We had a whole other video planned for today but we have to talk about the Cassidy-Graham bill, which is getting closer to passing despite our predictions last week.
Tag Archives: Medicaid Expansion
What Graham-Cassidy means for pre-existing conditions
https://www.axios.com/what-graham-cassidy-really-means-for-pre-existing-conditions-2487720743.html
Jimmy Kimmel’s takedown of Sen. Bill Cassidy, and Cassidy’s response, ripped open the question of whether the GOP’s latest health reform bill protects people with pre-existing conditions. Cassidy and co-sponsor Sen. Lindsey Graham insist it does — as did President Trump in a tweet last night — but experts say that’s not really the case.
The bottom line: The bill’s funding cuts could pressure states — even blue states — to waive protections for sick people, as a way to keep premium increases in check. Older, sicker people in every state could end up paying more as states try to make up for a funding shortfall.
What the bill does: The bill wouldn’t repeal the Affordable Care Act’s rules about pre-existing conditions. But they might end up only existing on paper, the Kaiser Family Foundation’s Larry Levitt said.
Graham-Cassidy doesn’t let states waive the part of the Affordable Care Act that says insurers have to cover sick people. But it does allow states to opt out of several other ACA rules that can cause people with pre-existing conditions to pay more for their health care. Those provisions include:
- The ban on charging sick people higher premiums than healthy people.
- The requirement that insurers cover “essential health benefits,” including prescription drugs. People who need expensive drugs might not have access to a plan that covers those drugs, requiring them to pay out of pocket.
- Services that aren’t “essential” benefits aren’t subject to the ACA’s ban on annual and lifetime limits.
- The bill also would also loosen rules about how much insurers can raise their premiums because of a customer’s age. (Older people are more likely to have pre-existing conditions.)
What supporters will argue: The bill requires states to say how their waivers would provide affordable and accessible coverage for people with pre-existing conditions. But there’s no definition of what that means, and there’s also no enforcement mechanism.
- “The bottom line is these protections are much more at risk under this bill than they are now,” said Cori Uccello, a senior health fellow with the American Academy of Actuaries.
Another level: At least theoretically, because the bill gives states so much control, a more liberal state like California might choose to preserve more of the ACA’s regulations than, say, Alabama. But this bill would radically redistribute federal health care funding — generally away from blue and purple states and toward red states. Those cuts could back blue states into seeking more expansive waivers.
- Caroline Pearson of Avalere told me: “if you have less money, you either cover fewer people, or you cover the same amount of people with less generous coverage. People with pre existing conditions are very reliant on having access to affordable insurance and need insurance that is comprehensive. So if a bill reduces the availability of comprehensive insurance, people with chronic conditions are going to be disproportionately harmed.”
Cassidy-Graham’s Waiver Authority Would Gut Protections for People with Pre-Existing Conditions
The revised Affordable Care Act (ACA) repeal plan from Senators Bill Cassidy and Lindsey Graham, which is also backed by Senators Dean Heller and Ron Johnson, would give states broad waiver authority to eliminate the ACA’s core protections for people with pre-existing health conditions. These waivers would come on top of the proposal’s elimination of the ACA’s marketplace subsidies and Medicaid expansion, its radical restructuring of the rest of the Medicaid program, and its large cuts to total federal funding for health insurance coverage.
Specifically, a little-noticed provision of the block grant funding states would receive under the plan would let them obtain waivers of ACA pre-existing conditions protections and benefit standards for any insurance plan subsidized by block grant funding. For example, a state that used a small portion of its block grant funding to provide even tiny subsidies to all individual market plans could then waive these protections for its entire individual market. Likewise, states that used block grant funding to offer or subsidize coverage for low-income people could offer plans with large gaps in benefits. States seeking waivers would have to explain how they “intend” to maintain access to coverage for people with pre-existing conditions, but they wouldn’t have to prove that their waivers would actually do so.
In particular, states could waive the ACA’s:
- Prohibitions against insurance companies charging people higher premiums based on their health status. While insurers would still be required to offer coverage to people with pre-existing conditions, they could offer them plans with unaffordable premiums of thousands or tens of thousands of dollars per month. For consumers, an offer like that is no different than a coverage denial.
- Requirements that plans cover “essential health benefits.” Before the ACA introduced the requirement that all plans cover a defined set of basic services, 75 percent of individual market plans excluded maternity coverage, 45 percent excluded substance use treatment, and 38 percent excluded mental health care, according to analysis by the Kaiser Family Foundation. Under the Cassidy-Graham proposal, states could let insurers restore these exclusions, leaving many people — especially those with pre-existing conditions — without access to the health services they need.
The waiver authority included in the Cassidy-Graham plan is similar to the so-called “MacArthur amendment” waivers that were included in the House-passed ACA repeal bill. Analyzing those waivers, the Congressional Budget Office concluded:
- States accounting for one-sixth of the nation’s population would choose to let insurers charge higher premiums based on health status. In those states, “less healthy individuals (including those with preexisting or newly acquired medical conditions) would be unable to purchase comprehensive coverage with premiums close to those under current law and might not be able to purchase coverage at all [emphasis added].”
- States accounting for half of the nation’s population would choose to let insurers exclude essential health benefits. In those states, “services or benefits likely to be excluded … include maternity care, mental health and substance abuse benefits, rehabilitative and habilitative services, and pediatric dental benefits.” People needing these services “would face increases in their out-of-pocket costs. Some people would have increases of thousands of dollars in a year.”
Announcing their revised plan, Senators Cassidy and Graham explained that they sought to revise their prior legislation to accomplish the goal of letting states waive the ACA’s core consumer protections. Apparently, they largely succeeded: if their bill were adopted, millions of people with pre-existing conditions would lose access to these protections, and, as a result, would lose access to needed coverage and care.
5 Ways the Graham-Cassidy Proposal Puts Medicaid Coverage At Risk
5 Ways the Graham-Cassidy Proposal Puts Medicaid Coverage At Risk
The Graham-Cassidy proposal to repeal and replace the Affordable Care Act (ACA) is reviving the federal health reform debate and could come up for a vote in the Senate in the next two weeks before the budget reconciliation authority expires on September 30. The Graham-Cassidy proposal goes beyond the American Health Care Act (AHCA) passed by the House in May and the Better Care Reconciliation Act (BCRA) that failed in the Senate in July. The Graham-Cassidy proposal revamps and cuts Medicaid, redistributes federal funds across states, and eliminates coverage for millions of poor Americans as described below:
- Ends federal funding for current ACA coverage and partially replaces that funding with a block grant that expires after 2026. The proposal ends both the authority to cover childless adults and funding for the ACA Medicaid expansion that covers 15 million adults. Under Graham-Cassidy, a new block grant, the “Market-Based Health Care Grant Program,” combines federal funds for the ACA Medicaid expansion, premium and cost sharing subsidies in the Marketplace, and states’ Basic Health Plans for 2020-2026. Capped nationally, the block grant would be lower than ACA spending under current law and would end after 2026. States would need to replace federal dollars or roll back coverage. Neither the AHCA nor the BCRA included expiration dates for ACA-related federal funds or eliminated the ability for states to cover childless adults through Medicaid.
- Massively redistributes federal funding from Medicaid expansion states to non-expansion states through the block grant program penalizing states that broadened coverage. In 2020, block grant funds would be distributed based on federal spending in states for ACA Medicaid and Marketplace coverage. By 2026, funding would go to states according to the states’ portion of the population with incomes between 50% and 138% of poverty; the new allocation is phased in over the 2021-2025 period. The Secretary has the authority to make other adjustments to the allocation. This allocation would result in a large redistribution of ACA funding by 2026, away from states that adopted the Medicaid expansion and redirecting funding to states that did not. No funding is provided beyond 2026.
- Prohibits Medicaid coverage for childless adults and allows states to use limited block grant funds to purchase private coverage for traditional Medicaid populations. States can use funds under the block grant to provide tax credits and/or cost-sharing reductions for individual market coverage, make direct payments to providers, or provide coverage for traditional Medicaid populations through private insurance. The proposal limits the amount of block grant funds that a state could use for traditional Medicaid populations to 15% of its allotment (or 20% under a special waiver). These limits would shift coverage and funds for many low-income adults from Medicaid to individual market coverage. Under current law, 60% of federal ACA coverage funding is currently for the Medicaid expansion (covering parents and childless adults). Medicaid coverage is typically more comprehensive, less expensive and has more financial protections compared to private insurance. The proposal also allows states to roll back individual market protections related to premium pricing, including allowing premium rating based on health status, and benefits currently in the ACA.
- Caps and redistributes federal funds to states for the traditional Medicaid program for more than 60 million low-income children, parents, people with disabilities and the elderly. Similar to the BCRA and AHCA, the proposal establishes a Medicaid per enrollee cap as the default for federal financing based on a complicated formula tied to different inflation rates. As a result, federal Medicaid financing would grow more slowly than estimates under current law. In addition to overall spending limits, similar to the BCRA, the proposal would give the HHS Secretary discretion to further redistribute capped federal funds across states by making adjustments to states with high or low per enrollee spending.
- Eliminates federal funding for states to cover Medicaid family planning at Planned Parenthood clinics for one year. Additional funding restrictions include limits on states’ ability to use provider tax revenue to finance Medicaid as well as the termination of the enhanced match for the Community First Choice attendant care program for seniors and people with disabilities. Enrollment barriers include the option for states to condition Medicaid eligibility on a work requirement and to conduct more frequent redeterminations.
Much is at stake for low-income Americans and states in the Graham-Cassidy proposal. The recent debate over the AHCA and the BCRA has shown the difficulty of making major changes that affect coverage for over 70 million Americans and reduce federal funding for Medicaid. Medicaid has broad support and majorities across political parties say Medicaid is working well. More than half of the states have a strong stake in continuing the ACA Medicaid expansion as it has provided coverage to millions of low-income residents, reduced the uninsured and produced net fiscal benefits to states. Graham-Cassidy prohibits states from using Medicaid to provide coverage to childless adults. With regard to Medicaid financing changes, caps on federal funding could shift costs to states and result in less fiscal flexibility for states. States with challenging demographics (like an aging population), high health care needs (like those hardest hit by the opioid epidemic), high cost markets or states that operate efficient programs may have the hardest time responding to federal caps on Medicaid spending. Faced with substantially reduced federal funding, states would face difficult choices: raise revenue, reduce spending in other areas, or cut Medicaid provider payments, optional benefits, and/or optional coverage groups.
Last-Ditch Effort By Republicans To Replace ACA: What You Need To Know
http://khn.org/news/last-ditch-gop-effort-to-replace-aca-5-things-you-need-to-know/
Republican efforts in Congress to “repeal and replace” the federal Affordable Care Act are back from the dead. Again.
While the chances for this last-ditch measure appear iffy, many GOP senators are rallying around a proposal by Sens. Lindsey Graham (R-S.C.) and Bill Cassidy (R-La.), along with Sens. Dean Heller (R-Nev.) and Ron Johnson (R-Wis.)
They are racing the clock to round up the needed 50 votes — and there are 52 Senate Republicans.
An earlier attempt to replace the ACA this summer fell just one vote short when Sens. Susan Collins (R-Maine), Lisa Murkowski (R-Alaska) and John McCain (R-Ariz.) voted against it. The latest push is setting off a massive guessing game on Capitol Hill about where the GOP can pick up the needed vote.
After Sept. 30, the end of the current fiscal year, Republicans would need 60 votes — which means eight Democrats — to pass any such legislation because special budget rules allowing approval with a simple majority will expire.
Unlike previous GOP repeal-and-replace packages that passed the House and nearly passed the Senate, the Graham-Cassidy proposal would leave in place most of the ACA taxes that generated funding to expand coverage for millions of Americans. The plan would simply give those funds as lump sums to each state. States could do almost whatever they please with them. And the Congressional Budget Office has yet to weigh in on the potential impact of the bill, although earlier estimates of similar provisions suggest premiums would go up and coverage down.
“If you believe repealing and replacing Obamacare is a good idea, this is your best and only chance to make it happen, because everything else has failed,” said Graham in unveiling the bill last week.
Here are five things to know about the latest GOP bill:
1. It would repeal most of the structure of the ACA.
The Graham-Cassidy proposal would eliminate the federal insurance exchange, healthcare.gov, along with the subsidies and tax credits that help people with low and moderate incomes — and small businesses — pay for health insurance and associated health costs. It would eliminate penalties for individuals who fail to obtain health insurance and employers who fail to provide it.
It would eliminate the tax on medical devices.
2. It would eliminate many of the popular insurance protections, including those for people with preexisting conditions, in the health law.
Under the proposal, states could “waive” rules in the law requiring insurers to provide a list of specific “essential health benefits” and mandating that premiums be the same for people regardless of their health status. That would once again expose people with preexisting health conditions to unaffordable or unavailable coverage. Republicans have consistently said they wanted to maintain these protections, which polls have shown to be popular among voters.
3. It would fundamentally restructure the Medicaid program.
Medicaid, the joint-federal health program for low-income people, currently covers more than 70 million Americans. The Graham-Cassidy proposal would end the program’s expansion under the ACA and cap funding overall, and it would redistribute the funds that had provided coverage for millions of new Medicaid enrollees. It seeks to equalize payments among states. States that did not expand Medicaid and were getting fewer federal dollars for the program would receive more money and states that did expand would see large cuts, according to the bill’s own sponsors. For example, Oklahoma would see an 88 percent increase from 2020 to 2026, while Massachusetts would see a 10 percent cut.
The proposal would also bar Planned Parenthood from getting any Medicaid funding for family planning and other reproductive health services for one year, the maximum allowed under budget rules governing this bill.
4. It’s getting mixed reviews from the states.
Sponsors of the proposal hoped for significant support from the nation’s governors as a way to help push the bill through. But, so far, the governors who are publicly supporting the measure, including Scott Walker (R-Wis.) and Doug Ducey (R-Ariz.), are being offset by opponents including Chris Sununu (R-N.H.), John Kasich (R-Ohio) and Bill Walker (I-Alaska).
On Tuesday 10 governors — five Democrats, four Republicans and Walker — sent a letterto Senate leaders urging them to pursue a more bipartisan approach. “Only open, bipartisan approaches can achieve true, lasting reforms,” said the letter.
Bill sponsor Cassidy was even taken to task publicly by his own state’s health secretary. Dr. Rebekah Gee, who was appointed by Louisiana’s Democratic governor, wrote that the bill “uniquely and disproportionately hurts Louisiana due to our recent [Medicaid] expansion and high burden of extreme poverty.”
5. The measure would come to the Senate floor with the most truncated process imaginable.
The Senate is working on its Republican-only plans under a process called “budget reconciliation,” which limits floor debate to 20 hours and prohibits a filibuster. In fact, all the time for floor debate was used up in July, when Republicans failed to advance any of several proposed overhaul plans. Senate Majority Leader Mitch McConnell (R-Ky.) could bring the bill back up anytime, but senators would immediately proceed to votes. Specifically, the next order of business would be a process called “vote-a-rama,” where votes on the bill and amendments can continue, in theory, as long as senators can stay awake to call for them.
Several senators, most notably John McCain, who cast the deciding vote to stop the process in July, have called for “regular order,” in which the bill would first be considered in the relevant committee before coming to the floor. The Senate Finance Committee, which Democrats used to write most of the ACA, has scheduled a hearing for next week. But there is not enough time for full committee consideration and a vote before the end of next week.
Meanwhile, the Congressional Budget Office said in a statement Tuesday that it could come up with an analysis by next week that would determine whether the proposal meets the requirements to be considered under the reconciliation process. But it said that more complicated questions like how many people would lose insurance under the proposal or what would happen to insurance premiums could not be answered “for at least several weeks.”
That has outraged Democrats, who are united in opposition to the measure.
“I don’t know how any senator could go home to their constituents and explain why they voted for a major bill with major consequences to so many of their people without having specific answers about how it would impact their state,” said Senate Minority Leader Chuck Schumer (D-N.Y.) on the Senate floor Tuesday.
Senate GOP Has 12 Days to Repeal Obamacare and No Room for Error
Senate Republicans making one last-ditch effort to repeal Obamacare have the daunting task of assembling 50 votes for an emotionally charged bill with limited details on how it would work, what it would cost and how it would affect health coverage — all in 12 days.
They need to act by Sept. 30 to use a fast-track procedure that prevents Democrats from blocking it, but the deadline doesn’t leave enough time to get a full analysis of the bill’s effects from the Congressional Budget Office. The measure would face parliamentary challenges that could force leaders to strip out provisions favored by conservatives. Several Republicans are still withholding their support or rejecting it outright.
And even if Republicans manage to get it through the Senate by Sept. 30, the House would have to accept it without changing a single comma.
Most Senate Republicans are still trying to figure out what it’s in the bill, which was authored by Republicans Lindsey Graham of South Carolina and Bill Cassidy of Louisiana. Until the past few days, most assumed that GOP leaders had no interest in reviving the Obamacare repeal effort after their high-profile failure to pass a measure this summer.
Republican Senator Steve Daines of Montana said he’s still trying to figure out how the bill will affect his state and wants to hear what GOP leaders say at a closed-door lunch Tuesday.
‘Active Discussion’
“It will be a very active discussion,” he said.
The new repeal bill would replace the Affordable Care Act’s insurance subsidies with block grants to states, which would decide how to help people get health coverage. The measure would end Obamacare’s requirements that individuals obtain health insurance and that most employers provide it to their workers, and it would give states flexibility to address the needs of people with pre-existing medical conditions.
But lawmakers won’t have much more information about the legislation by the time the Senate would have to vote. The CBO said Monday it will offer a partial assessment of the measure early next week, but that it won’t have estimates of its effects on the deficit, health-insurance coverage or premiums for at least several weeks. That could make it hard to win over several Republicans who opposed previous versions of repeal legislation.
So far, President Donald Trump has suggested he’d support the bill, but he hasn’t thrown his full weight behind it.
Majority Leader Mitch McConnell has told senators he would bring up the bill if it had 50 votes, and under fast-track rules he could do so at any time before Sept. 30. That’s the end of the government’s fiscal year, when the rules expire and the GOP would have to start over.
Several Holdouts
Republicans can only lose two votes in the 52-48 Senate and still pass the measure, with Vice President Mike Pence’s tie-breaker. There are at least four holdouts, and getting any of them to back the measure would require the senators to change their past positions. Pence, who would cast the potentially deciding vote, will return to Washington from New York Tuesday, where he’s been taking part in United Nations General Assembly events, to attend Senate GOP lunches.
Republican Rand Paul of Kentucky said Monday he’s opposed to the Graham-Cassidy bill, saying it doesn’t go far enough. John McCain of Arizona said he’s “not supportive” yet, citing the rushed legislative process.
Two other Republicans — Susan Collins of Maine and Lisa Murkowski of Alaska — have voted against every repeal bill considered this year in the Senate, citing cuts to Medicaid and Planned Parenthood as well as provisions that would erode protections for those with pre-existing conditions. The Graham-Cassidy bill contains similar provisions on those three areas.
“I’m concerned about what the effect would be on coverage, on Medicaid spending in my state, on the fundamental changes in Medicaid that would be made,” Collins told reporters Monday evening.
She said that Maine’s hospital association has calculated the state would lose $1 billion in federal health spending over a decade compared to current law.
“That’s obviously of great concern to me,” she added.
Hard Sell
Murkowski is getting a hard sell from Republican backers of the bill.
“What I’m trying to figure out is the impact to my state,” Murkowski told reporters Monday. “There are some formulas at play with different pots of money with different allocations and different percentages, so it is not clear.”
McCain, who is close friends with Graham, cast the deciding vote to sink an earlier repeal bill in late July when he made a dramatic return to the Senate after a brain cancer diagnosis. At the time, he made an eloquent plea for colleagues to work with Democrats and use regular legislative procedures instead of trying to jam it through on a partisan basis.
John Weaver, a former top adviser to McCain, said supporting Graham-Cassidy would require the Arizona senator to renege on his word.
‘Fair Process’
“I cannot imagine Senator McCain turning his back not only on his word, but also on millions of Americans who would lose health care coverage, despite intense lobbying by his best friend,” Weaver said in an email. “Graham-Cassidy, if truly attempted to pass, will bypass every standard of transparency and inclusion important to people who care about fair process.”
Despite the obstacles, the bill’s backers are putting on a good face about the prospects.
“We’re making progress on it,” said Republican Senator Ron Johnson of Wisconsin. “I’m still cautiously optimistic, but there are a lot of moving parts.” Johnson is planning a Sept. 26 hearing on the measure in the Homeland Security and Governmental Affairs Committee, which he leads. The Senate Finance Committee is planning its own hearing Sept. 25 on the measure.
“There’s a lot of interest,” Senator Pat Toomey of Pennsylvania said Monday. “Those guys have done some very good work.”
A number of Republicans are still pushing for changes to the bill, so the final version may evolve. It’s also subject to parliamentary challenges under the reconciliation process being used to circumvent the 60-vote threshold in the Senate. That could allow Democrats to strike provisions that take aim at Obamacare’s regulatory structure.
Last Chance
If it passed the Senate, the House would have to pass the bill without any changes. House Speaker Paul Ryan said Monday that the measure is Republicans’ last best chance to repeal Obamacare.
“We want them to pass this, we’re encouraging them to pass this,” Ryan told reporters at a news conference in Wisconsin. “It’s our best, last chance of getting repeal and replace done.”
But that won’t be easy either. The measure strives to equalize Medicaid funding between states, which means that some House Republicans from Medicaid expansion states could find it hard to support. That includes states like New York and California, which stand to lose federal funds under Graham-Cassidy. Those states have only Democratic senators, but have some GOP House members.
Another Run
In some ways, it’s remarkable that Republicans are mounting another run at repeal.
Two months ago, Majority Leader Mitch McConnell’s effort to pass a replacement with only Republican support suffered a spectacular defeat in the Senate. When members of the Senate health committee then began working on a bipartisan plan to shore up Obamacare, Graham and Cassidy revved up a new bid to get their GOP-only bill to the Senate floor.
Graham and Cassidy are hoping to channel the GOP’s embarrassment at failing to repeal Obamacare this summer after seven years of promising to do so. But Paul said Monday this legislation shouldn’t be treated like a “kidney stone” you pass “just to get rid of it.”
Despite all the obstacles, Democrats quickly geared up for another campaign against repeal, warning that the latest bill is a serious threat.
“This bill is worse than the last bill,” Senate Democratic leader Chuck Schumer of New York told reporters Monday. “It will slash Medicaid, get rid of pre-existing conditions. It’s very, very bad.”
Hospital group comes out against new ObamaCare repeal effort
Hospital group comes out against new ObamaCare repeal effort
America’s Essential Hospitals announced its opposition to a new ObamaCare repeal and replace bill, warning of cuts and coverage losses.
The group, which represents hospitals that treat a high share of low-income people, said it is opposed to a last-ditch bill to repeal ObamaCare from Sens. Bill Cassidy (R-La.), Lindsey Graham (R-S.C.), Dean Heller (R-Nev.) and Ron Johnson (R-Wis.).
Dr. Bruce Siegel, the group’s president and CEO, said in a statement the bill “would shift costs to states, patients, providers, and taxpayers.”
“Further, by taking an approach so close to that of the earlier House and Senate plans, it’s reasonable to conclude it would have a similar result: millions of Americans losing coverage,” he added.
America’s Essential Hospitals is one of the first major health groups to come out in opposition to the bill. Most have not yet weighed in on the measure, which was only introduced on Wednesday.
Many are also skeptical of the bill’s chances, but it appears to be gaining at least some momentum.
Cassidy told reporters Friday that he thought the bill had the support of 48-49 senators, just shy of the needed 50. Still, the effort faces long odds and a fast-approaching procedural deadline of Sept. 30.
America’s Essential Hospitals was one of the most outspoken opponents of the earlier repeal bills, along with other hospital groups. Many doctors groups were also opposed and many insurers eventually weighed in against provisions to change ObamaCare pre-existing condition rules.
Following the ACA Repeal-and-Replace Effort, Where Does the U.S. Stand on Insurance Coverage?
Conclusion and Policy Implications
The findings of this study could inform both short- and long-term actions for policymakers seeking to improve the affordability of marketplace plans and reduce the number of uninsured people in the United States.
Short-Term
The most immediate concern for policymakers is ensuring that the 17 million to 18 million people with marketplace and individual market coverage are able to enroll this fall.
Congress could take the following three steps:
- The Trump administration has not made a long-term commitment to paying insurers for the cost-sharing reductions for low-income enrollees in the marketplaces, which insurers are required to offer under the ACA. Congress could resolve this by making a permanent appropriation for the payments. Without this commitment, insurers have already announced that they are increasing premiums to hedge against the risk of not receiving payments from the federal government. Since most enrollees receive tax credits, higher premiums also will increase the federal government’s costs.9
- While it appears that most counties will have at least one insurer offering plans in the marketplaces this year, Congress could consider a fallback health plan option to protect consumers if they do not have a plan to choose from, with subsidies available to help qualifying enrollees pay premiums.
- Reinsurance to help carriers cover unexpectedly high claims costs.10 During the three years in which it was functioning, the ACA’s transitional reinsurance program lowered premiums by as much as 14 percent.
The executive branch can also play an important role in two ways:
- Signaling to insurers participating in the marketplaces that it will enforce the individual mandate. Uncertainty over the administration’s commitment to the mandate, like the cost-sharing reductions, is leading to higher-than-expected premiums for next year.
- Affirming the commitment to ensuring that all eligible Americans are aware of their options and have the tools they need to enroll in the coverage that is right for them during the 2018 open enrollment period, which begins November 1. The survey findings indicate that large shares of uninsured Americans are unaware of the marketplaces and that enrollment assistance makes a difference in whether people sign up for insurance.
Long-Term
The following longer-term policy changes will likely lead to affordability improvement and reductions in the number of uninsured people.
- The 19 states that have not expanded Medicaid could decide to do so.
- Alleviate affordability issues for people with incomes above 250 percent of poverty by:
- Allowing people earning more than 400 percent of poverty to be eligible for tax credits. This would cover an estimated 1.2 million people at an annual total federal cost of $6 billion, according to a RAND analysis.11
- Increasing tax credits for people with incomes above 250 percent of poverty.
- Allowing premium contributions to be fully tax deductible for people buying insurance on their own; self-employed people have long been able to do this.
- Extending cost-sharing reductions for individuals with incomes above 250 percent of poverty, thus making care more affordable for insured individuals with moderate incomes.
- Consider immigration reform and expanding insurance options for undocumented immigrants.
In 2002, the Institute of Medicine concluded that insurance coverage is the most important determinant of access to health care.12 In the ongoing public debate over how to provide insurance to people, the conversation often drifts from this fundamental why of health insurance. At this pivotal moment, more than 30 million people now rely on the ACA’s reforms and expansions. Nearly 30 million more are uninsured — because of the reasons identified in this survey. It is critical that the health of these 60 million people, along with their ability to lead long and productive lives, be the central focus in our debate over how to improve the U.S. health insurance system, regardless of the approach ultimately chosen.
Uninsured Rate In U.S. Falls To A Record Low Of 8.8%
Three years after the Affordable Care Act’s coverage expansion took effect, the number of Americans without health insurance fell to 28.1 million in 2016, down from 29 million in 2015, according to a federal report released Tuesday.
The latest numbers from the U.S. Census Bureau showed the nation’s uninsured rate dropped to 8.8 percent. It had been 9.1 percent in 2015.
Both the overall number of uninsured and the percentage are record lows.
The uninsured rate has fallen in all 50 states and the District of Columbia since 2013, although the rate has been lower among the 31 states that expanded Medicaid under the health law. California’s rate was 7.3 percent in 2016, less than half of its 17.2 percent rate in 2013.
“California has shown that the Affordable Care Act is working to expand health coverage and provide new patient protections,” said Anthony Wright, executive director of Health Access California, a consumer advocacy group. “While many thought our nation’s rising uninsured rate was unsolvable, the advancement in California shows that if policymakers and the public are united in trying to make reform work, we can do big things.”
The latest figures from the Census Bureau effectively close the book on President Barack Obama’s record on lowering the number of uninsured. He made that a linchpin of his 2008 campaign, and his administration’s effort to overhaul the nation’s health system through the ACA focused on expanding coverage.
When Obama took office in 2009, during the worst economic recession since the Great Depression, more than 50 million Americans were uninsured, or nearly 17 percent of the population.
The number of uninsured has fallen from 42 million in 2013 — before the ACA in 2014 allowed states to expand Medicaid, the federal-state program that provides coverage to low-income people, and provided federal subsidies to help lower- and middle-income Americans buy coverage on the insurance marketplaces. The decline also reflected the improving economy, which has put more Americans in jobs that offer health coverage.
The dramatic drop in the uninsured over the past few years played a major role in the congressional debate over the summer about whether to replace the 2010 health law. Advocates pleaded with the Republican-controlled Congress not to take steps to reverse the gains in coverage.
The Census numbers are considered the gold standard for tracking who has insurance because the survey samples are so large.
Among the states, the lowest uninsured rate last year was 2.5 percent in Massachusetts and the highest was 16.6 percent in Texas, the Census Bureau said. States that expanded Medicaid had an average uninsured rate of 6.5 percent compared with an 11.7 percent average among states that did not expand, the Census Bureau reported.
More than half of Americans — 55.7 percent — get health insurance through their jobs. But government coverage is becoming more common. Medicaid now covers more than 19 percent of the population and Medicare nearly 17 percent.
Hospital Impact—The only thing clear about healthcare policy is the continued lack of clarity
For healthcare leaders, it’s discouraging that federal policy decisions seem to be made at the last minute without much planning or consideration of unintended consequences.
I spent my Labor Day vacation in Monterrey, California, watching the waves crash into the sand and wondering what the future of healthcare will look like in the coming months and years. Some clarity is emerging that we have not seen in the past, and I feel comfortable making some observations and predictions:
- Congress will not revisit the repeal and replacement of the Affordable Care Act before the end of the year. It is simply dealing with far too many other issues—passing a budget, raising the debt ceiling, approving disaster aid for Harvey and Irma, not to mention its desire for tax reform—that lawmakers must address.
- While the Senate HELP committee is attempting a bipartisan effort to shore up the ACA, the issues listed above will make it almost impossible for such a law to be passed during this session.
- The leadership of the Department of Health and Human Services ideologically opposes the very concept of the ACA and is also responsible for implementing the law. The tension between those two facts will lead to confusion and uncertainty for those of us in healthcare.
- The passage of the ACA changed the terms of debate around healthcare reform. Granting health insurance to more than 20 million Americans has now shifted public opinion so that a solid majority believes the federal government should ensure that its citizens have insurance.
- The ACA is not failing, but going forward it can be undermined without congressional action.
As a former anatomic pathologist, I am always interested in postmortem examination of failures, and the failure of Republicans to repeal the ACA ranks high in any list of stunning political disasters. Pundits have identified several possible causes:
- Republicans never had a clear replacement plan or goal.
- Taking away benefits from 22 million Americans is politically unpopular.
- The ACA was not in a “death spiral.”
- The president did not exert necessary leadership to get GOP senators to support his unpopular position.
- Republican governors who had expanded Medicaid did not support the effort.
- Organized opposition to repeal led to most Americans not supporting repeal.
Autopsy results always arrive too late for those of us who are still alive, and it is more important for those of us in healthcare to interpret the mixed messages coming out of HHS and Congress so that our organizations can continue to care for patients under the current system.
HHS seems willing and eager to let states experiment with healthcare reform. Alaska has received approval for $323 million over five years to subsidize insurance carriers and stabilize its individual ACA marketplace. Iowa is likely to receive approval for a radical 1332 waiver approach to healthcare reform in the Hawkeye state, and other states are preparing waiver submissions.
Meanwhile, HHS actions that seem to undermine the ACA include refusing to guarantee cost-sharing reduction subsidies to insurance companies and slashing the budget to support ACA enrollment for 2018. HHS recently announced advertising budget cuts of 90% for 2018 and the navigator program cuts of 40%.
A recent study—detailed in a post on The Incidental Economist blog—compared Kentucky ACA enrollment under a Democratic governor who supported advertising and a Republican governor who cut advertising. It found that lack of TV advertising led to 450,000 fewer page views on the ACA website and 20,000 fewer unique visits to the enrollment website.
ACA supporters, meanwhile, have recently put together a private enrollment campaign for 2018 to fill in the gap created by HHS decisions, Axios reported.
Last week, the Senate HELP Committee heard from state insurance commissioners and governorsabout ideas to stabilize the ACA marketplaces. They include:
- Funding the cost-sharing reduction subsidies to insurance companies.
- Facilitating reinsurance programs.
- Expanding the ACA 1332 waiver programs to let states innovate.
- Funding enrollment activities such as advertising and navigator programs.
Although health policy experts largely support these recommendations, it is hard to see how such a divided Congress could pass such proposals. Even if such legislation were approved, it would likely come too late to impact health insurance company decisions for 2018.
So, as of early September, we are left with the ACA continuing to be the law of the land, but with those in charge of the federal government not entirely supporting its success. Healthcare organizations have difficulty caring for patients when the rules keep changing and when clarity is hard to come by. It is also discouraging that decisions seem to be made at the last minute without much planning or consideration for unintended consequences.
That said, we still need to keep taking care of patients. My advice is to:
- Continue to prepare for the transition from fee-for-service to value-based payments, but be aware that the Trump administration might slow down this process.
- Continue to cut unnecessary costs.
- Continue to improve the measurable quality of the care you give.
- Participate in efforts in your individual states to innovate through waiver programs.
- Collaborate with your physicians who are confused by all the uncertainty.
- Keep up to date with the frequent changes that nobody can predict.
HENRY KOTULA 