Tag Archives: Medicaid Expansion

Reversal: Some Republicans now defending parts of ObamaCare

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Reversal: Some Republicans now defending parts of ObamaCare

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The House’s debate over repealing ObamaCare has had an unintended effect: Republicans are now defending key elements of President Obama’s health law.

Many House Republicans are now defending ObamaCare’s protections for people with pre-existing conditions, in the face of an effort by the conservative House Freedom Caucus to repeal them.

Some Republican lawmakers are also speaking out in favor of ObamaCare’s expansion of Medicaid and its mandates that insurance plans cover services such as mental health and prescription drugs.

Rep. Patrick McHenry (R-N.C.), the GOP’s chief deputy whip, said Wednesday that the Freedom Caucus’s calls for states to be able to apply for waivers to repeal pre-existing condition protections are “a bridge too far for our members.”

Those ObamaCare protections include what is known as community rating, which prevents insurers from charging higher premiums to people with pre-existing conditions, and guaranteed issue, which prevents insurers from outright denying coverage to them.

McHenry spoke in personal terms about the importance of keeping in place those Affordable Care Act (ACA) provisions, contained in Title I of the law.

“If you look at the key provisions of Title I, it affects a cross section of our conference based off of their experience and the stories they know from their constituents and their understanding of policy,” McHenry said.

“My family history is really bad, and so my understanding of the impact of insurance regs are real, and I believe I’m a conservative, so I look at this, understand the impact of regulation, but also the impact of really bad practices in the insurance marketplace prior to the ACA passing,” he continued. “There are a lot of provisions that I’ve campaigned on for four election cycles that are part of the law now that I want to preserve.”

McHenry’s defense of those ObamaCare pre-existing condition protections is striking because just last year, House Republicans touted a healthcare plan, called A Better Way, that would have repealed the protections and replaced them with a different system.

Rather than ObamaCare’s protections, the Better Way plan would have protected people with pre-existing conditions only if they maintained “continuous coverage,” meaning they had no gaps in coverage. Unlike under ObamaCare, the plan would not extend the protections to people who were uninsured and trying to enroll in coverage. For those people, Republicans proposed subsidizing coverage through separate high-risk pools.

During a town hall at Georgetown University last year, Speaker Paul Ryan(R-Wis.) called for repealing ObamaCare’s community rating protection and allowing insurers to return to the days of “underwriting,” when they could charge people with pre-existing conditions more. Instead, sick people could get coverage subsidized through high-risk pools, he said.

“Open up underwriting, have more insurance companies, have more competition, and just pay for the person with the pre-existing condition to make sure that they can get affordable coverage when that moment happens and make it much more competitive for everybody else,” Ryan said then. “I think it’s a smarter way to do it economically and it gives people more freedom, more choices.”

Now, though, many House Republicans are defending the ObamaCare protections.

Why an Open Market Won’t Repair American Health Care

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AN AMERICAN SICKNESS
How Healthcare Became Big Business and How You Can Take It Back
By Elisabeth Rosenthal
406 pp. Penguin Press. $28.

A few years back, the future of American health policy appeared to hinge on how similar medical care was to broccoli. It was March 2012, and the Affordable Care Act (a.k.a. Obamacare) was before the Supreme Court. Justice Antonin Scalia zeroed in on its controversial requirement that all Americans purchase health insurance. Yes, everybody needs health care, Scalia conceded, but everybody needs food too. If the government could make people buy insurance, why couldn’t it “make people buy broccoli”?

The Affordable Care Act survived, of course — though not before a fractured court made the expansion of Medicaid optional, leaving millions of poorer Americans without its promised benefits. But the question Justice Scalia asked remains at the heart of a debate that has only intensified since: Why is health care different? Why does it create so much more anxiety and expense, heartache and hardship, than does buying broccoli — or cars or computers or the countless other things Americans routinely purchase each day?

For those leading the charge to roll back the 2010 law, the question has a one-word answer: government. President Trump’s point man on health policy, the former congressman (and ultrawealthy orthopedic surgeon) Tom Price, has said that “nothing has had a greater negative effect on the delivery of health care than the federal government’s intrusion into medicine through Medicare.” Senator Rand Paul (another surgeon) and House Speaker Paul Ryan have claimed that the affordability of Lasik eye surgery — generally not covered by health insurance — shows that a much freer health care market would be much less expensive. Their idea of “reform” is to cut back public and private insurance so consumers have “more skin in the game” and thus shop more wisely.

The physician-turned-journalist Elisabeth Rosenthal offers a very different answer in her eye-opening “An American Sickness.” Rosenthal — formerly a reporter for The New York Times, now the editor in chief of the nonprofit Kaiser Health News — is best known for a prizewinning series of articles, “Paying Till It Hurts.” In them, Rosenthal chronicled the seemingly endless pathologies of America’s medical-industrial complex, from prescription drugs that grew more costly as they became more dated to hip-replacement surgery so expensive it was cheaper for a patient to fly to a hospital in Belgium.

Rosenthal thinks the health care market is different, and she sums up these differences as the “economic rules of the dysfunctional medical market.” There are 10 — some obvious (No. 9: “There’s money to be made in billing for anything and everything”); some humorous (No. 2: “A lifetime of treatment is preferable to a cure”) — but No. 10 is the big one: “Prices will rise to whatever the market will bear.” To Rosenthal, that’s the answer to Scalia’s question. The health care market doesn’t work like other markets because “what the market will bear” is vastly greater than what a well-functioning market should bear. As Rosenthal describes American health care, it’s not really a market; it’s more like a protection racket — tolerated only because so many different institutions are chipping in to cover the extortionary bill and because, ultimately, it’s our lives that are on the line.

Consider the epicenter of America’s cost crisis: the once humble hospital. Thanks in part to hit TV shows, we think of hospitals as public-spirited pillars of local communities. Yet while most are legally classified as nonprofits, they are also very big businesses, maximizing surpluses that can be plowed into rising salaries and relentless expansion even when they are not earning profits or remunerating shareholders. And they have grown much bigger and more businesslike over time.

Rosenthal tells the story of Providence Portland Medical Center, a Northwest hospital system founded by nuns. Four decades ago, its operational hub in Portland, Ore., consisted of two modest hospitals: Providence and St. Vincent. As it happens, my mother was a nurse at St. Vincent for more than half those years, and thus had a front-row seat as Providence transformed from a Catholic charity into one of the nation’s largest nonprofit hospital systems, with annual revenues of $14 billion in 2015.

Along the way, Providence jettisoned most of its original mission, replacing nuns with number crunchers. Once run mainly by doctors, it filled its growing bureaucracy with professional coders capable of gaming insurance-reimbursement rules to extract maximum revenue. Meanwhile, Providence stopped paying doctors as staff and reclassified them as independent contractors (though not so independent they could skip a “charm school” designed by its marketers). Yet even as its C.E.O. earned more than $4 million, Providence touted itself as a “not-for-profit Catholic health care ministry” upholding the “tradition of caring” started by the nuns (now listed as “sponsors” in promotional materials). Rosenthal sums up the result as “a weird mix of Mother Teresa and Goldman Sachs.”

 

 

Insurance Coverage, Access to Care, and Medical Debt Since the ACA: A Look at California, Florida, New York, and Texas

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http://www.commonwealthfund.org/publications/issue-briefs/2017/mar/coverage-access-medical-debt-aca-california-florida-new-york-texas

Background

More than 30 million Americans now have health insurance under the provisions of the Affordable Care Act.1 These provisions include those that have allowed or encouraged people to enroll in coverage through expanded Medicaid eligibility, tax credits to help pay for premiums, state and federal outreach efforts, and consumer-friendly market regulations.2 A recent analysis found that the percentage of uninsured working-age adults dropped from 20 percent in 2010 to 12 percent in 2016.3

The law gives states flexibility in implementing provisions, including the choice of operating their own health insurance marketplace or leaving that task to the federal government. Moreover, in 2012, the U.S. Supreme Court gave states the option to decide whether or not to expand Medicaid eligibility to more lower-income adults. These choices, combined with each state’s unique demographics and history, have resulted in varying experiences among Americans. In this brief, we use data from the Commonwealth Fund Biennial Health Insurance Survey to examine differences in health insurance coverage, problems getting needed care because of costs, and medical bill and debt problems among 19-to-64-year-old adults in the nation’s four largest states: California, Florida, New York, and Texas.4

These states fall into two distinct categories. The first group, California and New York, both operate their own health insurance marketplaces and have expanded eligibility for Medicaid to adults with incomes at or below 138 percent of the federal poverty level—$16,394 for an individual or $33,534 for a family of four. Florida and Texas, the second group, are using the federal marketplace to enroll residents in health plans and have declined to expand Medicaid eligibility (Exhibit 1).

Conclusion

The Affordable Care Act has significantly affected health insurance coverage and access among U.S. adults. But the decisions made by state leaders in implementing federal policy, along with other state laws, have ongoing implications for their residents. California and New York began seeing declines in their adult uninsured rate earlier than other states because of such choices. California expanded eligibility for Medicaid even before 2014 by creating the Low Income Health Program, which provided coverage to adults with incomes less than 200 percent of poverty.20 New York expanded Medicaid eligibility to parents with incomes up to 150 percent of poverty and childless adults up to 100 percent of poverty starting in 2000.21 In addition, both states opted to establish their own marketplaces and have conducted expansive outreach campaigns to increase awareness of coverage options. Alternatively, Florida and Texas—although they have experienced robust enrollment in private plans through the federal health insurance marketplace—have not expanded Medicaid eligibility and have made less progress covering uninsured residents.

However, the variation in insured rates is not entirely the result of states’ decision. The ACA does not provide access to any new coverage options for undocumented immigrants. They are ineligible for Medicaid coverage and cannot purchase private plans through the marketplace, subsidized or unsubsidized. This is likely a contributing factor in Texas’s higher uninsured rate.

While expanded coverage is the necessary first step to improving timely access to care and reducing medical financial burdens among U.S. families, the quality and comprehensiveness of coverage across all sources of insurance—marketplace plans, individual market plans, employer-provided coverage, and Medicaid—also has a significant impact.

The gains documented in this survey and many other private and federal analyses indicate that the Affordable Care Act has been successful in insuring millions of Americans and enabling them to get health care they may not have been able to afford previously. Further expanding coverage and improving affordability should remain a priority. Alternatively, repealing the law without a replacement that is at least equally effective will risk reversing the substantial gains the nation has made.

 

In Health Bill’s Defeat, Medicaid Comes of Age

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When it was created more than a half century ago, Medicaid almost escaped notice.

Front-page stories hailed the bigger, more controversial part of the law that President Lyndon B. Johnson signed that July day in 1965 — health insurance for elderly people, or Medicare, which the American Medical Association had bitterly denounced as socialized medicine. The New York Times did not even mention Medicaid, conceived as a small program to cover poor people’s medical bills.

But over the past five decades, Medicaid has surpassed Medicare in the number of Americans it covers. It has grown gradually into a behemoth that provides for the medical needs of one in five Americans — 74 million people — starting for many in the womb, and for others, ending only when they go to their graves.

Medicaid, so central to the country’s health care system, also played a major, though far less appreciated, role in last week’s collapse of the Republican drive to repeal and replace the Affordable Care Act, also known as Obamacare. While President Trump and others largely blamed the conservative Freedom Caucus for that failure, the objections of moderate Republicans to the deep cuts in Medicaid also helped doom the Republican bill.

“I was not willing to gamble with the care of my constituents with this huge unknown,” said Representative Frank A. LoBiondo of New Jersey, a member of the centrist Tuesday Group caucus, noting that in three of the counties in his district in the state’s more conservative southern half, over 30 percent of all residents are covered by Medicaid.

In the Senate, many Republicans, echoing their states’ governors, had worried about jeopardizing the treatment of people addicted to opioids, depriving the working poor, children and people with disabilities of health care and in the long run reducing funding for the care of elderly people in nursing homes.

The Republican bill would have largely undone the expansion of Medicaid under the A.C.A., which added 11 million low-income adults to the program and guaranteed the federal government would cover almost all of their costs. It would have also ended the federal government’s open-ended commitment to pay a significant share of states’ Medicaid costs, no matter how much enrollment or spending rose. Instead, the bill would have given the states a choice between a fixed annual sum per recipient or a block grant, both of which would have almost certainly led to major cuts in coverage over time.

The nonpartisan Congressional Budget Office predicted that the Republican bill would have cumulatively cut projected spending on Medicaid by $839 billion and reduced the number of Medicaid beneficiaries by 14 million over the coming decade.

 

 

More States To Expand Medicaid Now That Obamacare Remains Law

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https://www.forbes.com/sites/brucejapsen/2017/03/26/more-states-to-expand-medicaid-now-that-obamacare-remains-law/#13cbbeaa19a6

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More states will pursue expansion of Medicaid health benefits for poor Americans under the Affordable Care Act after Republicans failed to repeal and replace the law.

The American Health Care Act, also known as Trumpcare, would’ve rolled back the ACA’s Medicaid expansion and put restrictions on states that tried to expand such coverage. But Speaker of the U.S. House of Representatives Paul Ryan Friday pulled the ACHA legislation Friday, making, “Obamacare the law of the land,” as he said.

At least two states– Kansas and North Carolina–are already working toward becoming the 32nd and 33rd states to expand Medicaid  under the ACA. They would join 31 states plus the District of Columbia that have taken advantage of generous federal funding available under the law, President Obama’s signature legislative achievement, according to the Advisory Board.

 And there may be even more states that will resurrect state legislative efforts to expand Medicaid. Before Trump was elected, Georgia, Idaho, Nebraska and South Dakota were considering Medicaid expansion. But Trump’s election, along with Republican control of Congress, prompted these states to put on the brakes for Medicaid expansion when an ACA repeal looked likely. “The effort to expand Medicaid in Georgia just died,” the Atlanta Journal-Constitution said Nov. 9, 2016, the day after Trump won the electoral college.

From 2014 through 2016, the ACA’s Medicaid expansion population is funded 100% with federal dollars. Beginning this year, states gradually have to pick up some costs, but the federal government still picks up 90% or more of Medicaid expansion through 2020. It was a better deal than before the ACA, when Medicaid programs were funded via a much less generous split between state and federal tax dollars.

With the federal funding still part of the ACA, Kansas lawmakers just last week were forging ahead and now have a hurdle lifted with the law in place for the “foreseeable” future, as Speaker Ryan said. A so-called “manager’s amendment” in Ryan’s failed ACHA bill took specific aim at Kansas and North Carolina, making the states “long shots” at expanding Medicaid until Friday’s failed Obamacare repeal.

GOP releases bills to repeal and replace ObamaCare

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http://thehill.com/policy/healthcare/322609-gop-releases-bill-to-repeal-and-replace-obamacare

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Click to access AmericanHealthCareAct.pdf

Click to access AmericanHealthCareAct_WM.pdf

House Republicans on Monday unveiled their long-awaited legislation to repeal and replace ­ObamaCare, with plans to quickly push the measure through committee votes this week.

The two measures dismantle the core aspects of ­ObamaCare, including its subsidies to help people buy coverage, expansion of Medicaid, taxes and mandates for people to have insurance. The bills also dramatically restructure the Medicaid program overall by capping federal payments.

In its place, Republicans would put a new system centered on a tax credit to help people buy insurance.

House Republicans plan to take up the legislation at a breakneck pace, with two committees — Energy and Commerce and Ways and Means — scheduled to hold votes on Wednesday. A vote in the full House is expected to soon follow, within weeks.

House Ways and Means Committee Chairman Kevin Brady (R-Texas) said Monday on Fox News that he’s confident the legislation will pass with solid Republican support despite recent party infighting over the details.

“We’ve been listening very carefully to our Republican members for months now to make sure we get it right,” he said. “I am confident we are going to pass this.”

Brady noted that many of the elements of the bills have passed the House “a number of times” over the years.

Speaker Paul Ryan (R-Wis.) in a statement claimed that ­ObamaCare “is rapidly collapsing” and vowed the GOP’s plan — dubbed the American Health Care Act — will “give every American access to quality, affordable health insurance.”

Republicans acknowledge that their plan will cover fewer people, saying that unlike ­ObamaCare, they are not forcing people to buy coverage through a mandate. They say their system is less intrusive and provides people a tax credit without mandates or a range of tax increases.

But the measures face a rocky path, particularly in the Senate. Four Republican senators earlier Monday objected to an earlier version of the House plan, saying that it fails to protect ­ObamaCare’s Medicaid expansion.

Even in the House, there are objections. Conservatives in the House Freedom Caucus object that the new tax credit is a “new entitlement.” They have enough votes to kill the legislation, but it remains to be seen whether they will actually vote against a bill that dismantles the core of ­ObamaCare.

The GOP measure significantly restructures the Medicaid program, which provides coverage for around 70 million poor, disabled and elderly people, to cap federal payments.

The repeal of the Medicaid expansion and ­ObamaCare’s subsidies would not take effect until 2020, meaning current enrollees could keep their coverage this year.

Republicans would also grandfather in current Medicaid enrollees so that they can stay on the program. But once 2020 arrives, the federal government would no longer provide the extra federal funds that allow for expansion.

That plan has drawn objections from more centrist Republican senators, who want to protect the expansion and are worried about constituents losing coverage and their states losing federal funds.

The legislation would maintain ­ObamaCare’s protections for people with pre-existing conditions, who could still not be denied coverage by insurers. Instead of ­ObamaCare’s mandate, the GOP plan would seek to encourage healthy people to sign up by allowing insurers to charge people 30 percent higher premiums if a new enrollee has had a gap in coverage.

The legislation also repeals nearly all of the taxes created by ­ObamaCare, including the medical device tax and health insurance tax, starting in 2018. The bills scrap a controversial Republican proposal in earlier drafts that would have started taxing some employer-sponsored health insurance.

To ensure that the legislation passes muster under special budgetary rules, it keeps ­ObamaCare’s “Cadillac tax” on generous plans after 2025. That provision, which could prove controversial, will help ensure that the measure does not add to the federal deficit in that decade.

http://thehill.com/policy/healthcare/320286-kasich-house-gop-medicaid-plan-very-bad-idea

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Kasich: House GOP Medicaid plan ‘very bad idea’

Kasich: House GOP Medicaid plan 'very bad idea'

Republican Ohio Gov. John Kasich on Sunday criticized the House Republicans’ plan to phase out ObamaCare’s expansion of Medicaid.

“I’m in Munich, but I understand that there was an initial effort by House Republicans to, for example, phase out Medicaid expansion, which means phasing out coverage,” Kasich said on CNN’s “State of the Union.” “That is a very, very bad idea, because we cannot turn our back on the most vulnerable. We can give them the coverage, reform the program, save some money and make sure that we live in a country where people are going to say, ‘At least somebody is looking out for me.’”

An outline of an ObamaCare replacement plan put forward by House Republicans on Thursday called for phasing out the Medicaid expansion by lowering the federal share of the cost back down to its traditional level, meaning that states would have to pour more of their own money into the program if they wanted to keep the expansion, a tall order.

 

Understanding the Intersection of Medicaid and Work

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http://kff.org/medicaid/issue-brief/understanding-the-intersection-of-medicaid-and-work/

Figure 3: Industries with largest number of workers covered by Medicaid, 2015

Issue Brief

Medicaid is the nation’s public health insurance program for people with low incomes. Overall, the Medicaid program covers more than 70 million Americans, or 1 in 5, including many with complex and costly needs for care. Historically, nonelderly, non-disabled adults accounted for a small share (27%) of Medicaid enrollees; however, the enactment and implementation of the Affordable Care Act (ACA) has expanded coverage to nonelderly adults with income up to 138% FPL, or $16,394 for an individual in 2016. As of January 2017, 32 states have implemented the ACA Medicaid expansion. By design, the expansion extended coverage to the working poor (both parents and childless adults), most of whom do not otherwise have access to affordable coverage. With the expansion to more “able-bodied” adults, questions have arisen about tying work to eligibility.

President Trump may consider waiver proposals with a work requirement, and the Administration and leaders in Congress are considering proposals to repeal the ACA and to transform Medicaid from an entitlement program with guaranteed federal matching dollars for states to a block grant with no entitlement and capped funding. Such proposals would grant states additional flexibility to design and administer their programs and potentially include an option to allow states to impose a work requirement for Medicaid beneficiaries, which is not allowed under current law.  This issue brief examines the work status of non-elderly, non-disabled adults with Medicaid coverage to understand the potential implications of work requirement proposals in Medicaid.

Key Takeaways
This brief provides an overview of work status of non-disabled, adult Medicaid enrollees and examines some of the policy proposals around tying Medicaid coverage to work.

  • Among non-disabled, non-elderly Medicaid adults (including parents and childless adults — the group targeted by the Medicaid expansion) nearly 8 in 10 live in working families, and a majority are working themselves. However, nearly half of working Medicaid enrollees are employed by small firms, and many work in industries with low ESI offer rates.
  • Among the non-disabled, non-elderly adult Medicaid enrollees who were not working, most report major impediments to their ability to work.
  • Under current law, states cannot impose a work requirement as a condition of Medicaid eligibility, but some states have sought to impose a work requirement for the Medicaid expansion population through waivers; the prior administration did not approve these requests.  The issue of work requirements may be re-examined by the new administration and may be debated in Congress as part of broader efforts to restructure Medicaid financing and core federal requirements.

 

THE SHAMEFUL REPUBLICAN ASSAULT ON MEDICAID

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http://www.newyorker.com/news/john-cassidy/the-shameful-republican-assault-on-medicaid?mbid=social_facebook

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In terms of political theatre, Donald Trump’s press conference on Thursday was the event of the week, or maybe the year. Strictly in policy terms, though, it was less important than the media briefing that Paul Ryan, the House Speaker, and other House Republican leaders held, also on Thursday, about their plans to abolish Obamacare and replace it with some version of what we might call Trumpcare, or maybe Trump/Ryancare.

There are still huge questions about what this new system will look like, and when it might be enacted. In a new seventeen-page paper, “Obamacare Repeal and Replace,” the G.O.P. lawmakers outlined proposals that are familiar from a plan that Ryan put out last year. They included expanded health savings accounts, financial aid for the establishment of high-risk pools at the state level, and the replacement of income-based subsidies to purchase individual insurance with universal tax credits.

But the paper also contained some huge gaps. It didn’t say how large the new tax credits would be, or how they and other elements of the reform would be paid for. To pay for its provisions, the 2010 Affordable Care Act levied more than a trillion dollars in tax increases over a decade. The Republican replacement will, in all likelihood, cover millions fewer people than Obamacare, but it will still have to be paid for. Ryan and his colleagues were largely silent on where the tax burden would fall.

For all this deliberate obfuscation, though, House Republicans are now being very clear about one thing: whatever legislation emerges after the Senate and the White House have weighed in, it will almost certainly roll back the Obama Administration’s expansion of Medicaid, the federal health-insurance program for poverty-stricken and low-income households. Under the outline released on Thursday, the current Medicaid system would be replaced by block grants to the states, and the extra federal money that went to Medicaid as part of the A.C.A. would gradually be removed. In effect, the Medicaid expansion would be slowly suffocated.

GOP Considers Medicaid Reforms for Reconciliation Bill

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https://morningconsult.com/2017/02/14/gop-considers-medicaid-reforms-reconciliation-bill/

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House Republicans are weighing specific reforms to Medicaid that could be included in a reconciliation measure to overhaul the Affordable Care Act.

How to deal with the federal expansion of Medicaid under the ACA is one of the main unanswered questions as Congress works to overhaul Obamacare — one that has exposed divisions between the House’s most conservative members and GOP lawmakers from states that chose to expand the federal program for low-income Americans.

Rep. Brett Guthrie (R-Ky.), the vice chairman of the Energy and Commerce Health Subcommittee, said Tuesday that lawmakers are considering what types of reforms — specifically shifting to per capita allotments or allowing states to choose block grants — could be included in a House reconciliation bill to repeal the ACA.

“We’re going to deal with Medicaid reform in reconciliation, is kind of what was discussed. There’s no details yet,” Guthrie told reporters Tuesday after a House GOP conference meeting. Guthrie led a working group focused on Medicaid reforms in the last Congress.

Rep. Michael Burgess (R-Texas), who chairs the health subcommittee, told reporters Medicaid reform would be a discussion all week. House Majority Whip Steve Scalise’s office held a listening session Tuesday afternoon with members on Medicaid, and other committees are also gathering feedback. House Republicans are expecting to learn more information about health reform in a Thursday conference meeting focused on Obamacare.

House Speaker Paul Ryan attended the GOP senators’ policy lunch on Tuesday, and told attendees that appropriators and the authorizing committees are working out Medicaid reforms, Sen. Marco Rubio (R-Fla.) said.

In the House, proposals to transition to per capita allotment or block grants were included in the House GOP’s “Better Way” agenda, rolled out last year.