Tag Archives: CHIP Reauthorization

Beyond Showmanship And Spite: Toward A Health Care “Grand Bargain”

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , , , , , , , , , • Leave a comment

https://www.healthaffairs.org/do/10.1377/hblog20171116.24714/full/

Is a deal on health care possible? Conventional wisdom says no. “Repeal and Replace” is dead, and Republicans have moved on. So have many Democrats, toward pursuit of a single-payer plan that’s going nowhere on Capitol Hill but energizes the party’s core. Last month, President Donald Trump said he’ll “dismantle” the Affordable Care Act (ACA) on his own—and backed this up with executive orders that risk the stability of the insurance exchanges.

Democrats are angry that Trump and congressional Republicans want to repeal the ACA and roll back its expansion of health insurance coverage. Republicans are angry that Democrats pushed “Obamacare” through Congress on a party-line basis, and they see the ACA as big government running amok. Both parties are positioning themselves for primaries, and neither shows much interest in the risky work of compromise.

We’re alarmed. One of us is a Cato Institute-friendly “free-market”eer who wrote a book arguing (tongue in cheek) that Medicare is the work of the Devil. The other helped to develop President Barack Obama’s 2008 campaign health plan and believes that failure to ensure everyone’s access to health care is an assault on human decency. But we’ve come together because we believe that failure to resolve the present impasse will have hugely destructive consequences for millions of Americans’ access to health care—and for our national confidence in our political system’s capacity to function.

Designing A Deal

President Trump has cut off cost-sharing reduction subsidies to insurers and issued a directive to allow coverage options less comprehensive than the ACA requires—measures that threaten to unravel the individual and small-group markets by incentivizing younger and healthier people to exit. Meanwhile, the uncertainty that besets federal funding under the ACA for Medicaid expansion poses huge fiscal risks for states, as does Congress’s failure, so far, to renew funding for the Children’s Health Insurance Program (CHIP). And over the longer term, soaring private and public spending on medical services that deliver doubtful value erodes US productivity and well-being.

We think a bipartisan “grand bargain” to stabilize the US health care system is feasible—if key decision makers can move beyond showmanship and spite. To this end, we outline a deal that: honors but balances the competing values at stake, steadies both market and public mechanisms of medical care financing, and puts the nation on a path toward sustainability in health spending.

Our grand bargain builds on federalism. Vastly different values, priorities, and interests stand in the way of nationwide health policy uniformity. Allowing states to sort out controversial matters within broader limits than the ACA now imposes would permit creative policy alternatives to unfold and encourage local buy-in. We needn’t and shouldn’t mandate definitive answers to bitterly contested questions that can be reasonably negotiated at the state or local level. Instead, we should open political and market pathways for the emergence of answers to these questions over time.

Moving to this long game will require all sides to pass on their pursuit of a quick political win. Doing so is the key to moving from cycles of backlash and volatility to a system that builds confidence and delivers high-quality, compassionate health care to all.

The Long Game: Seven Steps Toward a Compromise that Can Work And Endure

With these basic principles in mind, we propose the following seven steps:

Moving Beyond Maximalism—Medicaid Rollback And “Medicare for All”

Republicans should end their campaign to roll back the ACA’s Medicaid expansion, and Democrats should stand down on their quest for single payer. Both pursuits inspire true believers but will go nowhere on Capitol Hill for the imaginable future.

State Flexibility

Give states more flexibility to design their Medicaid programs and to govern their insurance exchanges. One approach would be to simply allow states complete flexibility to design their own coverage rules. Alternatively, we could give states more flexibility but ensure, via federal law, that Medicaid and plans sold on the exchanges provide affordable access to effective preventive, diagnostic, and therapeutic services. States could also be allowed but not required to offer a public option through their exchanges. Instead of an all-or-none answer to the public plan question, the nation would have a framework for market-driven, state-by-state resolution. Similarly, states should be allowed to decide whether to prohibit, permit, or require enrollment of Medicaid beneficiaries in private plans. Finally, when it comes to care that serves culturally contested purposes—including, but not limited to, gender reassignment or confirmation and late termination of pregnancies for nontherapeutic reasons—states should be given autonomy to go their own ways. More federalism will achieve greater stability than would temporary nationwide imposition of one or another approach by whichever party happens to hold the electoral upper hand.

Health Savings Accounts That Appeal To Everyone

An expanded role for tax-protected health savings should have bipartisan appeal. We propose that every lawful US resident be auto-enrolled in a health savings account (HSA), funded through a refundable tax credit, scaled to income and family size. People could opt out but would lose this credit if they did. Few would do so, enabling HSAs to become a means for pursuing both market discipline and social equity.

Repeal The Individual Mandate

Sacrilege, you’re surely thinking, if you’re a Democrat who’s spent seven-plus years defending the mandate, the ACA’s most disliked element. But the mandate isn’t needed to keep healthy people in community-rated risk pools—it’s the intensity of the incentives, whether framed as penalties or subsidies, that matters. Even the mandate’s most outspoken economist-defender, Jonathan Gruber, concedes that high-enough subsidies for the purchase of insurance can substitute for it.

Such subsidies could be supplied in conservative-friendly fashion by allowing all who buy coverage on the exchanges to put HSA funds (including the tax credit we urge) toward their premiums. Sign-up for coverage could also be made more user-friendly through auto-enrollment, subject to opt-out, in “silver” plans (for tax filers who aren’t otherwise covered and aren’t Medicaid eligible). A more robust approach might condition the refundable HSA tax credit on tax filers’ purchasing insurance (or not opting out of auto-enrollment).

Congressional Authorization Of Funding For Both The ACA’s Cost-Sharing Reductions And CHIP

There is bipartisan support for restoring the ACA’s cost-sharing reduction subsidies and extending CHIP. Although annual appropriations are the norm, Congress should guarantee funding for the cost-sharing reductions for a two-year period, with automatic renewal for an additional two years if per capita subsidies rise by no more than the Consumer Price Index (CPI) during the prior two years. By so doing, Congress can reaffirm its authority over appropriations while helping to stabilize markets for individual coverage. Likewise, Congress should renew CHIP’s funding for several years—we urge three as a compromise—to both stabilize state budgets and secure health care for the millions of children who depend on this program.

The “Long Game”—Reining In Medical Spending

A long-term effort to contain spending growth is essential for US fiscal stability and consumer well-being. The ACA created a framework for doing this. The Independent Payment Advisory Board (IPAB) can limit Medicare spending, subject to congressional veto, if growth exceeds target rates. And the 40 percent “Cadillac tax” on high-cost private health plans will cover a rising share of the private market as medical costs increase. Together, these policies have the potential to contain clinical spending by capping demand. But there’s bipartisan opposition to both. The IPAB, which hasn’t yet been established, and the Cadillac tax, now delayed until 2020, are fiercely opposed by stakeholders with lots to lose, and they’re at high risk of repeal.

A grand bargain should follow through on both of these strategies, plus add similar restraints on Medicaid spending and on the amounts spent to subsidize coverage through the exchanges. Most other nations employ global budgeting to control health spending. For reasons of federalism, public philosophy, and market structure, global budgeting isn’t an option for the US. But a coordinated scheme of restraint, based on the best available behavioral and economic modeling, could apply similar braking power to our entire health economy. There’s plenty of room for argument about design details (that is, should per capita growth targets be based on the CPI? The CPI plus 1 percent?) and methods of restraint (that is, the IPAB approach? Spending caps for public programs? The Cadillac tax versus caps on tax deductibility of insurance premiums?). Continued bipartisan evasion will only make the problem worse.

Pursuing Therapeutic Value

Much more must be done to use health care resources wisely as constraints tighten. Tying financial rewards closely to clinical value via paymentpractices, market exclusivity policies, and other incentives will be critical—and will require the clearing of legal and regulatory obstacles. Voluntary action must also play a role: The grand bargain we’ve sketched here creates myriad opportunities for providers, patients, and insurers to gain by insisting on value from a sector of the economy that too often fails to deliver it.

To be sure, politics could foil all efforts to forge compromise. But there is a way forward. Our proposals achieve much that is important to both the ACA’s fiercest critics and staunchest defenders. They work in concert to address the political and market crises that immediately threaten our health care system, while laying the foundation for a long-term approach to control medical spending’s unsustainable growth.

What’s Next for CHIP?

Posted on by • Posted in Uncategorized • Tagged , , , • Leave a comment

http://www.commonwealthfund.org/publications/blog/2017/oct/whats-next-for-chip

 

The Children’s Health Insurance Program (CHIP) offers a critical health insurance pathway for children living in families with modest means. These families’ incomes exceed the basic Medicaid eligibility standard for children but they lack access to employer insurance for their children, either because none is offered or because of a phenomenon known as the “family glitch,” which bars working parents with affordable employer coverage for themselves from getting marketplace subsidies for their children.

CHIP fills these gaps, reaching nearly 9 million children. And because of its popularity, as well as a streamlined enrollment process built into the original law in 1997 and expanded under Affordable Care Act, CHIP has had a remarkable impact on children’s access to health insurance. By 2016, just 4 percent of U.S. children lacked health insurance. Yet Congress has still not reauthorized federal funding for this program.

Unlike Medicaid, which rests on a permanent federal funding authorization, CHIP funding authority must be periodically renewed. Administering CHIP is complex for states because they typically offer CHIP in two forms: coverage through Medicaid for children with incomes just above the Medicaid eligibility cutoff and a separate, companion program for children living in families with slightly higher incomes. As a result, there is a need to transition children between two sources of insurance coverage (and potentially separate managed care plans and provider networks) as family incomes fluctuate.

Fundamental to smooth program operation is reliable federal funding, which accounts for the lion’s share of CHIP program costs. The most recent federal extension came in 2015 as part of legislation that extended funding through September 30, 2017. Congress has therefore known about CHIP’s 2017 funding cliff for more than two years.  States have been unequivocal about the need for steady financing in order to avert coverage interruptions. In the face of continued financial instability, their agencies may need to cease enrollment and freeze coverage — and therefore access to care — for children already enrolled (along with some 370,000 pregnant women also covered through CHIP).

Congress failed to take up CHIP in advance of the deadline because the winter, spring, and summer were consumed by the ACA repeal-and-replace battle. CHIP never was part of this fight; none of the bills considered — even the proposals that would have fundamentally impaired Medicaid’s ability to function effectively for the nation’s 36 million poorest children — proposed to end CHIP. Indeed, the Graham-Cassidy bill would have built on CHIP. But only at the end of September, when the Senate set aside Graham-Cassidy, did Congress return to CHIP.

On October 4, committees in both the House of Representatives and the Senate completed their work on a CHIP extension. Both the House and Senate measures would extend federal CHIP funding for five years and both sides are in agreement on the proper federal CHIP funding level. In other words, the two committees are aligned on the policy.

The House CHIP measure also contains provisions to address other pressing matters such as a delay in scheduled reductions in federal Medicaid payments to hospitals that treat a disproportionate percentage of low-income patients and an increase in federal Medicaid payments to Puerto Rico to help the Commonwealth’s recovery from Hurricane Maria. The House CHIP measure is also part of a suite of other noncontroversial bills expected to move at the same time, including extension of the Health Center Grant Fund, which provides basic grant funding to the nation’s nearly 1,400 federally funded community health centers.

Congress still needs to determine the final contours of the bill, including whether to proceed with the controversial spending offsets the House has identified, in particular a $6.3 billion cut over 10 years to the Prevention and Public Health Trust Fund, which supports core public health services. As yet there is no word on next steps, even as states begin to fall over the edge of the fiscal cliff. Children covered through Medicaid CHIP are safe for the moment, although declining CHIP funding for Medicaid-enrolled children can be expected to trigger other offsetting Medicaid program cuts. But coverage for approximately 4 million children enrolled in separate CHIP programs is very much on the line.

Many hard decisions in a jam-packed fall schedule await Congress. Given the strong bipartisan support for CHIP and its totally predictable expiration, it is surprising — and unfortunate — that CHIP remains on the Congressional docket.

Congress misses deadline to reauthorize CHIP

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , • Leave a comment

http://www.healthcaredive.com/news/congress-misses-deadline-to-reauthorize-chip/506252/

Dive Brief:

  • The Children’s Health Insurance Program (CHIP), which provides coverage to 9 million children, expired this weekend after Congress failed to reauthorize the program before the Sept. 30 deadline.
  • There is still hope that Congress will approve a reauthorization quickly, but state leaders are concerned if Congress doesn’t act soon they will run out of money for the program, which is mostly paid for with federal funds. House and Senate lawmakers have said they will pursue CHIP legislation this week.
  • The Medicaid and CHIP Payment and Access Commission (MACPAC) estimated that if CHIP isn’t reauthorized three states and the District of Columbia will run out of program funding by the end of the year and another 27 states will run dry in the first quarter of 2018.

Dive Insight:

MACPAC warned that stopping CHIP funding will impact state budgets and force states to decide whether to continue coverage on their own dime. If states limit or stop CHIP coverage, hospitals and providers could feel the brunt of fewer insured children and more bad debt. This is especially true for children’s hospitals.

Jim Kaufman, vice president of public policy at Children’s Hospital Association (CHA), recently told Healthcare Dive that CHIP is important for children’s hospitals. “CHIP is good for kids, and that makes it good for children’s hospitals and children’s providers,” Kaufman said.

Not reauthorizing CHIP quickly could especially be an issue for the three states (Arizona, Minnesota and North Carolina) and the District of Columbia, which are expected to run out of CHIP money by the end of the year.

There was hope last month that Congress might be able to reauthorize the program in time. A bipartisan group of senator agreed on a reauthorization bill in September that would have extended CHIP for another five years. However, momentum for that bill stalled when Capitol Hill turned its attention to the Graham-Cassidy ACA repeal legislation. Graham-Cassidy died without a floor vote, and Congress didn’t take up CHIP reauthorization before the deadline.

CHIP, which costs about $14 billion annually, was created in 1997 as a way to provide more health insurance coverage to children of families with low and moderate incomes. The federal government sends CHIP money to states annually, based on previous spending of the funds and populations factors. The states must spend the federal money within two years. Money that isn’t used goes back to the federal government to reallocate to states with CHIP funding shortfalls.

Congress has reauthorized the program periodically since its creation. CHIP has wide support and studies have shown the program helps reduce hospitalizations and child mortality and increase quality of care. When the program was created, 15% of children were uninsured. That number is now about 5% because of CHIP, the Affordable Care Act and Medicaid expansion.

Grassley Pressing to Include Drug Pricing Measures in CHIP Reauthorization

Posted on by • Posted in Uncategorized • Tagged , , , , , , • Leave a comment

https://morningconsult.com/2017/10/03/grassley-pressing-include-drug-pricing-measures-chip-reauthorization/

Image result for high drug prices

 

  • The CREATES Act would crack down on practices employed by some brand-name drugmakers to thwart generic competition.
  • The Preserve Access to Affordable Generics Act targets deals between brand-name drugmakers and their generic counterparts to delay the market entry of competing drugs.

Sen. Chuck Grassley, a senior member and former chairman of the powerful Senate Finance Committee, is pressing GOP leaders to tackle high drug prices in a critical bill to renew funding for the Children’s Health Insurance Program.

Grassley (R-Iowa), who has tried for years to advance legislation targeting rising prescription drug costs to little avail, is pushing two bills as potential offsets for CHIP funding.

Both measures have some bipartisan support, but neither has advanced in previous congressional sessions amid fierce pushback from the pharmaceutical industry. But with urgency on Capitol Hill to renew CHIP, which expired last week, Grassley is taking a shot at getting the bills — the CREATES Act and the Preserve Access to Affordable Generics Act — included in the reauthorization as partial offsets.

The CREATES Act would crack down on practices employed by some brand-name drugmakers to thwart generic competition, while the Preserve Access to Affordable Generics Act targets deals between brand-name drugmakers and their generic counterparts to delay competing drugs from entering the market.

Experts on Grassley’s staff have talked with staff on the Senate Finance Committee and in leadership about the proposals ahead of a committee markup of the CHIP legislation on Wednesday, according to a senior GOP aide.

Supporters from the health sector, which include health insurers, providers and patient organizations, say their chances have never been better, given public outrage at exorbitant drug prices, bipartisan desire to address the issue in Congress and interest in drug prices from within the Trump administration. The proposals have even united progressive advocacy group Public Citizen and the conservative FreedomWorks.

Still, despite unprecedented momentum to tackle rising prescription costs, it is still far from certain whether Grassley will be successful. Senate Finance Committee Chairman Orrin Hatch (R-Utah) has not endorsed either measure and has sometimes sided with brand-name drugmakers on divisive pricing issues. Hatch’s office did not respond to a request for comment on Tuesday.

“It is a delicate conversation between two chairmen who’ve been here for more than a cup of coffee,” Rodney Whitlock, Grassley’s former health policy expert, said in an interview Tuesday. Whitlock is now vice president of health policy at the consulting firm ML Strategies LLC.

Political procedure also complicates Grassley’s effort. Both drug pricing measures have been referred to the Senate Judiciary Committee, which Grassley chairs, while the Senate Finance Committee has jurisdiction over CHIP.

A spokesman for Senate Majority Leader Mitch McConnell (R-Ky.) directed a request for comment to Grassley’s office.

Why ACA market upheaval still looms large despite failure to repeal the law

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , , , , , , , • Leave a comment

http://www.healthcaredive.com/news/why-aca-market-upheaval-still-looms-large-despite-failure-to-repeal-the-law/449117/

Whether lawmakers are done with efforts to repeal the ACA or not, some important changes for healthcare could be on the horizon.

At least one part of the healthcare industry is still looking to Washington D.C. after the flurry of activity last month, if only for one action. In addition to the highly public failure to pass major healthcare legislation before leaving town for a month, Congress and President Donald Trump also left the Affordable Care Act (ACA) exchange markets in a dangerous flux by not taking action on the cost-sharing reduction (CSR) payments for insurers.

It’s not clear whether Congress will continue to take up Republican healthcare legislation to repeal the ACA when it returns. Even within the party, senators are singing different tunes, while President Donald Trump continues to pressure lawmakers to get an ACA repeal bill on his desk. A bipartisan group with members from both chambers has a few ideas, but the majority of lawmakers appear ready to move on. Regardless, they will still have to take up reauthorization of the Children’s Health Insurance Program (CHIP) in September, potential reigniting some debates around the ACA.

If GOP leaders do declare ACA repeal off the table for this year, its opponents will look to the executive branch for efforts to weaken the law and its effects. Here’s what to look out for.

Cost-sharing reduction payments

Payers have been begging for assurance that CSRs will continue to be paid, but the White House and Congress have so far refused. The result has been many payers pulling out of the exchange markets or reducing their footprints, as well as premium hikes of 30% or more. Just last week, Anthem announced it is pulling out of the Nevada and Virginia exchange markets and reducing its participation in Georgia.

Not paying the CSRs would increase federal spending, because the higher premiums will require higher premium subsidies for the 84% in the exchanges who qualify for help. That’s not to mention the 30,000 or more who would have no insurance options.

Trump hasn’t been shy about his plan to halt any efforts that stabilize the exchange markets (like CSRs) in an effort to sabotage the ACA and force unwilling Democrats to cooperate on a repeal bill. Others in the GOP, however, have been reluctant to hurt constituents with such an overtly political play.

America’s Health Insurance Plans has said it is imperative the CSRs are funded. “These benefits are essential to making coverage and care affordable for American families who receive them,” the organization said. “Clarity and commitment to this funding is needed to eliminate confusion and anxiety for consumers.”

It may soon be too late for CSR payments to matter for next year. Payers must sign their contracts with HealthCare.gov by Sept. 21. The CMS and some states have tried to give insurers more flexibility because of the uncertainty by pushing back rate filing deadlines. Connecticut said it will allow payers to refile their rates if the CSR payments are eliminated, and California allowed them to file two sets of rates, one of which assumes no CSRs.

Weakening the ACA

Trump’s threat to “let Obamacare implode” may go beyond refusing to shore up the exchange markets. His administration has already pulled advertising and promotion of the exchanges, and is being investigated by the Government Accountability Office for pushing the GOP healthcare bills in official HHS communication channels. Immediately after his inauguration, Trump signed a wide-ranging executive order instructing federal agencies to “exercise all authority and discretion available to them to waive, defer, grant exemptions from, or delay any provision or requirement” of the ACA that imposes a fiscal or regulatory burden.

No major changes have resulted from the order so far, but it could be used to roll back benefit requirements for preventive care, contraception and mental health services.

HHS Secretary Tom Price could also make changes that weaken the ACA’s individual mandate. Repealing the mandate would mean 15 million fewer Americans would have coverage by 2026 and result in premium increases of about 20%, according to the Congressional Budget Office. Watering down the requirement instead of ditching it completely would have less drastic results, but there would still be an impact.

Price could create more exemptions for the mandate or attempt to force the Internal Revenue Service to stop enforcing it. Either of these actions would add turmoil to the exchanges markets and undermine the efforts of the ACA.

Reauthorizing CHIP

Those watching health legislation in Congress are eyeing CHIP reauthorization as a possible vehicle for changes to the ACA. Lawmakers will be hesitant, though, as CHIP is a successful program with bipartisan support.

The program, which turned 20 years old this past weekend, covered nearly 9 million children in fiscal 2016. CHIP coverage is more affordable than employer-sponsored or marketplace coverage, while children covered under CHIP are more likely to have a usual source of care and regularly attend well-child visits, according to the Medicaid and CHIP Payment and Access Commission, which recommends Congress extend CHIP funding through 2022.

The commission estimates more than a million children would lose coverage if CHIP loses funding.

Bipartisan legislation and state waivers

A bipartisan group of about 40 members of the House is proposing some relatively small changes to the ACA that have received support from both sides of the aisle in the past. The plan is to put them in a bill that would also immediately fund the CSRs.

Their suggestions include exempting smaller businesses from the employer mandate, a fund states can go to for help covering people with high care costs and more flexibility and guidance for states looking to apply for ACA waivers. Another possible measure is repeal of the medical device tax.

Their proposal is to change the employer mandate by having it apply only to businesses with 500 or more employees, instead of the current requirement for businesses with 50 or more workers. Analysis from the Urban Instituteand Rand Corporation has shown the employer mandate has little effect on the number of people who have coverage, partly because nearly all businesses with at least 50 employees offered coverage even before the mandate went into effect.

The ACA has always given states the option of applying for a waiver that allows them to eschew essential health benefits and other requirements — as long as they can prove their plans will cover the same number of people with coverage that is just as comprehensive and affordable. HHS under President Barack Obama was careful in ensuring that state proposals met those guidelines, but current HHS Secretary Tom Price has said he wants to encourage more waivers and will be less strict with approvals of those waivers and Medicaid demonstration waivers.

With this in mind, some recent proposals have included aspects that would have previously been rejected. Last week, Maine applied for a Medicaid demonstration waiver that includes work requirements and asset testing. Those measures are likely to restrict access to coverage for people with low incomes.

Many of the options available for Congress and the executive branch could roil the industry, but some bipartisan options could provide much needed clarity. Summer is usually pretty quiet in Washington D.C., but this year has not been business as usual. Healthcare leaders would be wise to be ready for new developments with the ACA and beyond.

Republicans learn the limits of reconciliation with failed ACA repeal

Posted on by • Posted in Uncategorized • Tagged , , , • Leave a comment

https://www.brookings.edu/blog/fixgov/2017/07/28/limits-of-reconciliation-and-failed-aca-repeal/?utm_campaign=Brookings%20Brief&utm_source=hs_email&utm_medium=email&utm_content=54757954

Image result for senate

With late night drama not often seen on the Senate floor, Republicans’ latest attempts to pass a bill repealing the Affordable Care Act failed last night, thanks in part to a divide the party’s congressional leaders, especially in the Senate, could simply not bridge.

In Congress, we expect that the majority party’s choices about what to work on and how to work on it will be guided, in large part, by their desire to maintain and grow their majority in the future. As the process went on over the past several months, it became increasingly clear that, for the current GOP leadership, what they thought was best for the party’s collective fortunes was adopting something that they could credibly claim “repeals Obamacare.” After all, doing so has been one of their central campaign promises since the law was adopted in 2010—and what helped account for some of their electoral success since that time. The content of the narrow bill to which Senate Republicans retreated in an attempt to keep the process moving reflects this priority, in that it contained symbolic provisions that would be easy for voters to understand as “Obamacare repeal” should the bill have ultimately become law. Chief among these provisions was the repeal of the requirement that individuals purchase health insurance, known as the individual mandate. This provision is among the law’s best known and the change in the Senate bill would have been easy for voters to understand. Under Obamacare, they were required to do something; under the Republican bill, they would not have been.

At the end of the day, however, individual Senate Republicans concluded that even if leaders had judged that “repealing Obamacare” was in the best interests of the party collectively, they could not support the different proposals drafted to actually get there. This was perhaps most true of Senators Susan Collins (R-Maine) and Lisa Murkowski (R-Alaska), who opposed beginning debate and all three alternative proposals considered this week. There were also, however, 11 other senators who voted no on at least one of the alternatives offered this week. While some of those votes may have been strategic, as members knew that the proposal would not ultimately be enacted, they do help illustrate the persistent divides within the Republican Party about the best way to proceed on health policy. In an era of high party polarization and a well-sorted electorate, this kind of cross-pressuring, where what’s good for the party is not necessarily good for the individual member, is less common than it once was. But as the experience of the last few months suggests, those situations can still and do arise.

While the choice by Republicans to pursue their collective goal of “repealing Obamacare” through the fast-track budget reconciliation process meant that Senate Majority Leader Mitch McConnell (R-Ky.) only needed to find 50 votes, it also constrained his task in important ways. The rules of the budget process, including the Byrd Rule, place restrictions on the content of reconciliation bills and amendments to them. While it can be difficult to know exactly how these rules shape a particular piece of legislation, one consequence of them is that leadership does not necessarily have as much room to maneuver in terms of deal-making as they might have on other bills. What’s more, by turning to a process that did not require the support of any Democrats to move forward, Republicans could not rely on the opposition of the other party as a useful foil while they sought to build a winning coalition. Instead, all attention was focused on the party’s internal conflicts and inability to reach agreement—a task made harder by the presence of a same-party president without the policy expertise or interest to help broker the necessary deals. Special legislative procedures that prevent filibusters, in sum, can help majority parties get legislative wins, but only if the party agrees internally on the policy particulars of what that win should look like.

As an agenda item, health care generally and Obamacare specifically aren’t going anywhere any time soon. The Children’s Health Insurance Program, which covered about 9 million children in 2016, needs to be reauthorized by the end of September, and uncertainty about the continued payment of certain subsidies for some Obamacare enrollees on the individual marketplace remains. But with a range of other major issues needing action in the coming weeks—including spending bills and the debt ceiling—Republicans appear ready to move on from their legislative pursuit of their biggest collective goal of recent years.

The BCRA is dead, but don’t take your eye off Capitol Hill

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , • Leave a comment

http://www.healthcaredive.com/news/the-bcra-is-dead-but-dont-take-your-eye-off-capitol-hill/447356/

Image result for keeping an eye on

The healthcare industry may have dodged a bullet, but this week’s legislative stumbles for the GOP don’t mean healthcare is off the table for Congress. Here’s what to watch.

The bulk of the Affordable Care Act (ACA) has survived the latest Republican efforts to repeal it, as Senate leaders were forced to admit Tuesday their best chance to fulfill years of campaign promises to gut the law has floundered.

The Senate plan to replace the ACA sank Tuesday night when the total number of Republicans opposing the bill rose to four. Republican Senate Leader Mitch McConnell immediately pivoted to an effort to repeal the ACAwithout a replacement plan. Only hours later, however, that plan also became unrealistic, as moderate Republicans said such a move would be too risky and they would not vote for it.

Industry groups were happy with the news. Scores of policy experts and healthcare professionals had railed against both the Senate and House bills to replace the ACA. Congressional Budget Office estimates found they would take away health insurance coverage for more than 20 million people. Both proposals also drastically cut Medicaid and eliminated protections for people with pre-existing conditions.

Millions more uninsured would have caused a hefty increase in uncompensated care costs for hospitals. The Commonwealth Fund estimated both replacement bills would have meant nearly a million healthcare jobs lost by 2026.

The industry may have dodged a bullet, but this week’s legislative stumbles for the GOP don’t mean healthcare will be off the table in Congress. Here’s what to watch.

Stabilizing the individual market

The most immediate concern for payers with ACA repeal out of the picture is cost-sharing reduction (CSR) payments and the stabilization of the individual market. McConnell has said legislation to help shore up the market would be needed if the Senate’s Better Care and Reconciliation Act (BCRA) failed. But at least one lawmaker — Senate Majority Whip John Cornyn — said Tuesday he would “not be part of any bailout of insurance companies.”

President Donald Trump said Tuesday that Republicans should “let Obamacare fail” and pin the blame on Democrats. This would likely mean withholding CSRs, a position Trump has repeatedly advocated.

CSRs are meant to help insurers pay for beneficiaries with more care needs and therefore higher costs. They help payers keep a balanced risk pool. Congress and the White House have so far refused to commit to the payments for next year, and insurance companies pulling out of the ACA exchange markets have cited that inaction as a major reason for withdrawal.

The Trump administration still has to decide whether to continue defending a lawsuit against the White House from House Republicans claiming the Obama administration was paying the CSRs without proper appropriation. Payers are hoping Republicans agree to commit to future CSRs with a clearly above-board fund.

Republicans who balk at the CSRs may try to push their own ideas for how to stabilize the market. They have previously proposed changing the age band to allow insurers to charge older people more and tightening requirements for special enrollment periods. The BCRA included $112 billion to help payers stabilize the market, but that funding lasted only two years and assumed the other numerous changes the BCRA called for would go into effect.

Payers would much prefer a commitment to funding CSRs with a clearly above-board fund. That would certainly help steady the ACA marketplaces, but Republican rhetoric about the markets’ “death spiral” is overblown. The CBO has said the individual market would remain stable in most areas under current law, and a Kaiser Family Foundation report showed that payers are regaining profitability in the market while stability is increasing.

Executive actions

The White House will likely be making its own plans in case efforts in Congress fall through.

Trump has said very little about healthcare policy during his time in office. Other than a few tweets, Trump didn’t participate in vote-wrangling for the ACA replacement bills and didn’t make much use of his bully pulpit.

He held a celebratory press conference in the Rose Garden when the House passed its ACA replacement bill and also supported the BCRA. When the Senate bill failed, he immediately called for a repeal without replacement, but the administration didn’t elaborate on when a replacement might come or what it would look like.

Trump has already issued one major executive order on healthcare. Immediately after taking office, he told federal agencies to “exercise all authority and discretion available to them to waive, defer, grant exemptions from, or delay any provision or requirement that of the Act that would impose a fiscal burden on any state or a cost, fee, tax, penalty, or regulatory burden on individuals, families, healthcare providers, health insurers, purchasers of health insurance, or makers of medical devices, products, or medication.”

The IRS under Trump is still technically enforcing the individual mandate, although it also accepted tax returns that don’t indicate whether the filer has health insurance. With the failure to replace the ACA in Congress, Trump could push for complete abandonment of the requirement. Without the mandate, healthy people who don’t need much care would be less likely to get coverage and risk pools would become more unstable.

HHS has already indicated it will allow more state waivers under the ACA, letting states dictate what benefits are required and how people qualify for Medicaid. Conservative states have started planning waiver applications with aspects like a requirement that Medicaid beneficiaries have a job.

The administration could also weaken the ACA by refusing to publicize it. Immediately after Trump took office, the government scaled back advertising for the ACA open enrollment period. This led to fewer signups in the typically busy final days of enrollment. Without a push for young and healthy people to enroll, risk pools could again get off balance.

It hasn’t meant much yet, but with repeal off the table for now, the administration could push for more use of the order. Executive action could be tricky, however, as HHS remains understaffed.

Bipartisan options

Although Republicans and Democrats are far apart on nearly every aspect of healthcare reform, they could find that working together is their only chance of getting anything passed.

One jumping off point could be the bill put forward earlier this year by two of the more moderate Senate Republicans. It would repeal the individual and federal mandates as well as essential health benefits, but keep some aspects of the ACA, like a ban on coverage caps. It would also allow states to implement their own alternative plans, possibly with federal assistance.

Giving more control to state governments — a tactic embraced by HHS Secretary Tom Price — appeals to the left in some ways, but Democrats and patient advocates will oppose any weakening of protections for people with pre-existing and chronic conditions. Republican plans that throw out coverage mandates cannot guarantee such protections because they can easily create unbalanced risk pools.

One initiative that has nearly universal support is MACRA, as well as the movement toward value-based care in general. As providers deal with implementing MACRA payment model changes, Congress may be asked to make some tweaks or delays.

It’s unlikely any major healthcare changes in the near future will be bipartisan, but lawmakers willing to reach across the aisle could try to tackle some smaller issues.

CHIP reauthorization

Another chance to pass healthcare legislation will come at the end of September when the Children’s Health Insurance Program (CHIP) is set to expire. Lawmakers want to ensure the program continues, but may also see it as a possible vehicle for other bills. Republicans have already delayed hearings on renewing CHIP as they’ve debated how to move forward on healthcare changes.

This could be the route for a bill to stabilize the individual market. Republicans and Democrats may try to use this opportunity to push through other changes, but any delay that threatens the continuation of CHIP will be heavily criticized.