Trump Threatens Health Subsidies to Force Democrats to Bargain

In the weeks since President Trump’s attempts to replace the Affordable Care Act collapsed, the administration has debated what to do: Try again? Shore up the insurance marketplaces? Or let the whole system collapse?

Mr. Trump has failed to get enough support from his own party, but he hopes to get the Democrats’ help by forcing them to the negotiating table with hints about the chaos he could cause.

His bargaining chip is the government subsidies paid to insurance companies so they can reduce deductibles and other out-of-pocket costs for low-income consumers — seven million people this year.

In an interview with The Wall Street Journal this week, Mr. Trump threatened to withhold the subsidy payments as a way to induce the Democrats to bargain with him.

For now, Democrats are resisting and using his maneuver against him to energize their own party. And they warn that Mr. Trump will be blamed if the insurance markets collapse and people lose coverage next year.

“Republicans are in control of government,” Senator Claire McCaskill, Democrat of Missouri, said Thursday after a town-hall-style meeting in her home state. “If they blow up what access to health care there is right now, they’re going to own it.”

The president’s tone differs from that of Republicans in Congress, who have repeatedly promised a smooth transition away from the law they call Obamacare. “We don’t want to pull the rug out from under people,” the House speaker, Paul D. Ryan, has said.

If the subsidies are interrupted, insurers say, some health plans will increase premiums and others will withdraw from the individual insurance market. That will, in turn, affect millions of other people who do not receive the subsidies.

The issue could come to a head within weeks. When the House reconvenes on April 25, the first order of business will be a spending bill to replace the current stopgap law, which expires three days later. Democrats are determined to put money for the health insurance subsidies into that bill, and some Republicans on the House and Senate Appropriations Committees are open to the idea. But ultimately, the decision will be made by Republican leaders in the two chambers.

If the spending is allowed to continue, the Congressional Budget Office estimates that the federal government will pay $135 billion in cost-sharing subsidies to insurers from 2018 to 2027.

The cloud of uncertainty swirling around the subsidies stems from a court ruling in a lawsuit that House Republicans filed against the Obama administration in 2014. Judge Rosemary M. Collyer of the Federal District Court in Washington ruled last year that spending on the subsidies “violates the Constitution” because Congress never appropriated money for them. She ordered a halt to the payments, but suspended her order to allow the government to appeal.

The Trump administration has not made clear whether it will press the appeal filed by the Obama administration. In a letter to Mr. Trump this week, the U.S. Chamber of Commerce joined the American Medical Association, the American Hospital Association and insurers in seeking “quick action” to guarantee continuation of the subsidies. Without the subsidies, they said, more people will be uninsured and unable to pay medical bills.

Democrats say they will not negotiate with Mr. Trump until he stops his drive to repeal the Affordable Care Act. “President Trump is threatening to hold hostage health care for millions of Americans, many of whom voted for him, to achieve a political goal of repeal that would take health care away from millions more,” said the Senate Democratic leader, Chuck Schumer of New York.

 

 

The CBO report raises five serious questions

https://www.washingtonpost.com/blogs/right-turn/wp/2017/03/14/the-cbo-report-raises-five-serious-questions/?_hsenc=p2ANqtz-8z9Sylks_wibB_-6SdY9AQGBM3g03O-yrykjFdnlayePaRf6KdLp5erCdoZM5RZvXTKhGTRTUJKrOfKMio5kAnhglcYQ&_hsmi=45675040&utm_campaign=KHN%3A%20Daily%20Health%20Policy%20Report&utm_content=45675040&utm_medium=email&utm_source=hs_email&utm_term=.86ffca0b81b7

The Congressional Budget Office report on the American Health Care Act — showing that as many as 24 million people could lose health insurance, Medicaid would be drastically cut and older, poorer Americans would suffer the most — leaves us with a number of questions:

Why did House Speaker Paul Ryan (R-Wis.) force votes in two committees and then spring the disturbing CBO score, revealing that members voted rashly (not knowing the effects) or don’t care about loss of coverage and regressive consequences? Perhaps he is so convinced that his members will vote for anything that he made no effort to spare them from votes they one day (Election Day 2018, for example, and especially in districts Hillary Clinton carried) will regret. It is far from clear what he thought he was going to “get away with.” Unlike President Trump, he cannot merely dismiss inconvenient facts and plunge forward. Well, he can, but he puts his members’ seats and his own speakership at risk.

What’s the point of passing something so obviously unacceptable to the Senate? Sen. Susan Collins (R-Maine) blasted the effort: “The CBO estimate that millions of Americans could lose their health insurance coverage if the House bill were to become law is cause for alarm. It should prompt the House to slow down and reconsider certain provisions of the bill.” Her colleague and Trump supporter Sen. David Perdue (R-Ga.) echoed Sen. Tom Cotton’s advice on Sunday to “get this right.” Sen. Lindsey Graham (R-S.C.) argued, “[L]et’s say the CBO is half-right. That should be cause for concern. So, rather than attacking the CBO as the exclusive way of moving forward, I would think the prudent thing for the party to do is to look at the CBO report and see if we can address some of the concerns raised.” Sen. Bill Cassidy (R-La.) scoffedat the notion the bill would really save money. “Society is going to pay for health care whether it’s through insurance or not,” he remarked.

 

CBO: Republican healthcare bill would cover millions fewer than ACA but reduce federal deficit

http://www.fiercehealthcare.com/aca/cbo-republican-healthcare-bill-would-cover-millions-fewer-than-aca-but-reduce-federal-deficit?mkt_tok=eyJpIjoiTW1OaFl6TXlZVFF6WldKayIsInQiOiI3eHNMN1ZraGpJWHJ0eUFFRmdzaDRjVFVsOXBpV0VKVzdtWlU1UmxTbVZWRkpnMDhEN0Rrb3cyZlwvM0NmZnFJMXZTOG1KYXlLRHc0YWNUQzA3MmhpOVNQRFN4WmNsNUZVQmNQTGdPWE5UNUczUGppRUFGZ2dwelltaldGXC9IM3pWIn0%3D&mrkid=959610&utm_medium=nl&utm_source=internal

capitol

The Congressional Budget Office on Monday released its highly anticipated score of House Republicans’ healthcare bill, finding that it would increase the number of uninsured individuals by millions, but also lower individual market premiums in the long run and decrease the federal deficit.

Congress uses the CBO’s cost estimates to evaluate the effects of any major legislation, and policymakers were particularly eager to get its estimate for the American Health Care Act given the high political stakes associated with the bill.

Here’s a brief rundown of the CBO’s estimates (PDF):

  • In 2018, 14 million more people would be uninsured under the GOP bill than under the Affordable Care Act—mostly due to the repeal of the individual mandate penalties. By 2026, that number would swell to 24 million because of changes to subsidies in the individual market and in the Medicaid program.
  • Relative to projections for the ACA, the Republicans’ bill would lead to higher average premiums in the individual market before 2020—15% in 2018 and 20% in 2019—and lower average premiums after that. The CBO notes, though, that premium changes under the new proposal would differ “significantly” for people of different ages, given the bill’s provision that allows insurers to charge older customers up to five times more for coverage.
  • Enacting the legislation would reduce federal deficits by $337 billion from 2017 to 2026, with the largest savings coming from reductions in Medicaid spending and eliminating the ACA’s subsidies for individual market customers. The largest costs, on the other hand, would come from the bill’s elimination of many of the ACA’s taxes and its creation of a new tax credit for health insurance.
  • The CBO estimates that the individual market would probably be stable in most areas under either the ACA or the AHCA. While tax credits under the newly proposed bill would be less generous than the ACA’s subsidies, other changes such as grants to states from the Patient and State Stability Fund would lower average premiums enough “to attract a sufficient number of relatively healthy people to stabilize the market,” the agency said.

Before the score emerged, the Trump administration had already cast doubt on the merits of the CBO’s projections. White House Press Secretary Sean Spicer pointed out during a press briefing Monday that the agency had originally projected 24 million people would be enrolled through the Affordable Care Act exchanges as of 2016, but the number ended up being only about 10.4 million.

“The CBO was off by more than half last time,” he said.

Later, he acknowledged that some senators are likely to look at the CBO’s score when evaluating the American Health Care Act, and it’s important to remind them of the agency’s past track record.

Previously, The Commonwealth Fund issued an analysis that sought to dispel such criticism of the agency’s estimates about the ACA. It concluded that while the CBO overestimated marketplace enrollment and costs and underestimated Medicaid enrollment, overall its projections were “reasonably accurate,” and closer to realized experience than the estimates of many other prominent forecasters.

 

CBO report predicts 24 million would lose coverage by 2026 under American Health Care Act

http://www.healthcarefinancenews.com/news/cbo-report-predicts-24-million-would-lose-coverage-2026-under-american-health-care-act

Image result for CBO report predicts 24 million would lose coverage by 2026 under American Health Care Act

An estimated 14 million people would lose coverage under the American Health Care Act, a number that would rise to 24 million by 2026, according to a Congressional Budget Officer report released Monday afternoon.

Most of the initial loss would be due to repeal of the federal mandate for individuals to buy coverage, due to lack of a financial penalty and higher premiums.

Uninsured numbers would rise due to the bill’s repeal of Medicaid expansion. Some states would discontinue the expansion. Also per beneficiary spending caps would affect coverage, the CBO said.

Due to a lack of subsidies for insurance purchased in the nongroup market and to the Medicaid program, the increase in the number of uninsured people relative would rise to 21 million in 2020 and then to 24 million in 2026, the CBO said.

“In 2026, an estimated 52 million people would be uninsured, compared with 28 million who would lack insurance that year under current law,” the CBO said.

Premiums are expected to rise 15 to 20 percent in 2018 and 2019.

Older Americans would pay five times the amount on their premiums as compared to younger enrollees.

 

CBO ignites firestorm with ObamaCare repeal score

http://thehill.com/policy/healthcare/323652-cbo-millions-would-lose-coverage-under-gop-healthcare-plan

Image result for congressional budget office

The Congressional Budget Office (CBO) on Monday projected that the number of people without health insurance would grow by 14 million in 2018 under the Republican ­ObamaCare replacement bill, with that number rising to 24 million in a decade.

The bombshell estimate was larger than even many analysts had predicted, stirring fresh doubts about whether the legislation can pass ahead of a possible vote in the House next week.

Democrats highlighted President Trump’s campaign promises to provide “insurance for everybody,” saying the bill falls woefully short.

“The CBO’s estimate makes clear that TrumpCare will cause serious harm to millions of American families,” Senate Democratic Leader Charles Schumer (N.Y.) said in a statement.

“Tens of millions will lose their coverage, and millions more, particularly seniors, will have to pay more for health care. The CBO score shows just how empty the president’s promises, that everyone will be covered and costs will go down, have been.”

The CBO estimated that 24 million people would become uninsured by 2026 under the bill, largely due to the proposed changes to Medicaid. Seven million fewer people would be insured through their employers over that same time frame because some people would choose not to get coverage and some employers would decline to offer it.

The CBO calculated that premiums would decrease an average of 10 percent by 2026 after an initial increase of 15 percent to 20 percent due to the repeal of ­ObamaCare’s requirement that everyone buy coverage. Costs would rise for older people but fall for younger people, it said.

Out-of-pocket costs, including deductibles, “would tend to be higher” under the GOP plan than under ­ObamaCare because of looser requirements on insurers. High deductibles have been one of the GOP’s main lines of attack against ­ObamaCare.

 

Federalism and the End of American Healthcare Act

http://www.yalelawjournal.org/forum/federalism-and-the-end-of-obamacare

Federalism and the American Health Care Act

Image result for federalism and the american healthcare act

Republicans may talk the talk of devolving health care policy to the states, but that’s not what the American Health Care Act does. Instead, it starves health reform of the funding upon which it depends.

Most significantly, Republicans intend to phase out the Medicaid expansion and to impose a hard cap on federal contributions. If a recession forces a state to exceed its cap in a given year, any overruns will come out of its Medicaid payments the following year. With that kind of shortfall, the states will have to make savage Medicaid cuts to make ends meet.

Republicans also want to slash the subsidies that make insurance affordable in the private market. Under the ACA, no one making less than four times the poverty level has to devote more than 10 percent of her income toward private coverage; most pay much less. The American Health Care Act would erase that affordability guarantee and, instead, extend age-based subsidies that would be much too meager for most people to afford coverage.

If federal money is withdrawn, states will be stuck. Because of the countercyclical trap and ERISA, they won’t be able to enact and sustain coverage expansions on their own. The end result will not be the diversity that federalism celebrates. It will be a uniformly crappy system that leaves millions of the sick and poor without coverage.

It doesn’t have to be this way. A group of Republican senators led by Bill Cassidy (R-LA) and Susan Collins (R-ME) has floated an alternative, the Patient Freedom Act of 2017, that retains the ACA’s funding streams while giving the states more room to choose how to use that money. That’s a model that deserves serious attention from both Republicans and Democrats. It might enable partisans on both sides move past the rancorous debate over the ACA.

For now, however, the Republicans seem intent on dismantling coverage gains across the entire United States. Their proposals trade on the rhetoric of states’ rights, but they would have the perverse effect of inhibiting state power. That’s bad for federalism — and bad for the country.

 

Fitch: Changes to Medicaid in ACA repeal bill pose risks for hospitals

http://www.beckershospitalreview.com/finance/fitch-changes-to-medicaid-in-aca-repeal-bill-pose-risks-for-hospitals.html

Image result for hospital credit ratings

House Republicans’ proposed ACA repeal and replacement plan, known as the American Health Care Act, calls for changes to Medicaid that expose states and hospitals to new fiscal risks, according to a Fitch Ratings report.

The AHCA would eliminate Medicaid’s entitlement structure and restructure the program’s federal funding to a per-capita cap system on Jan. 1, 2020. This change is intended to slow Medicaid spending growth. The Kaiser Commission on Medicaid and the Uninsured estimates switching to a per-capita cap system would reduce federal spending on Medicaid by $1 trillion (or 26 percent) over 10 years. This reduction would require states to make significant budgetary changes and could result in reduced reimbursement for hospitals, according to the report.

The AHCA calls for the government to freeze expanded Medicaid programs on Jan. 1, 2020, and restrict funding only to people who were enrolled in the expanded programs as of Dec. 31, 2019. Under the ACHA, states that expanded Medicaid “will be faced with a unique policy predicament of denying Medicaid access to individuals who would otherwise qualify beginning in 2020, or taking on significant costs they had anticipated would be bored largely by the federal government,” according to Fitch.

Moody’s: GOP’s American Health Care Act is credit negative for nonprofit hospitals

http://www.beckershospitalreview.com/finance/moody-s-gop-s-american-health-care-act-is-credit-negative-for-nonprofit-hospitals.html

OR Efficiencies

If House Republicans’ proposed ACA repeal and replacement plan, known as the American Health Care Act, were to become law in its current form it would be credit negative for nonprofit hospitals, according to Moody’s Investors Service.

The components of the AHCA most likely to negatively affect hospitals are transitioning federal Medicaid payments to a per-capita payment to the states, the Medicaid expansion freeze in 2020 and how subsidies are calculated for individuals who purchase insurance on the exchanges, according to Moody’s.

Under the legislation, the uninsured rate would rise, which would cause hospitals’ bad debt and uncompensated care costs to increase, according to Moody’s.

The AHCA’s retention of Medicaid expansion and elimination of scheduled disproportionate share cuts for states that did not expand Medicaid would have a positive impact on nonprofit hospitals, according to Moody’s. However, the rating agency said the positive effects are not enough to compensate for the credit negative components of the AHCA.

Getting the Brush-off on Health

http://otherwords.org/getting-the-brush-off-on-health/

health-care-obamacare

Someone recently asked me whether I consider myself a liberal or a conservative on healthcare. But what does that even mean?

We all want the same thing: affordable coverage we can actually use, lower costs, and a healthier population. I don’t think the ACA achieved all of these goals, but getting coverage for over 20 million people was a huge step in the right direction.

Why tear down years of progress and start from scratch when we can simply fix what we have?

Behold the G.O.P. Civil War on Health Care

 

As people began to digest the Republican health care plan on Tuesday, a few things became clear:

1. “This isn’t an Obamacare repeal, it’s a Medicaid repeal,” as the political writer Jonathan Allen put it.

Many Republicans have long viewed Medicaid — a health insurance program for the poor, the disabled and some elderly — with skepticism. This plan would make very large cuts to the program. The details are somewhat technical, and Edwin Park of the Center on Budget and Policy Priorities explains them. But the real-world effects will be concrete: Many people will lose coverage, and some kinds of care, if the bill becomes law.

2. Conservative policy experts hate the bill, and the criticisms come from both the far right and the center right.

Peter Suderman of Reason had an excellent frame for understanding the right’s civil war over health care: Conservatives don’t even agree on what their goals are. Making health care less expensive? Reducing the government’s role? Ensuring that the poor receive fewer subsidies?

Lacking this agreement, many Republicans have pretended that a magical health plan exists, one that would cover everyone, provide good insurance and cost less money. Wouldn’t that be nice!