House Republicans left for spring break last week, without reaching a deal to repeal and replace the Affordable Care Act. Their bill to overhaul the health care system collapsed on the House floor last month, amid divisions in the caucus.
Even without Congress, however, President Trump has the authority to modify important provisions of the health law, including many that House Republicans sought to change or repeal. Here are some examples of actions he could take (or has already taken):
https://www.axios.com/dont-expect-medicaid-work-requirements-to-make-a-big-difference-2338186318.htm
Liberals and conservatives have irreconcilable differences of policy and principle over the issue of Medicaid “work requirements.” But their impact depends on how they are implemented and is likely to be very small — because most people on Medicaid who can work already are.
With Trumpcare dead for now, expect Republican governors to begin submitting waiver proposals to the Department of Health and Human Services to move their Medicaid programs in a more conservative direction. Medicaid “work requirements” are likely to be an element of many of those waiver requests, possibly from Republican-led states now looking to expand Medicaid under the Affordable Care Act.
During the Obama administration, HHS rejected mandatory work requirements as inconsistent with the purposes of the Medicaid statute, spurning requests from Arizona, Indiana, and Pennsylvania under a previous governor. Under the Trump presidency, HHS is expected to approve them.
Medicaid “work requirements” are not requirements to work in a literal sense. Generally, this is how states would define them:
Liberals find Medicaid work requirements repugnant because they believe that Medicaid beneficiaries want to work if they can, and that providing health coverage to people who cannot afford it is an obligation of any moral nation. Conservatives who favor work requirements see Medicaid coverage as another form of government welfare benefit, like cash assistance, requiring reciprocal obligations from beneficiaries, and a disincentive to work.
The reality, though, is that most Medicaid beneficiaries are working already, and the vast majority of those who are not working are likely to be exempted from all but the most draconian Medicaid work requirements when front-line caseworkers apply state rules.
As the chart shows:
Medicaid work requirements send signals conservatives like and liberals reject. As I learned a long time ago designing and implementing a leading welfare reform program as Commissioner of Human Services in New Jersey, the fight about policy and principle can get hot when it comes to work requirements, but their impact depends on how they are implemented.
With most beneficiaries working or with good reasons not to be, that impact will be small.
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.
Block grant funding of public health insurance: the Canadian example
Speaker Paul Ryan wants to reform Medicaid by “block granting” the program, that is,
by capping federal funding and turning control of the program over to states. The aim of such reforms is to reduce federal funding over the long term, while preserving a safety net for needy, low-income Americans. An additional valuable aim of this effort has been to advance federalism by reducing the federal government’s role and giving states and governors more freedom and flexibility in managing their Medicaid programs and helping people in their states.
What are the likely consequences of block granting? Benjamin Sommers and David Naylor write in JAMA about how Canada’s joint federal/provincial funding of health care provides lessons about the likely consequences of block granting.
Canada is a single payer health care system. However, there isn’t a Canadian single payer. Rather, there is a single payer for each province: I am covered by the Ontario Health Insurance Plan (OHIP). These plans are primarily funded by provincial taxes. However, provinces also receive a health transfer from the Canadian federal government, i. e., a block grant. The provincial health insurance plans are run by provincial health ministers, not the federal minister in Ottawa.
So, does provincial autonomy facilitate experimentation and tailoring by the provinces? Sommers and Naylor think not.
there is little evidence that the alleged advantages of block grants have materialized in Canada. Advocates argue that with greater flexibility and proper incentives, states can reduce costs by improving the efficiency of care. In Canada, however, the provinces’ primary means of coping with budget pressures under block grants has been to reduce funding to hospitals and bargain harder with provincial medical associations. Ironically, then, if this scenario plays out in the United States, it would exacerbate one of the chief Republican criticisms of Medicaid — that it pays clinicians such low rates that they have reduced incentives to care for low-income patients.
Indeed, physician refusal to take Medicaid patients is one of Speaker Ryan’s central criticisms of Medicaid.
What about the effects of a block grant system on federal funding of health care?
Once block funding was initiated in 1977, health care funding became a line item in the federal budget that could be arbitrarily cut or capped for fiscal or political reasons, as opposed to a level of spending pegged to the needs and health care use of the population. Importantly, these cuts occurred under both conservative and liberal federal governments.
When the Canadian health transfer began, the federal government paid 50% of provincial costs. However, the transfer has steadily declined, until it is now about 20%. Sommers and Naylor predict that US federal block grants would also decline, and this is clearly one of Speaker Ryan’s goals.
However, Canadian health care spending per capita has not declined.
As the cost of providing care has risen, but the federal health transfer has stayed fixed or declined, the provinces have taxed more and the federal government has taxed less. The provincial governments hate this, because they would rather have the federal government make the unpopular choice to raise taxes. But it’s not clear whether block granting has made a big difference in the health care received by Canadians.
American states could similarly increase taxes in response to a declining federal Medicaid block grant, but would they? The key difference between Canadian public health insurance and Medicaid is that the former is universal, while the latter is means-tested. Ontarians prefer lower taxes, but if Ontario decreases funding for OHIP, every Ontarian will experience longer waits for care. But American states can cut Medicaid — and reduce taxes — without affecting the health care of better off and able-bodied citizens.
The affluent and able-bodied are also the citizens most likely to vote. American states determine their own voting procedures. Block granting gives states an incentive to manage voting so as to reduce the participation of the marginalized communities who are most in need of public health insurance. Block granting is likely to undermine the health care for the poor and disabled, and it could reinforce the post-Shelby County v. Holder efforts to restrict voting.
This is the last in a series of three posts. I’ve proposed three approaches that Republicans might use to get out of the dilemma they are in over health care:
The Case for a Responsible Federalism
We have had federalism in health care for many decades. The grandaddy of them all is the open-ended Medicaid program which obligates Uncle Sam to pony up federal matching dollars in lock-stop with state willingness to put up their dollars. As AEI health policy expert Joe Antos recently pointed out, Medicaid has needed fixing for 50 years. But even before that we have had federal grant-in-aid programs dating back to the 1930’s that channeled federal dollars into health care. In my view, responsible federalism in health care would entail reforming the perverse fiscal incentives embedded in Medicaid while also offering states much greater flexibility to solve their health problems without the heavy hand of Uncle Sam.
As a friend once told me, “Government is about compromise.” That friend was Tommy Thompson, a four-term governor of Wisconsin who went on to serve in George W. Bush’s cabinet as secretary of health and human services.
With the failure of the American Health Care Act, recently proposed by Republicans in the U.S. House of Representatives, it is clear that the Affordable Care Act (ACA) will continue to serve millions of Americans for the foreseeable future. Of course, the ACA (or Obamacare) remains a flawed law. But rather than allow it to “implode” or “collapse,” as some suggest it will (e.g., President Trump), a group of Republican and Democratic leaders in Washington should take action and fix the broken elements of the ACA for the good of the millions of Americans who depend on it. It is time for a compromise.
What might such a bipartisan agreement look like? Here are some ideas.
Since 2000, the percentage of employers offering health benefits has declined in California and nationwide, although coverage rates among offering firms have remained stable. Only 55% of firms reported providing health insurance to employees in 2016, down from 69% in 2000. These findings underscore the important role that Medi-Cal and Covered California play in providing insurance to working Californians — coverage that could be negatively impacted if the Republicans repeal and replace the Affordable Care Act.
Nineteen percent of California firms reported that they increased cost sharing in the past year, and 27% of firms reported that they were very or somewhat likely to increase employees’ premium contribution in the next year. The prevalence of plans with large deductibles also continues to increase.
California Employer Health Benefits: Prices Up, Coverage Down presents data compiled from the 2016 California Employer Health Benefits Survey.
Other key findings include:
The complete Almanac report, as well as past editions, is available under Document Downloads.
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).
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.
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 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.
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.
HENRY KOTULA 