacare, you can keep it,” Graham has said, using a common nickname for the health-care law. “If you want to replace it, you can.”
In reality, that may not be true. The Medicaid expansion and subsidy funding would be cut sharply compared to current spending, going to zero in a decade.
“You can’t actually keep the same program if your federal funding is being cut by a third in 2026,” said Aviva Aron-Dine, a senior fellow at the left-leaning Center on Budget and Policy Priorities. And even putting aside the cuts, she said, the block grant structure would fundamentally change the health-care landscape. “[Funding] is capped, so it wouldn’t go up and down with the economy,” when fewer or more people become eligible for subsidies.
Republicans contest this. The drop in funding “gives strong incentives for the states to be more efficient with their program,” said Ed Haislmaier, a senior fellow at the conservative Heritage Foundation. That is, states may be able to maintain the ACA structure and regulations as long as they streamline operations.
If the streamlining turns out to be insufficient, the cuts would hit liberal states the hardest, according to a report by the Center for Budget and Policy Priorities. This is largely because they tend to be the biggest spenders on health care: They’ve expanded Medicaid and aggressively signed people up for marketplace coverage. They have the most to lose.
On the whole, Aron-Dine says, “This is a lot more similar to the [Senate repeal bill] than different. All of them end with devastating cuts to marketplace subsidies, Medicaid, and weakening of consumer protections.”
Haislmaier agreed, pointing out the Cassidy-Graham plan was originally intended as an amendment to the Senate bill.
Here’s the nitty gritty of what would change, compared to the ACA and the Senate plan that failed in July:
Who would need to be covered
Under the Cassidy-Graham plan, the mandates would be eliminated at the federal level. States could choose to keep the measure, replace it or get rid of it completely.
How they would pay for coverage
The federal health insurance subsidies that help most people with ACA marketplace plans afford their coverage would change. This bill would shift those subsidies to the state-level, so people in some states may see their subsidy scaled back or eliminated.
Proposed changes to Medicaid
The bill would restructure Medicaid and decrease its funding. That would make it very difficult for states to maintain the Medicaid expansion.
Obstacles await as Congress resumes health care fight
Republican hopes for repealing and replacing former President Barack Obama’s health care law are still twitching in Congress, though barely.
Leaders lack the votes to pass something and face a fresh obstacle — the Senate parliamentarian ruled Friday that Republicans only have the ability to dismantle the law with 51 votes until the end of the month.
It’s among several health issues lawmakers face when they return from summer recess, even as fights over the budget and helping Texas recover from Hurricane Harvey grab center stage.
WHEN WE LEFT OFF IN LATE JULY
Senate Majority Leader Mitch McConnell, R-Ky., tried to push three plans through his chamber erasing the 2010 law called Obamacare. Republican defections denied him the 50 votes needed, with Vice President Mike Pence ready to seal victory with a tie-breaking vote.
The excruciating last roll call failed 51-49. Three Republicans voted “no,” one more than McConnell could afford to lose. President Donald Trump used August to insult McConnell for that flop, even suggesting he might need to relinquish his leadership post, inflaming tensions between the White House and congressional Republicans and lacerating party unity.
_____
OBAMACARE REPEAL MEETS THE PARLIAMENTARIAN
Republicans have used a procedure that’s prevented Democrats from killing the health bill by filibuster. It takes 60 votes to defeat a filibuster. Without that special step, Republicans controlling the Senate 52-48 would need support from eight Democrats to repeal Obamacare, impossible given unanimous Democratic opposition.
The safeguard against filibusters was included in a budget for the government’s 2017 fiscal year that Republicans pushed through Congress in January.
That protection expires at the end of September, the Senate’s nonpartisan parliamentarian, Elizabeth MacDonough, has ruled. That’s when the fiscal year ends.
Sen. Bernie Sanders, I-Vt., the ranking member of the Budget Committee, said in light of the ruling, “we need to work together to expand, not cut, health care for millions of Americans who desperately need it.”
That leaves Republicans with only September to nurture their slim repeal hopes unless the GOP-run chamber votes to overrule her.
___
A LAST REPEAL PUSH
This repeal push comes from GOP Sens. Lindsey Graham of South Carolina, Louisiana’s Bill Cassidy and Nevada’s Dean Heller.
They’ve proposed funneling Obamacare’s federal dollars directly to states and erasing its requirements that people buy coverage and companies offer it to employees. They’d cut and reshape Medicaid, halt Obama subsidies that reduce consumers’ out-of-pocket costs and repeal the tax on some medical devices.
GOP aides say the proposal is evolving.
There’s no sign sponsors have enough Republicans to prevail and McConnell hasn’t been publicly encouraging. Further reducing its chances, lawmakers need September to prevent a damaging federal default and a government shutdown, help Texas recover from Harvey and craft a GOP tax overhaul.
“If people can show me 50 votes for anything that would make progress on that, I’ll turn back to it,” McConnell said in early August of repealing Obamacare.
___
A BIPARTISAN TRY
The brightest hope comes from Senate health committee chairman Lamar Alexander, R-Tenn., and Washington state Sen. Patty Murray, that panel’s top Democrat. They’re seeking a deal on continuing federal payments to insurance companies who reduce costs for lower-earning customers.
Even this will be uphill.
Obama’s law requires the cost reductions and government subsidies to insurers, but a court has ruled Congress hasn’t legally authorized the payments. Obama and Trump have continued them, but Trump keeps threatening to stop, calling them an insurance company bailout. Many conservatives agree.
Yet those payments are a priority for Democrats and many Republicans. They and the nonpartisan Congressional Budget Office say halting the subsidies will force insurers to boost premiums for millions.
In exchange, Republicans want to revise parts of Obama’s law. They’ve suggested making it easier for insurers to avoid some Obama coverage requirements or steps like curbing lawsuits against health care providers.
Alexander wants to extend the insurers’ subsidies for one year while Democrats want two years or more. Another hurdle: Democrats have little interest in relaxing Obama’s law.
“Nobody is going to put their fingerprints on sustaining Obamacare without some sort of reform element,” Rep. Tom Cole, R-Okla., said of Republicans.
___
CHILDREN’S HEALTH
Funding for the popular Children’s Health Insurance Program expires Sept. 30. It provided health care to more than 8 million low-income children in 2015.
Democrats and most Republicans want to extend the program and success seems likely. First they must compromise on details like how many years to finance it and at what levels.
Washington pays for most of the federal-state program, and in recent years the federal share was bumped up by 23 percent for each state. Many Republicans want to phase out that boost, but Democrats are resisting.
Some Republicans say Congress needn’t act by Sept. 30 because states have enough money to continue coverage. Democrats and program advocates say without fresh funds by September’s end, some states would be forced to make cuts to wind down services.
GOP lawmakers, Trump at odds over insurance payments
Lawmakers are facing off with President Trump over key ObamaCare payments that are in jeopardy after the collapse of efforts to repeal the healthcare law.
Trump is threatening to cancel the payments, known as cost-sharing reductions (CSRs), as part of his effort to make ObamaCare “implode.”
But he is running into opposition from key Republicans, including Senate Finance Committee Chairman Orrin Hatch (Utah) and House Ways and Means Committee Chairman Kevin Brady (Texas), who say they want to find a way to guarantee the payments, which reimburse insurers for giving discounted deductibles to low-income ObamaCare enrollees.
If the payments were cancelled, insurers have warned they would either have to spike premiums to make up for the lost money, or drop out of the market altogether, limiting people’s options for coverage.
Trump could announce that he is cancelling the payments as early as Tuesday.
Rep. Chris Collins (R-N.Y.), one of Trump’s top supporters on Capitol Hill, told CNN on Monday that he had encouraged Trump to announce the cancellation on Tuesday.
Trump has long warned that he could cancel the payments, though it is unclear if he will follow through.
In addition to a premium spike that experts estimate could reach 20 percent, Democrats warn that there would be a political fallout as well if people blame Trump for the chaos.
A Kaiser Family Foundation poll in May found that 63 percent of the public thinks Trump and congressional Republicans are responsible for problems with the Affordable Care Act going forward.
Senate Democratic Leader Chuck Schumer (N.Y.) on Monday said there would be a “Trump tax” on people’s premiums if he cancelled the payments.
Trump seemed to refer to cancelling CSRs on Saturday when he tweeted: “If a new HealthCare Bill is not approved quickly, BAILOUTS for Insurance Companies and BAILOUTS for Members of Congress will end very soon!”
Trump has alternated between saying he will simply cause ObamaCare to implode and calling for Congress to repeal the law.
In another tweet on Saturday, Trump called for Congress not to give up on repeal and to vote on it before acting on any other bill.
Many congressional Republicans have called for continuing the CSR payments.
In a statement Friday, Brady warned that “simply letting Obamacare collapse” would cause “even more pain” for people in his district facing high premiums and fewer choices.
“For those trapped in Obamacare, we must continue to look for immediate solutions to deliver relief, stop premiums from soaring even higher, and help people get the health care that’s right for them,” Brady said.
Hatch told Reuters in an interview Monday that he did not want to provide funding for the CSRs, but “I think we’re going to have to do that.”
Sen. Lamar Alexander (R-Tenn.), chairman of the Senate health committee, has also called for Congress to act on the payments. His committee will be holding hearings on improving the stability of the ObamaCare markets in the near future, which could lead to bipartisan action.
“I guess I’m hopeful that the administration, the president will keep making them and if he doesn’t then I guess we’ll have to figure out from a congressional standpoint what we do,” Sen. John Thune (R-S.D.), the No. 3 Senate Republican, said on Monday.
Sen. John Cornyn (R-Texas), the No. 2 Republican, noted that Trump would have to sign legislation guaranteeing the payments, making it a “challenge.” He also said that the prospect of action by Congress is a “real live issue.”
A House GOP aide said Monday that Republicans are still looking at different legislative vehicles for temporarily guaranteeing the CSR payments.
Democrats are pushing for Congress to guarantee the payments soon, to reduce uncertainty for insurers ahead of an Aug. 16 deadline for filing their premium rates for next year.
In more momentum for congressional action, a bipartisan group of more than 40 House lawmakers on Monday unveiled a proposal to fix problems with ObamaCare, including guaranteeing funding for the CSRs, which would take the issue out of Trump’s hands.
“Cutting off those payments further destabilizes the individual market and these are real people,” Rep. Tom Reed (R-N.Y.), one of the leaders of the bipartisan effort in the House, told The Hill on Monday.
Reed said that while he still supports repeal of the health law, Republicans should try a different, bipartisan, direction rather than “engage in insanity by doing the same thing over and over again.”
Still, there are other Republicans who are still pressing to repeal and replace ObamaCare.
Sens. Lindsey Graham (R-S.C.) and Bill Cassidy (R-La.) have both attended meetings at the White House in recent days focused on trying to revive such legislation.
The two senators have written a measure that would convert current ObamaCare spending into a block grant given to states, which is aimed at giving states flexibility. Democrats warn the block grants would be significantly less than current spending levels, leading to cuts.
The proposal faces a steep path to passage, especially given that McConnell indicated he is moving on from repeal efforts for now.
Reed said that he had kept House GOP leaders apprised of the bipartisan group’s work.
“I hope so,” Reed said when asked if leadership is open to bipartisan action on healthcare. “The other path is not working.”
HENRY KOTULA 