Tag Archives: Health Insurance Coverage Adequacy

There’s one Obamacare repeal bill left standing. Here’s what’s in it.

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https://www.washingtonpost.com/graphics/2017/politics/cassidy-graham-explainer/?utm_term=.c90e0ce41aa2

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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.

 

Trump wants one last Senate push on Obamacare repeal

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http://www.politico.com/story/2017/09/05/trump-obamacare-repeal-senate-242346

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The odds are slim, but the White House still hopes for action on a bill drafted by Lindsey Graham and Bill Cassidy.

President Donald Trump and some Senate Republicans are refusing to give up on Obamacare repeal, even after this summer’s spectacular failure and with less than a month before a key deadline.

The president and White House staff have continued to work with Republican Sens. Lindsey Graham of South Carolijna and Bill Cassidy of Louisiana over the summer on their proposal to block grant federal health care funding to the states. And though the bill is being rewritten and Congress faces a brutal September agenda, Trump and his allies on health care are making a last-gasp effort.

“He wants to do it, the president does. He loves the block grants. But we’ve got to have political support outside Washington,” Graham said in an interview. He said the bill needs to have a “majority of the Republican governors behind the idea” to gain momentum in the Senate.

But there’s far more work to do even than that. Senate Majority Leader Mitch McConnell would need to find room on the packed calendar this month to hold another uncertain push to repeal Obamacare on party lines. The Senate has only until the end of the month to pass the measure using powerful budget reconciliation procedures, but is also planning to fund the government, raise the debt ceiling, write a new defense policy bill and extend a host of expiring programs.

Cassidy said he hopes to have the bill text finalized by this week and has declined to reveal details about what changed in the bill during August.

“We are still refining the legislative language — just things you got to clear up,” he said. “We think we have good legislation, good policy.”

The Congressional Budget Office would also still need time to analyze the cost of the bill, a process that could take several weeks.

Trump berated McConnell and the Senate GOP over the summer for falling one vote short of sending repeal into conference with the House in July, when Sen. John McCain of Arizona voted down the GOP’s “skinny” repeal bill. So the White House has continued to work on the Graham-Cassidy bill behind the scenes, seeing it as the best option to make progress, according to several administration officials.

The bill would keep most of Obamacare’s taxes and devolve many spending decisions to the states. It was submitted as an amendment to the repeal bill in July but did not receive a vote; aides say it could not pass the Senate in its current form.

Trump has intermittently told aides he wants progress on health care and is still frustrated that the bill failed. The White House’s legislative team has talked with Republican governors in recent weeks and is planning to bring more to the White House, according to one of the officials. Internally, White House officials say they have listened to concerns from governors and tried to tweak the state block grant formulas.

Hill leadership hasn’t played a central role in the effort.

McConnell said in Kentucky last month that the path forward is “somewhat murky” and pointed to efforts by Sen. Lamar Alexander (R-Tenn.) to stabilize insurance markets as one avenue forward, though he doubted Democrats’ resolve on the bipartisan effort.

“We’re going to see what Sen. Alexander and his team can do on a bipartisan basis. The Democrats have been pretty uninterested in any reforms. They’re really interested in sending money to insurance companies but not very interested in reforms,” McConnell said then.

Inside the White House, there is little hope that a health care bill can happen quickly, with a stacked legislative agenda. And some close to the president prefer he would focus on tax reform and other immediate fiscal issues.

The Senate parliamentarian has ruled that the chamber’s reconciliation instructions, which allow the GOP to evade a Democratic filibuster and the chamber’s 60-vote requirement, expire at the end of the month. Republicans are planning to use their next budget measure to pass tax reform via a simple majority. But Graham insisted there’s a short window to fulfill the party’s seven-year promise if the GOP goes into overdrive, starting this week.

“It’s possible, yes. But you’ve got to do it quickly … introduce it this week, have a hearing soon about the bill, then the process is set to actually take it to floor and vote,” Graham said. “Everything has to fall in place.”

State officials plead for bipartisan ObamaCare fix

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State officials plead for bipartisan ObamaCare fix

State officials plead for bipartisan ObamaCare fix

State insurance officials pleaded with senators on Wednesday to quickly act to stabilize the ObamaCare markets, calling for a multiyear extension of key payments to help fund premiums for low-income customers.

Congress must pass a fix by the end of September to shore up the wobbly individual markets, several officials said, in particular funding for key ObamaCare insurer payments known as cost-sharing reductions (CSR).

“The CSR funding issue is the single most critical issue that you can address to help stabilize insurance markets for 2018 and potentially bring down costs,” Tennessee’s insurance commissioner Julie Mix McPeak told the Senate Health Committee.

The panel kicked off a series of hearings Wednesday on stabilizing the markets. If Congress can pass a bill, it would represent the biggest bipartisan update since President Obama signed the law in 2010.

Health committee Chairman Lamar Alexander (R-Tenn.) wants to find consensus by the end of next week. To sell the fix, he and ranking member Patty Murray (D-Wash.) held a private meeting with senators not on the committee and the witnesses who testified as Wednesday’s hearing.

“If we can do two things, that would be two more things that we have agreed on in a bipartisan way in the last seven years in health insurance,” Alexander told reporters.

“And then let the leaders see if we can pass it, and hope the House does and that the president signs it.”

Despite some pushback that could still come from conservatives calling the payments an “insurer bailout,” Alexander and Murray hope to cobble together a bipartisan group that agree some continuation of the payments is necessary.

The cost sharing subsidies, which reimburse insurers for giving discounted deductibles and co-pays to low-income customers, have been made by the Trump administration on a month-to-month basis.

Republicans had sued the Obama administration over the payments, calling them unconstitutional, but many have since acknowledged they need to continue at least in the near term to prevent steep premium hikes.

Insurers have asked for long-term certainty on the payments, threatening to hike premiums and leave the ObamaCare markets altogether if they don’t get it.

Democrats, and some Republicans like Alexander, agree Congress should fund the payments, but there’s disagreement on the time frame.

Alexander wants to fund the payments through 2018 while Murray has pushed for multiple years.

“It is critical that we work toward a multiyear solution in order to provide the kind of certainty that will have the most impact on families’ premiums and choices in the marketplaces,” Murray said.

America’s Health Insurance Plans, the nation’s largest insurer trade association, and other stakeholder groups urged Congress to fund the payments through at least 2019.

“Without two years of CSR funding, uncertainty will persist and the Congress will need to address these same issues early next year,” the groups wrote in a letter to the committee Tuesday.

Meanwhile, Republicans say a bipartisan health bill must include changes to ObamaCare’s state waivers so states have more control over what their insurance plans look like.

Alexander said ObamaCare’s waivers should be amended so “states can have more flexibility to devise ways to provide more coverage with more choices and lower costs.”

“It just hasn’t been very appealing to states because it is a difficult tool to use,” he said.

This point was echoed by Pennsylvania’s insurance commissioner Theresa Miller, who called the process to get approved cumbersome.

“Baseline coverage requirements should be kept intact as much as possible … but make it easier for states to respond to market issues,” she said.

For example, it takes at least six months to get a waiver approved with the federal government, which the commissioners said made it difficult to quickly respond to market issues.

But Democrats have been wary of anything they say could result in coverage losses and the availability of less comprehensive insurance plans.

The Senate GOP’s ObamaCare repeal plan, which failed in a dramatic vote with Sen. John McCain (R-Ariz.) joining two other Republicans in opposition, contained language intended to make it easier for states to approve less comprehensive plans.

However, Democrats say that is going in the wrong direction.

We should be “moving forward not backward on affordability, coverage and quality of care,” Murray said.

“We’re all well aware threading this needle won’t be easy,” she said, “but I do believe an agreement that protects patients and families from higher costs and uncertainty, and maintains the guardrails in our current health care system, is possible.”

Several commissioners also recommended setting up a temporary reinsurance program to help insurers with high cost patients with the intent of lowering premiums for healthier ones.

“Congress should enact a federal reinsurance program with a minimum duration of three years,” said Washington state insurance commissioner Mike Kreidler, adding that it would “significantly help stabilize the individual health insurance market.”

But Alexander indicated it’s unlikely for the bill to include reinsurance funding, noting that the U.S. is already trillions in debt.

“If a reinsurance program is such a good idea … why don’t states do it?” he asked, suggesting states impose small fees on every insurance plan sold to help fund it.

Democrats are also pushing for a bill to restore ObamaCare outreach funding after the Trump administration announced drastic cuts to the program.

Alaska’s insurance director Lori Wing-Heier said the cuts concern her because “these programs reduce the number of uninsured citizens and maximize public participation.”

Out-of-Pocket Costs, Financial Distress, and Underinsurance in Cancer Care

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http://jamanetwork.com/journals/jamaoncology/fullarticle/2648318?utm_source=STAT+Newsletters&utm_campaign=cf53ee7567-MR&utm_medium=email&utm_term=0_8cab1d7961-cf53ee7567-149578673

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The financial burden of cancer treatment is a well-established concern.1,2 Owing to cost sharing, even insured patients face financial burden and are at risk for worsened quality of life3 and increased mortality.4 Underinsured patients (those spending more than 10% of their income on health care costs) are a growing population,5 and are at risk given the looming heath policy and coverage changes on the horizon. In this setting, little is known about what expectations patients have regarding those costs and how those cost expectations might impact decision making.

Methods

After approval from the institutional review board at Duke University Medical Center, we conducted a cross-sectional survey study of financial distress and cost expectations among patients with cancer presenting for anticancer therapy. We enrolled a convenience sample of adult patients at a comprehensive cancer center and at 3 affiliated rural oncology clinics. Patients provided written informed consent and were compensated with $10 for completing the survey. Trained interviewers surveyed patients in person.

We abstracted the electronic health record for cancer diagnosis, stage, type of treatment, and duration of treatment at the time of enrollment. Demographics including race and income were obtained from the patient. Patient out-of-pocket expenses were based on patient’s best estimation of recent, averaged monthly costs. We surveyed patients about whether their actual costs met their expectations, and about how much they were willing to pay out-of-pocket for cancer treatment, not including insurance premiums. Financial distress was measured using a validated measure. We measured median relative cost of care, defined as monthly out-of-pocket costs divided by income. Expected financial burden, willingness to pay, and subjective financial distress were dichotomized to assess the impact of unexpected costs and high financial distress. We used hypothesis testing to examine variables associated with burden and distress. Multivariable logistic regression included specific variables of interest along with select variables found to be statistically significant in bivariate testing. Statistical analyses were performed using SAS software (version 9.4, SAS institute).

Results

Of 349 consecutive patients approached, 300 were eligible and agreed to participate, and 3 withdrew (86% response rate). Of the 300 patients, 157 (52%) were men. Patient characteristics, income, and costs are described in the Table along with unadjusted analyses. Forty-nine (16%) patients reported high or overwhelming financial distress (score >7).

The median relative cost of care was 11%. The relative cost of care for patients with high or overwhelming distress was 31% vs 10% for those with no, low, or average financial distress. One hundred eighteen (39%) participants endorsed higher than expected financial burden from cancer care. In unadjusted analysis, unexpected burden was associated with being younger, unmarried, nonwhite, unemployed/not retired, having lower household income, higher costs, colorectal/breast cancer diagnosis, lower quality of life and higher financial distress (Table). In adjusted analysis, experiencing higher than expected financial burden was associated with high or overwhelming financial distress (OR, 4.78; 95% CI, 2.02-11.32; P < .01) and with decreased willingness to pay for cancer care (OR, 0.48; 95% CI, 0.25-0.95; P = .03).

Discussion

More than one-third of insured cancer patients receiving anticancer therapy faced out-of-pocket costs that were greater than expected, and patients with the most distress were underinsured, paying almost one-third of their income in health care-related costs. Patients at risk for unexpected costs had less household income and faced higher out-of-pocket costs.

Facing unexpected treatment costs was associated with lower willingness to pay for care, even when adjusting for financial burden. This suggests that unpreparedness for treatment-related expenses may impact future cost-conscious decision making. Interventions to improve patient health care cost literacy might impact decision making. Indeed, the Institute of Medicine has listed cancer cost-related health literacy as a high priority for future research, and this priority has been included in the Center for Medicare and Medicaid’s Oncology Care Model.6 Future studies should test interventions for cost mitigation through shared decision making.

Outside Of Washington, There Is A New Vital Center In Health Care Reform

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http://healthaffairs.org/blog/2017/07/31/outside-of-washington-there-is-a-new-vital-center-in-health-care-reform/

Larissa Pisney of Denver joins others during a protest outside the office of U.S. Rep. Mike Coffman, R-Colo., over the health care overhaul bill up for a vote in the U.S. House Thursday, May 4, 2017, in Aurora, Colo. (AP Photo/David Zalubowski)

Republicans in Congress are mired in political quicksand. Following passage of the Affordable Care Act (ACA) in 2010, they locked themselves into a promise to repeal and replace it at the behest of ultra-conservative donors and party activists who control the GOP’s nomination process. Since 2010, however, Americans and rank-and-file Republicans increasingly came to expect help meeting the rising costs of medical care and insurance and to accept the ACA’s tangible programs to address these concrete challenges.

The Democrats created their own political trap. They passed the ACA on the promise of making health care affordable but deductibles and rising premiums continued to present a burden to many Americans.

Both parties are missing, however, the vital center on health reform that has formed since 2010. Americans are frustrated with Democrats for not delivering on their promise of affordability, and they are now alarmed with Republican efforts to repeal—instead of improve—the ACA’s coverage of costs.

Tracking Changes In Public Opinion

Most public opinion polls are unable to track these changes in opinion about health care because they are only snapshots, drawn from a moment in time. To remedy this, we have been gathering panel data, tracking the views of the same group of Americans every two years since the ACA’s passage in 2010. This equips us to study how individuals respond to the ACA as they experience or learn more about the law’s provisions over time. Specifically, we conducted four waves of interviews in the two-month period leading up to national elections from 2010 to 2016 when health reform received heightened attention; this avoided the risk of choosing an arbitrary month when health reform might have arbitrarily lost or gained salience.

The first wave was conducted by the Survey Research Institute (SRI) at Cornell University and consisted of a national sample of 1,200 adults. Abt SRBI (now part of Abt Associates) conducted the last three waves, returning to the same individuals. All waves asked identical questions and were administered by telephone, using only landlines in 2010 and adding mobile phones in 2012, 2014, and 2016. Forty-nine percent of the original 2010 survey (587 individuals) responded to all four waves. Survey weights were applied to each survey to match representative demographic targets and allow us to generalize from our panel to the adult population in the United States.

Why Americans Dislike Health Reform

Republicans have been eager to highlight the unpopularity of the Affordable Care Act, also known as “Obamacare.” Exhibit 1 shows that unfavorable assessments of the ACA have steadily increased since its passage. Unfavorability rose from 44 percent in 2010 to 58 percent in 2016.

Exhibit 1: Increasingly Unfavorable Views Of The Affordable Care Act (Percent)

Question: “As you may know, a major health care bill was signed into law in 2010. Given what you know about this law, do you have a generally favorable or generally unfavorable opinion of it, or do you have a neutral opinion, neither favorable nor unfavorable?” Exhibit 1 presents the “unfavorable” responses.

Why are Americans increasingly disenchanted with the ACA? The public’s displeasure emanates to a large extent from frustrations with health care costs. Democrats promised to lower the costs of medical care and insurance with the enactment of the ACA. They did succeed to slow the rate of increase in national health care spending and insulate most subsidized enrollees in its insurance Marketplace from premium increases, as the Congressional Budget Office reports (Note 1). Yet, the costs of medical care remain high, and premiums and deductibles are out of the reach of some Americans.

The source of the public’s rising frustration with health care costs is picked up in Exhibit 2. The first grouping of bars on the left shows increasing frustration with costs for medical treatments that are not covered by insurers. By 2016, 14 percent expressed dissatisfaction with the amount and number of treatments that their insurance covered, a 6-point increase from 2014. One-third of Americans also expressed dissatisfaction in 2016 with the out-of-pocket costs that they were forced to pay because of gaps in their insurance coverage, as shown in the middle cluster. This is an 8-point increase from 2014.

Exhibit 2: Rising Concerns About Affordability (Percent)

Question: Several questions asked respondents to indicate their satisfaction or dissatisfaction with individual features of the health care system—“The number and kind of treatments your health insurance will cover” and “The amount you spend out of pocket on health care costs your insurance doesn’t cover.” A separate item asked respondents to indicate their agreement or disagreement with the statement: “Public officials care about making health care more affordable for people like me.” (Exhibit 2 shows “disagreement” with the statement.)

The public’s disappointment with the persistent burden of health care costs leads it to blame lawmakers for a lack of responsiveness. The bars on the right in Exhibit 2 indicate that a growing majority of Americans disagree with the statement that, “Public officials care about making health care more affordable for people like me.” Fifty-eight percent of Americans disagreed with this statement in 2016, a 10-point increase since 2012.

In addition, the sense that the ACA has not delivered the affordability that Democrats promised may help account for the sharply stronger conclusion in recent years that the ACA’s taxes present a heavier burden. Exhibit 3 shows that the proportion of Americans who believe that their taxes have increased a lot or a little has risen from 43 percent in 2012 to 56 percent in 2016. This growing perception that the ACA has increased taxes rests on inaccurate assumptions. The ACA’s financing primarily relies on two taxes on individuals whose yearly income exceeds $200,000 or for married couples earning more than $250,000—an increase in Medicare’s tax on earnings by 0.9 percent and a new 3.8 percent tax on capital gains from investments. These taxes fall on less than 2 percent of tax filers, according to the non-partisan Tax Policy Center (Note 2).

Exhibit 3: Growing Perception That The Affordable Care Act Increased Taxes (Percent)

Question: “Do you think that the new health care law enacted in 2010 has increased the taxes that you pay, decreased the taxes that you pay, or has it had no impact on the taxes that you pay?”

Americans Oppose Repeal Because They Appreciate The Effects Of Health Reform

Considering the strong public disapproval of repeal, President Donald Trump and congressional Republicans are discovering that it is a mistake to equate the public’s frustrations with the ACA with support for repealing its programs. When respondents reported “unfavorable” views of the law, we followed up with a question asking them whether they would prefer either “repeal[ing] [the ACA] as soon as possible,” or “giving the law more time to have a chance to work, with lawmakers making necessary changes along the way.” In Exhibit 4, we combined those who favored giving it “a chance to work” with those who expressed “favorable” overall views of the law. This shows that since 2010 more Americans favored the law or wanted to give it time to be improved than backed repeal. Although support for repeal inched up since 2010, a greater percentage of Americans consistently favored the ACA and improving it over repeal by a 41-to-37 margin in 2010 and by 49-to-43 in 2016.

Exhibit 4: More Americans Prefer To Keep And Improve The Affordable Care Act Than Repeal It (Percent)

Question: This figure is based on two survey questions. The first is the following: “As you may know, a major health care bill was signed into law in 2010. Given what you know about this law, do you have a generally favorable or generally unfavorable opinion of it, or do you have a neutral opinion, neither favorable nor unfavorable?” Respondents who had an unfavorable view were asked a second question about their view about the law’s future: “The law should be given more time to have a chance to work, with lawmakers making necessary changes along the way, OR the law should be repealed as soon as possible?” The repeal bar reports responses from the second question; the other bar adds together favorable responses in the first question with the “law should be given more time” responses.

Support for keeping and improving the ACA stems from a growing appreciation for its concrete effects. Exhibit 5 shows that rising percentages pinpoint the ACA’s tangible programs as having either “a great deal” or “quite a bit” of an impact on themselves and their family (other options included “some,” “a little,” and “none”). There is greater recognition in 2016 compared to 2010 or 2012 of the impact of allowing parents with insurance to continue to cover their children until they are 26 years old. More than one in five Americans now report that the ACA expanded their access to health insurance. In addition, nearly one in four Americans, 24 percent, voiced appreciation for the impact of the ACA’s assistance to seniors to pay for prescription medications. Moreover, recognition of a personal impact resulting from the ACA’s tax credits and other subsidies to help people purchase health insurance has remained stable since 2014 and is higher than in earlier years.

Exhibit 5: Rising Appreciation Of The Impact Of The Affordable Care Act (Percent)

Question: “I’m going to read to you a list of some of the features of the health care law that was enacted in 2010. For each one, please answer this question: “How much of an impact has this feature had on you and your family: a great deal, quite a bit, some, a little, none?” Respondents are asked about the following features of health reform: coverage of adult children on their parents’ insurance plans until they are 26 years old; access to health insurance or medical care supported or provided by government; help for seniors to pay for prescription drugs; and tax credits and other subsidies to help people pay for health insurance. Exhibit 5 combines “a great deal” and “quite a bit.”

The New Vital Center On Health Reform

Overall evaluations of the ACA follow the partisan pattern that is familiar today: 68 percent of Democrats have favorable views versus 9 percent of Republicans. What stands out, however, is that the ACA’s tangible effects are starting to loosen rigid partisan dividing lines. Exhibit 6 shows the percentage of Americans reporting a personal impact from at least one of the four provisions presented in Exhibit 5. Democratic elected officials enacted the ACA, and, not surprisingly, majorities of rank-and-file Democrats have generally singled out the law’s effects from early on: 51 percent of Democrats reported an impact from at least one of the law’s features in 2010; by 2016, this recognition remained largely stable, inching up to 54 percent. Strikingly, however, the percentage of Republicans perceiving an impact on themselves or their families has increased by 8 percentage points, from 26 percent in 2010 to 34 percent in 2016 despite vociferous GOP attacks on the ACA. Among independents, the proportion soared by 23 points, from 28 percent to 51 percent. These findings indicate that appreciation for the ACA has expanded beyond the ranks of Democratic partisans who were predisposed to favor it; growing numbers of Americans across the political spectrum increasingly value the impacts of health reform in their own lives.

Exhibit 6. Widening Appreciation Of The Affordable Care Act’s Impact (Percent Reporting Impact Of A New Benefit)

Exhibit 6 presents the percentage of respondents who reported that at least one of the four provisions presented in Exhibit 5 had a “great deal” or “quite a bit” of impact on themselves or their family.

The crux of the public discontent with the ACA—and the repeal proposals by Republicans—is the amount paid for insurance coverage. Respondents to the survey appear to share the complaint of ACA critics that insurance costs are too high. After high expectations following the ACA’s enactment, satisfaction with the cost of health coverage has dropped by 10 points—from 73 percent satisfied in 2010 to 63 percent in 2016. This general assessment misses, however, a crucial condition—whether or not individuals are covered by government programs such as Medicare, Medicaid, or a subsidy financed by the ACA. We found a striking pattern among Republicans, Democrats, and independents: By a margin of 20 points or more, individuals with government coverage were consistently more satisfied with the cost of insurance than those who rely on private health plans. For instance, 79 percent of Republicans with government coverage were content with insurance costs as compared to 56 percent without this coverage. Independents outside the sway of either major party expressed the highest satisfaction when experiencing government coverage (100 percent) and exhibit the largest gap between those covered and those without coverage (41 points).

In short, Republican public officials continue to spotlight what they perceive as the disappointment of Americans with ACA coverage, but the reality is that the most dissatisfied are those who lack government insurance. In fact, most Americans (including Republicans) who benefit from government insurance are content with their coverage.

Health Reform’s New Vital Center

Public opinion toward the ACA has been poorly understood because of an apparent contradiction. On the one hand, a growing share of the public harbor unfavorable views of the ACA as a whole, and proponents of repeal have seized on this dissatisfaction to claim a popular mandate. On the other hand, the discontent of Americans stemmed from disappointment with the ACA for not satisfying their expectations of genuine protection from the burden of costs. Far from wanting to be rid of the ACA, Americans are looking to it to deliver more effective protection.

In the immediate aftermath of World War II, the historian Arthur Schlesinger, Jr., wrote of the “vital center” about the direction of America that was supported by both major political parties and most Americans. Despite today’s fractiousness in Washington over health reform, everyday Americans are converging toward a new vital center of support for health care reform.

Awareness of the ACA’s tangible impacts fits into a robust notion of collective responsibility instead of the individualist approach advocated by conservatives. Since the ACA’s passage, nearly nine out of 10 Americans have consistently embraced access to health care as a “basic right.” Not surprisingly, nearly all Democrats embrace the principle of health care as a right. What stands out is that rank-and-file Republicans overwhelming and increasingly hold the same view—rising from 64 percent in 2010 to 72 percent in 2016. Contrary to the position of Washington Republicans, establishing health care as a birthright owed to Americans is now widely shared. Republican proposals, such as those that would allow states to opt out of some of the ACA’s core consumer protections (including those guaranteeing coverage for individuals with preexisting medical conditions), may well tap into this strain of public opinion and provoke broad opposition.

Elected officials in Washington and, particularly, steadfast opponents of health reform are sliding to the margins of public opinion. The daily problems that Americans face in paying for medical care and insurance mean that pragmatism is trumping ideology. In the past, federal lawmakers responded to broad public agreement and worked across the aisle to improve the flaws in the original legislation that produced Social Security in 1935 and Medicare in 1965. The question today is whether Washington can return to that pragmatic tradition and catch up to the emerging vital center in Americans’ attitudes toward health reform.

Note 1

Congressional Budget Office. American Health Care Act: cost estimate. Washington (DC): CBO; 2017 Mar 13.

Note 2

Tax Policy Center. Tax units above and below the $250,000/$200,000 threshold, 2013–2022. Washington (DC): TPC; 2012 Nov 26

Scripps CEO Chris Van Gorder responds to healthcare vote

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http://www.beckershospitalreview.com/hospital-management-administration/scripps-ceo-chris-van-gorder-responds-to-healthcare-vote.html

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When Sen. John McCain, R-Ariz., cast his decisive vote Thursday night to stall GOP efforts to repeal the ACA, Chris Van Gorder, president and CEO of San Diego-based Scripps Health, took it not as a rejection of specific policies but instead a rejection of partisan politics.

In a written statement, Mr. Van Gorder emphasized that while healthcare has been subject to divisive political rhetoric during recent reform efforts, it is vital not to lose sight of the actual goal of healthcare professionals — to provide patients with quality care.

“The health care vote in Washington is important, but not as important as what we do every day and ensuring we’re able to do it,” says Mr. Van Gorder. “For now at least, the ACA will continue with its current provisions for care delivery. Despite its challenges with reduced reimbursements, this will provide us some increased stability as we plan for the future.”

Mr. Van Gorder points out that the political process is vital to deciding how care is paid for and delivered, and he encourages politicians to work across the aisle to craft legislation that provides Americans with robust coverage.

“That said, when it comes to health care legislation, representatives from both parties agree the ACA needs to be changed. But any healthcare bill passed unilaterally by one party — whether it’s the ACA in 2010 or repeal/replace in 2017 — will not stand the test of time,” said Mr. Van Gorder. “Something as complex, life changing and personal as healthcare deserves thoughtful consideration and debate and a true dialogue with those on the front lines of health care delivery.”

Trump on tricky legal ground with ‘Obamacare’ threat

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http://abcnews.go.com/Health/wireStory/trump-tricky-legal-ground-obamacare-threat-48962076

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President Donald Trump’s threat to stop billions of dollars in government payments to insurers and force the collapse of “Obamacare” could put the government in a legal bind.

Law experts say he’d be handing insurers a solid court case, while undermining his own leverage to compel Democrats to negotiate, especially if premiums jump by 20 percent as expected after such a move.

“Trump thinks he’s holding all the cards. But Democrats know what’s in his hand, and he’s got a pair of twos,” said University of Michigan law professor Nicholas Bagley. Democrats “aren’t about to agree to dismantle the Affordable Care Act just because Trump makes a reckless bet.”

For months, the president has been threatening to stop payments that reimburse insurers for providing required financial assistance to low-income consumers, reducing their copays and deductibles.

Administration officials say the decision could come any day.

Playing defense, some insurers are preemptively raising premiums for next year. For example, BlueCross BlueShield of Arizona this week announced a 7.2 percent average hike for 2018. But there would likely be no increase if the subsidies are guaranteed, the company said. And BlueCross BlueShield of North Carolina earlier requested a 22.9 percent average increase. With the subsidies, the company said that would have been 8.8 percent.

The “cost-sharing” subsidies are under a legal cloud because of a dispute over whether the Obama health care law properly approved the payments. Other parts of the health care law, however, clearly direct the government to reimburse insurers.

With the issue unresolved, the Trump administration has been paying insurers each month, as the Obama administration had done previously.

Trump returned to the subject last week after the GOP drive to repeal the health care law fell apart in the Senate, tweeting, “As I said from the beginning, let ObamaCare implode, then deal. Watch!”

He elaborated in another tweet, “If a new HealthCare Bill is not approved quickly, BAILOUTS for Insurance Companies…will end very soon!”

It’s not accurate to call the cost-sharing subsidies a bailout, said Tim Jost, a professor emeritus at Washington and Lee University School of Law in Virginia.

“They are no more a bailout than payments made by the government to a private company for building a bomber,” he said.

That’s at the root of the Trump administration’s potential legal problem if the president makes good on this threat.

The health law clearly requires insurers to help low-income consumers with their copays and deductibles. Nearly 3 in 5 HealthCare.gov customers qualify for the assistance, which can reduce a deductible of $3,500 to several hundred dollars. The annual cost to the government is about $7 billion.

The law also specifies that the government shall reimburse insurers for the cost-sharing assistance that they provide.

Nonetheless, the payments remain under a cloud because of a disagreement over whether they were properly approved in the health law, by providing an “appropriation.”

The Constitution says the government shall not spend money without a congressional appropriation.

Think of an appropriation as an electronic instruction to your bank to pay a recurring monthly bill. You fully intend to pay, and the money you’ve budgeted is in your account. But the payment will not go out unless you specifically direct your bank to send it.

House Republicans trying to thwart the ACA sued the Obama administration in federal court in Washington, arguing that the law lacked specific language appropriating the cost-sharing subsidies.

A district court judge agreed with House Republicans, and now the case is on hold before the U.S. appeals court in Washington. A group of state attorneys general is asking the appeals court to let them join the case, in defense of the subsidies.

Both Bagley and Jost have followed the matter closely, and disagree on whether the health law properly approved the payments to insurers. Bagley says it did not; while Jost says it did.

However, the two experts agree that insurers would have a solid lawsuit if Trump stops the payments. Insurers could sue in the U.S. Court of Federal Claims, which hears claims for money against the government.

“The ACA promised to make these payments — that could not be clearer — and Congress has done nothing to limit that promise,” said Bagley.

“I think there would very likely be litigation if the Trump administration tries to cut off the payments,” said Jost.

Another way to resolve it: Congress could appropriate the money, even if temporarily, for a couple of years. Some prominent GOP lawmakers have expressed support for that.

If the president makes good on his threat, experts estimate that premiums for a standard “silver” plan would increase by about 19 percent. Insurers could recover the cost-sharing money by raising premiums, since those are also subsidized by the ACA, and there’s no question about their appropriation.

But millions of people who buy individual health care policies without any financial assistance from the government would face prohibitive cost increases.

And more insurers might decide to leave already shaky markets.

“This is not a game,” said California Attorney General Xavier Becerra. “Millions of people would not be able to afford health insurance for their families.”

When High Deductibles Hurt: Even Insured Patients Postpone Care

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When High Deductibles Hurt: Even Insured Patients Postpone Care

In November 2015, Tina Heck was in her garage lifting 40-pound bags of wood pellets to fuel her heating stove, when something went very wrong with her back.

“The next day, I could barely walk,” said the 55-year-old who lives on an acre of land in Nevada City, Calif., 60 miles northeast of Sacramento. The cause: a bulging disc in her lower spine, which shoots pain down her leg and makes her back stiff.

The injury wasn’t Heck’s only setback. The initial MRI, cortisone shot and doctor visit cost her $3,000 because her health plan requires her to shell out $5,000 before insurer payments kick in. She doesn’t want to explore other treatment options because of that high deductible. Heck, who makes $68,000 a year in marketing for a nonprofit, is not willing to add more debt on top of her credit-card and mortgage payments.

“I’m in pain every day,” she said, but “it’s not bad enough to go into debt.”

The concept behind high-deductible plans was to lower premiums and reduce overall health costs by ensuring that consumers shared the financial burden of their own health care decisions. But evidence is mounting: High deductibles have actually forced people to delay care that could prevent health emergencies later or improve their quality of life.

Regardless of what happens to the Affordable Care Act, such plans are likely to become more widespread as health care costs continue to rise. Just over half of people with health plans from their employers now have a deductible of $1,000 or more, up from 10% in 2006, according to the Kaiser Family Foundation. (Kaiser Health News, which produces California Healthline, is an editorially independent program of the foundation.)

“People who have medical problems that can be put off tend to do so much more now because of the high deductible,” said Dr. Ted Mazer, a San-Diego based head and neck surgeon who is president-elect of the California Medical Association.

Dr. Mazer blurb: Dr. Ted Mazer, president-elect of the California Medical Association, says some of his patients delay various tests and treatments because of the high deductibles and copays associated with their health plans.  (Courtesy of Kurt Kohnen)

Annual deductibles can amount to many thousands of dollars on some plans. Covered California bronze plans, with the lowest premiums available on the exchange, carry deductibles of $6,300 for an individual and $12,600 for a family.

A Kaiser Family Foundation survey released this year showed that 43% of insured people reported having trouble paying their deductible, up from 34% in 2015. (Kaiser Health News, which produces California Healthline, is an editorially independent part of the foundation.)

In one study by the liberal advocacy group Families USA, more than a quarter of people in high-deductible plans delayed some type of medical service such as a doctor visit or diagnostic test. And 44% of adults with high out-of-pocket expenses put off medical care, according to a nonpartisan Commonwealth Fund study.

Another recent study by researchers at the University of California-Berkeley and Harvard University found that people with high-deductible plans spent 42% less on health care before meeting their deductibles, primarily by reducing the amount of health care they received, not by shopping around for a better price.

Jonathan Kolstad, associate professor of economics at UC-Berkeley’s business school and co-author of the study, said patients dropped both needed care, such as diabetes medication, and potentially unnecessary care, such as imaging for headaches.

“Left to their own devices, people [in high-deductible plans] seem ill-equipped to make their own decisions” about what care they need, and what care they don’t, Kolstad said.

Mazer said that, in his practice, people have delayed all kinds of treatment that may not save “life or limb” but involved medical conditions that interfered with breathing or sleeping.

He said he’s had patients who needed a biopsy to determine if an abnormal vocal cord was cancerous, and they put it off because of the cost.

“I have to make the phone call and say, ‘We’re looking at a mass that may be malignant and if you put it off you’re putting yourself at risk,’ ” Mazer said. “And I’ll tell you, we’ve had people take that risk.”

Recent Republican proposals to repeal Obamacare have promoted the use of high-deductible plans by allowing people to put away more tax-free dollars into the health savings accounts that consumers use in conjunction with those plans. And experts said the proposals would also spur the growth of these plans — by cutting the subsidies available through exchanges, inducing customers to look for cheaper plans with higher deductibles.

Conservatives say insurance that promotes personal financial responsibility helps tamp down overall health costs. Hoover Institution analysts, for example, argue that high deductibles encourage patients to “choose wisely.”

But new evidence suggests that putting off care can be dangerous and, eventually, more costly to patients.

A March 2017 Harvard study found that low-income patients with diabetes who had high-deductible plans delayed visits for complications such as skin infections and pneumonia. They wound up getting more expensive care later on.

Patients may try to treat their conditions at home, or hope they go away — but if that approach fails, “they then have to seek care at the emergency department,” said Frank Wharam, a health policy researcher at Harvard Medical School and lead author of the study.

Wharam said the middle-income earners he studied didn’t suffer any adverse effects from health care choices they made in high-deductible plans, adding that more studies are needed on that group.

Sabrina Corlette, from the Georgetown University Center on Health Insurance Reforms, said that until national health policy addresses the “underlying costs of care,” patients in high-deductible plans will likely be stuck with the difficult task of figuring out what medical attention they need or can afford.

Heck said the symptoms from her back injury have changed — the pain is in a different part of the body than it was right after the injury. But she’s not even considering a trip to a nearby clinic for a new assessment. That would require another MRI, she said, which could cost at least $1,500, and it might not even help her. If her deductible weren’t as high, she’d feel “freer” to explore other health care options, she said.

For now, she’s taking a lot of ibuprofen and seeing a chiropractor.

“A lot of people get stuck in this place,” she said.

Would your plan cover John McCain’s treatment?

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https://www.healthinsurance.org/blog/2017/07/25/would-your-plan-cover-john-mccains-treatment/

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The Arizona Senator’s health plan will ensure top-notch glioblastoma treatment, but how would Americans with other health coverage fare?

Last week, we heard the sad news that Senator John McCain has been diagnosed with glioblastoma. McCain had surgery at Phoenix’s Mayo Clinic in mid-July, and it’s expected that he’ll also receive chemotherapy and radiation, along with other potential treatments. Senator McCain has proven time and again that he’s tough as nails, and appears to be facing this latest battle head-on. One thing that he likely has on his side is top-notch health insurance.

McCain is 80, which means he’s presumably been on Medicare for 15 years. Currently serving federal lawmakers are able to obtain employer-subsidized coverage in the Washington DC small-business exchange, and they can have this coverage in addition to Medicare.

How good is McCain’s coverage?

McCain hasn’t said publicly exactly what insurance he has, and his office has not responded to my inquiry. But the most likely scenario is that he has Medicare plus employer-sponsored coverage through the DC exchange – a very comprehensive benefits package.

There are certainly lots of other people who have similar coverage arrangements – either because they’re still working after turning 65, like McCain, or because they receive generous retiree health benefits that supplement their Medicare coverage. For those who don’t, there are private Medicare supplements available that cover virtually all of the out-of-pocket costs associated with Medicare.

But health coverage in the United States is a bit of a mixed bag, with some people having much better coverage than others. A serious illness tends to shine a spotlight on the flaws that exist in some health plans, so let’s take a look at how the average American facing a glioblastoma diagnosis would fare under various health plans.

Employer-sponsored health insurance

Most employer-sponsored health insurance plans provide pretty solid health coverage. According to a 2016 Kaiser Family Foundation analysis, the average deductible for covered workers was about $1,500, and that doesn’t count the 17 percent of covered workers whose plans had no deductible at all.

In addition, the average employer paid more than two-thirds of the total premiums. And the tax exclusion of employer-sponsored insurance premiums amounts to a subsidy that cost the federal government $250 billion in fiscal year 2016.

However, employer-sponsored health insurance is, by definition, linked to employment. A person going through a serious illness like glioblastoma might not be able to continue working, depending on the specifics of the treatment.

As long as the employer has at least 20 employees, the employee will be able to continue the coverage under COBRA for 18 months, even if he or she is unable to work. But COBRA is expensive, as the employer contribution to the premiums and the tax exclusion of the premiums are eliminated. (COBRA premiums are counted as a medical expense for the purpose of itemized medical deductions, but only expenses that exceed 10 percent of your income can be deducted this way.)

Although most employer-sponsored plans provide good coverage, that’s due in part to the ACA. It was not uncommon – particularly in low-wage, high turnover industries – for employers to offer “mini-meds” before the ACA, with exceedingly low benefit caps. (The ACA’s ban on lifetime and annual benefit limits means that these plans are no longer offered to employees.)

A mini-med with a $2,000 or $5,000 annual benefit maximum would not have done much in the face of glioblastoma. Vox reported that just the initial craniotomy to remove a blood clot above Senator McCain’s eye would likely have been billed at more than $76,000. And that was before the cancer diagnosis.

ACA-compliant individual market coverage

The pre-ACA individual market included plenty of solid plans. But dubious coverage also abounded, and regulations varied considerably from one state to another.

The ACA imposed a bevy of regulations on the individual health insurance market, bringing all new (as of 2014) plans up at least a basic minimum standard. Individual major medical coverage can no longer be sold without the ACA’s essential health benefits.

And for those benefits, insurers cannot limit how much they’ll pay during a year or over the course of an insured’s lifetime. (Sadly, another Arizona resident with cancer, Arijit Guha, died in 2013 at age 32. Guha’s health insurance plan had a $300,000 lifetime cap – which is no longer allowed, thanks to the ACA – and his treatment, including chemotherapy that cost $11,000 per session, quickly exceeded that limit.)

Individual-market plans also cannot discriminate against people with pre-existing conditions, either by charging them higher prices or declining their applications (both of those were standard practice in nearly every state prior to 2014). Notably, Senator McCain has a history of melanoma, which would have virtually guaranteed a declined application in the individual market pre-ACA if he had been in need of non-group coverage for some reason.

A person with ACA-compliant individual market coverage would have solid coverage for glioblastoma. The maximum out-of-pocket costs during 2017 would be $7,150, although most plans have out-of-pocket maximums below that threshold. And 57 percent of people who enrolled through the exchanges in 2017 have cost-sharing subsidies, which further reduce the out-of-pocket costs.

The American Cancer Society explains in more detail how the ACA improves access to care for people with cancer. But the short story is that a person facing glioblastoma with a 2017 individual health insurance policy has a much more secure financial safety net than someone with the same diagnosis a decade ago.

Medicaid

Medicaid provides comprehensive coverage. Although the benefits available under traditional Medicaid vary from one state to another, Medicaid expansion coverage is required to include the ACA’s essential health benefits. (The Senate’s Better Care Reconciliation Act – BCRA – would eliminate this requirement after 2019.)

Medicaid has minimal cost-sharing, limited to no more than 5 percent of a family’s annual income.

It’s true that compared with private health insurance and Medicare, fewer medical providers accept Medicaid. But the majority do work with Medicaid. (According to a Kaiser Family Foundation analysis, about 69 percent of office-based physicians accept new Medicaid patients, while about 85 percent accept new privately-insured patients.)

Short-term health insurance

The ACA implemented regulations that apply to virtually all types of health insurance. But some plans are not regulated by the law, including short-term health insurance.

As evidenced by the name, short-term plans are limited in their duration. As of 2017, a short-term plan can last no more than three months, although people who remain healthy can purchase a second short-term plan after the first one ends.

Short-term plans do not cover pre-existing conditions. So if you were to be diagnosed with glioblastoma while covered under a short-term plan, the first thing the insurer would do is go back through your medical records to make sure that you didn’t have any symptoms prior to enrolling in the plan.

Assuming you were healthy before you enrolled, your short-term plan would start to cover your treatments. But you would be facing a looming and inflexible coverage termination date, along with annual and lifetime benefit maximums. Short-term plans vary considerably in quality – some have lifetime benefit maximums of $250,000 or less, while others provide benefits well in excess of a million dollars. In the case of a glioblastoma diagnosis, coverage would end when the policy reached its predetermined end date, or when you hit your benefit maximum – whichever happened first.

Either way, you’d want to hope that you had other coverage already lined up and ready to go at that point. The cancer diagnosis would make it impossible to obtain another short-term policy.

And since a short-term plan is not considered minimum essential coverage, the termination of the short-term policy would not trigger a special enrollment period for individual or employer-sponsored insurance. You would still be able to enroll in a regular individual-market plan, or an employer plan if you’re eligible for one, during regular annual open enrollment. But you might experience a significant gap in coverage, which can be disastrous in the middle of cancer treatment.

A limited-benefit plan

Limited-benefit plans are another category of coverage that’s not regulated by the ACA (despite attempts by the Obama Administration to place some regulations on certain types of fixed indemnity coverage).

Fixed indemnity means that the plan pays a specific dollar amount if the insured has a covered claim. For example, the plan might pay $1,000 per day for hospitalization, or $50 for a doctor visit. There’s no cap on how much the patient has to pay, and these plans often have very low annual and lifetime benefit limits.

So imagine a plan that will pay $2,000 per day for hospitalization, for up to 25 days. It will also pay $2,500 for an outpatient surgical procedure and $2,500 for an inpatient surgical procedure. And it will pay $625 for anesthesia, but it does not cover prescriptions (these numbers are from a real plan currently available in the limited benefit market).

Remember that McCain’s craniotomy – before the glioblastoma was even diagnosed – likely cost $70,000. He was home very soon after the surgery, so if he was hospitalized at all, it wasn’t more than a day or two. A limited benefit plan like the one described above would have paid $2,000 for each day in the hospital (which amounts to zero dollars if the procedure didn’t result in an inpatient stay), $2,500 for the surgery, and $625 for the anesthesia. That would leave a sizeable chunk of the $70,000 bill as the patient’s responsibility.

And all of that is before the treatment for the glioblastoma even begins.

A Cruz Amendment plan

In mid-July, Senator Ted Cruz introduced an amendment to the BCRA aimed at reducing regulations on health insurance plans. The Cruz Amendment, if included in the BCRA, would allow insurers to offer non-ACA-compliant plans as long as they also offered at least one Silver plan, one Gold plan, and one plan that complies with the BCRA’s benchmark standards (58 percent actuarial value).

The non-compliant plans would likely range from decent to terrible, since they would have wide latitude in terms of the consumer protections they’d be able to waive. Essentially, it would be a return to the pre-ACA days when there was more of an “anything goes” approach to health insurance. Plans would be available without essential health benefits, would not have to cover pre-existing conditions, and could be offered with higher out-of-pocket limits than ACA compliant plans.

These plans would likely appeal to healthy people, as they would be less expensive than ACA compliant plans. But a person who seems perfectly healthy can be diagnosed with glioblastoma, at which point the holes in the coverage become glaringly apparent.

What about those who lack McCain’s coverage

In glioblastoma, Senator McCain is facing a fierce battle, and our hearts go out to him and his family. But thanks to McCain’s health coverage, he won’t have to worry about how to pay for his treatment. I’m glad he has that health coverage.

Senator McCain is not alone in his battle. There are more than 12,000 Americans who will be diagnosed with glioblastoma this year. Unfortunately, many of them do not have the level of health coverage that McCain has. Even with the best health insurance, the diagnosis plunges each family into an immensely challenging situation. With lesser – or no – coverage, the challenge becomes even more insurmountable.

Nobody deserves cancer. And nobody deserves to have to fight cancer with less-than-adequate health insurance. With our current medical know-how, we can’t keep everyone from getting cancer. But we can make sure that as many people as possible are covered by high-quality health insurance. We owe it to all the lesser-known John McCains out there to work towards that goal.

That means pushing back against any sort of “reform” that would result in fewer people with insurance. It also means rejecting proposals that would allow junk insurance plans to flood the market, lulling consumers into a false sense of security – until they’re diagnosed with brain cancer.

 

GOP wrestles with soaring deductibles in healthcare bill

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GOP wrestles with soaring deductibles in healthcare bill

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Senate Republicans have run into another problem in passing their ObamaCare replacement bill: It could increase deductibles by thousands of dollars, potentially alienating moderates who are already skeptical of the bill.

An analysis released Thursday by the nonpartisan Congressional Budget Office (CBO) concluded that a single policyholder purchasing a standard benchmark plan under the GOP bill could face a deductible of $13,000 in 2026.

Under current law, an individual making $56,800 would have a deductible of $5,000, while someone making $26,500 would have an $800 deductible.

A higher deductible is the tradeoff Republicans made when they decided that lowering premiums would be a top priority for their legislation; plans with lower premiums generally have higher deductibles.

“The way we come together, the way we bring together senators all across the ideological spectrum, is focusing on lowering premiums,” Sen. Ted Cruz (R-Texas) said on Fox News on Friday.

“If we’re lowering premiums, that’s a win for everyone.”

Deductibles could become so high under the GOP plan, the CBO said, that many low-income people might decide not to purchase a health insurance plan, even if the premiums were low.

That could be an issue for moderates who have worried about coverage losses, especially for those who gained coverage through ObamaCare’s Medicaid expansion.

The Republican legislation ends the expansion by 2023, and those people will be eligible for tax credits to buy insurance under the GOP plan.

Under the Senate bill, the tax credits for purchasing coverage are tied to ObamaCare’s less generous “bronze” plans that have lower premiums and higher deductibles.

Another factor driving the higher deductibles under the Republican proposal, according to the CBO, is the elimination of ObamaCare insurer payments known as cost sharing reduction subsidies. These payments reimburse insurers for giving discounted deductibles to low-income people.

In an attempt to address the issue, the White House is trying to win over moderates by proposing to allow states to use some Medicaid funding to help low-income people pay for their deductibles.

Higher deductibles for low-income people are a concern, said Sen. Bill Cassidy (R-La.), but he hopes the new White House proposal will fix that.

Senate Republican leaders are also considering offering $200 billion to states that expanded Medicaid, which would be funded by leaving in two of ObamaCare’s taxes on high earners.

That money would come in addition to $132 billion the revised bill already sets aside for a long-term state innovation fund and $45 billion to treat opioid addiction.

“If there’s enough to make it real that someone who is lower-income can get the assistance they need to afford insurance, then that matters,” Cassidy told reporters Thursday.

Sen. Mike Rounds (R-S.D.) said the purpose of leaving those taxes in was to “redistribute” that money to people facing higher costs under the bill.

“What we’re trying to do is allow more local control in some areas so individual states can do some things to help people based on what their needs are,” he said.

“That’s why we kept some of that tax revenue in place. So we can redistribute some of that money to help them because they have no place else to go.”

But some lawmakers question whether the additional funding would make a difference.

While the proposal would add $200 billion in funding, the legislation would cut $756 billion from Medicaid over the next decade, which includes the rollback of the expansion.

“As long as we are fundamentally changing Medicaid and taking some $700 billion out of the program, I do not see myself supporting a bill that does that,” Sen. Susan Collins (R-Maine) told reporters Thursday.

The CBO noted in its score that funding provided to states for stabilization would likely be used to reduce premiums, not deductibles, though the analysis did not include the additional $200 billion.

“The CBO expects that most of these funds would be used to lower premiums. There’s not a lot of money left over for cost-sharing,” said Cynthia Cox, an insurance expert with the Kaiser Family Foundation.