http://www.politico.com/story/2017/05/24/cbo-obamacare-repeal-health-care-238795
Here are some key facts and figures from the new CBO report on the American Health Care Act, the House-passed bill to repeal and replace Obamacare. CBO stressed the uncertainty of its estimates, given that it’s hard to know which states would take up the chance to opt out of certain key parts of Obamacare. All figures are for the decade spanning 2017-2026 unless otherwise specified.
Senate Republicans are showing early divisions over what to do about ObamaCare’s protections for people with pre-existing conditions.
Some conservatives, including Sen. Mike Lee (R-Utah), want to simply repeal those provisions and other ObamaCare regulations and leave them up to the states.
But advocates of a more centrist approach, like Sen. Bill Cassidy (R-La.), are speaking out in favor of pre-existing condition protections and endorsing a “Jimmy Kimmel test” for the bill, where no one can be denied coverage.
Other senators are exploring a middle ground where states would have to automatically enroll people in health insurance before they could get a waiver for the regulations, though conservatives object to that idea as Washington overreach.
The disagreements over what to do about preexisting conditions point to the larger difficulty facing Senate Republicans as they seek to find consensus on a host of contentious issues in the healthcare bill.
Pre-existing Conditions and Medical Underwriting in the Individual Insurance Market Prior to the ACA
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Before private insurance market rules in the Affordable Care Act (ACA) took effect in 2014, health insurance sold in the individual market in most states was medically underwritten.1 That means insurers evaluated the health status, health history, and other risk factors of applicants to determine whether and under what terms to issue coverage. To what extent people with pre-existing health conditions are protected is likely to be a central issue in the debate over repealing and replacing the ACA.
This brief reviews medical underwriting practices by private insurers in the individual health insurance market prior to 2014, and estimates how many American adults could face difficulty obtaining private individual market insurance if the ACA were repealed or amended and such practices resumed. We examine data from two large government surveys: The National Health Interview Survey (NHIS) and the Behavioral Risk Factor Surveillance System (BRFSS), both of which can be used to estimate rates of various health conditions (NHIS at the national level and BRFSS at the state level). We consulted field underwriting manuals used in the individual market prior to passage of the ACA as a reference for commonly declinable conditions.
Medicaid, the nation’s public health insurance program for low-income children, adults, seniors, and people with disabilities, covers 1 in 5 Americans, including many with complex and costly needs for medical care and long-term services. Most people covered by Medicaid would be uninsured or underinsured without it. The Affordable Care Act (ACA) expanded Medicaid to reach low-income adults previously excluded from the program and provided federal funding to states for the vast majority of the cost of newly eligible adults.
President Trump and other GOP leaders have called for far-reaching changes to Medicaid, including caps on federal funding for the program. In the debate about Medicaid’s future, some critics of the program have made statements that are at odds with data, research, and basic information about Medicaid. To inform policy decisions that may have significant implications for Medicaid, the low-income people it serves, and the states, this brief highlights 10 key Medicaid facts.
http://www.chcf.org/publications/2017/03/employer-health-benefits
The majority of Californians rely on their employers for health insurance, but these benefits continue to shrink as the cost to workers continues to rise.
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 California firms reported providing health insurance to employees in 2016, down from 69% in 2000. Implementation of the Affordable Care Act (ACA) in 2014 does not appear to have impacted the overall trend in employer offer rates.
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.
For those with pre-existing medical conditions, the House-passed health bill became notorious for a last-minute addition that would let insurers once again charge them higher premiums in the individual market based on their health status. But the focus on this single provision distracts from a troubling fact: even without it, the bill would threaten health care for those with pre-existing conditions in four broader ways.
A per capita cap would set annual limits on federal funding per beneficiary that would grow more slowly than actual health care costs. A block grant would cap the amount of overall federal Medicaid funding the state could receive. Either way, states would receive significantly less federal funding compared to current law, under which the federal government pays a fixed share of state Medicaid costs, and the funding cuts would grow deeper each year.
Faced with large cuts in federal funding, states would have no choice but to sharply cut their programs. Consequently, tens of millions of people with pre-existing conditions – including millions of children with disabilities and special health care needs – would face the threat of Medicaid cuts. They could lose coverage entirely or go without needed care as states scaled back covered benefits and payments to medical providers.
Home- and community-based services, an optional Medicaid benefit that most states already limit based on available funds, would be at particular risk. These services, which include nursing and home health care and help with chores, meals, transportation, and other services, let seniors and other low-income people with serious health problems remain in their homes instead of having to go to a nursing home.
That would force states to pay three to five times more for the ACA’s Medicaid expansion. Most or all of the 31 states and Washington, D.C. that have adopted it would have no choice but to drop it because they could no longer afford it.
The Medicaid expansion now covers 11 million people, including many who have pre-existing conditions. For example, almost 30 percent of those benefitting from the Medicaid expansion have a mental illness or substance use disorder. By effectively ending the Medicaid expansion starting in 2020, the House bill would leave millions of low-income people with pre-existing conditions without coverage.
For example, a 60-year-old woman with $22,000 of annual income who faced the national average benchmark premium would pay $8,200 more in premiums after accounting for federal tax credits than she does now. The Congressional Budget Office projects that uninsured rates for people age 50-64 would double due to the House bill. Some 84 percent of people age 55-64 have pre-existing health conditions.
Plans would no longer need to offer a comprehensive set of benefits and could exclude even core benefits such as maternity services and mental health care. Nor would they have to limit the amount that people with expensive health care must pay out-of-pocket for deductibles and other cost-sharing each year. Insurers could again place annual and lifetime limits not only on individual and small-group plans but also on coverage that people get from large employers, leaving millions with costly pre-existing conditions to once again worry about exhausting their benefits.
All told, then, the House bill would bring back the highly-flawed, pre-ACA individual insurance market that made it impossible for millions with pre-existing conditions to get adequate, affordable health coverage. Additionally, it would threaten the coverage of millions of Medicaid recipients with pre-existing conditions.
That’s not a health care system that should make us proud.
When stripped of emotion and hyperbole, the debate about repealing and replacing the Affordable Care Act (ACA) is fundamentally about how to stretch limited funds to offer health care to two populations in need: the poor, who receive health care through Medicaid, and the “near-poor,” who were frequently without coverage prior to the ACA’s enactment. While millions of the near-poor remain uninsured today, six out of 10 limited-income individuals who purchased health care through the ACA’s health insurance Marketplaces were uninsured prior to the ACA. It is this near-poor and recently insured population, and how to cost-effectively provide health care for them, that is the focus of this post.
Many insurers have ably managed their sicker- and poorer-than-expected Marketplace membership by borrowing from the playbook of the most similar market, Medicaid. In short, we believe that the “Medicaidization” of the Marketplaces is a necessary and positive trend, and we remind policy makers that regardless of legislation or regulatory change, health plans must employ the Medicaidization playbook to well-serve a population that both parties believe needs coverage.
Health insurance Marketplaces—the centerpiece of the ACA—provide health insurance in government-refereed individual and small-group markets. However, health plans offering coverage through Marketplaces have been confronted with challenges. Enrollment is roughly 12 million, far behind original Congressional Budget Office projections of 21 million by 2016. This is largely because fewer employers than expected dropped employee coverage after the law passed and because many younger and healthier people have chosen to remain uninsured or covered by their parents’ insurance. As a whole, Marketplace enrollees are sicker and more costly than expected, and more than 80 percent receive means-tested subsidies to buy down some of their insurance costs. Furthermore, lawsuits and congressional actions have hobbled the ACA’s risk mitigation programs and threaten its subsidies. As a result, several health plans left the Marketplaces in 2017 in many states, and at least one—Humana—will exit entirely in 2018.
While the struggles of the ACA-reformed markets and the insurers that operate within those markets are well-documented, there have also been some success stories. Medicaid-focused health plans, as well as commercial plans that adopted tactics common in the Medicaid market, have performed at near break-even or better while serving the near-poor population in the Marketplaces. The relative success of Medicaid-focused plans in the Marketplaces contrasts with the struggles of national for-profit insurers and has led to the Medicaidization of the Marketplaces.
The term “Medicaidization” is not new to this post. It has been used by others, sometimes with a negative connotation. So it is helpful to define the term more precisely. Medicaidization, as used here, describes a set of practices—from sensitivity to sociocultural issues to utilization management—that have evolved to serve the Medicaid population. Because of socioeconomic disadvantage and poor health, this population responds to its health care needs very differently than other populations. However, the term “Medicaidization” belies the fact that health plans beyond those that focus on Medicaid are capable of deploying these same practices—such as several Blues and provider-owned plans—as described below.
A rival group of Republican senators is seeking leverage to influence the direction of the Senate’s ObamaCare replacement bill.
The group, led by Sens. Susan Collins (R-Maine) and Bill Cassidy (R-La.), has been meeting “a couple times a week,” according to Sen. Shelly Moore Capitol (R-W.Va.).
Cassidy is a physician and Collins is a former state insurance commissioner. Both have been outspoken opponents of the House-passed American Healthcare Act, and have co-sponsored their own version of an ObamaCare repeal bill called the Patient Freedom Act.
Cassidy told The Hill he and Collins have been meeting with Senate leaders to talk about their legislation. However, he noted the politics of the Senate mean that every member’s voice matters.
“When you only have 52 senators, everybody has significant leverage. That tight vote margin means everyone is essential,” Cassidy said.
The main GOP working group on healthcare includes 13 men backed by Senate leadership who are seeking to bridge the divide between conservatives and centrists.
What ever legislation emerges from that group is likely to be the bill that comes to the Senate floor.
But if all of the Senate’s Democrats oppose the measure, Senate Majority Leader Mitch McConnell (R-Ky.) will only be able to afford two defections.
That gives the other group leverage.
“Let’s look at it practically,” Capito told The Hill. “You can only lose two votes on any one issue … so I think a bloc of four or five can be very effective.”
Health lobbyists have noted many members of the leadership-led group have been fairly measured in their criticisms of the House bill approved earlier this month.
Collins and Cassidy, in contrast, both seem keen on turning sharply from the House bill.
The House managed to narrowly pass its ObamaCare repeal bill by finding a delicate balance between hard-line conservatives and moderates. Now the Senate is looking to achieve the same feat, only with a smaller margin for error.
Senate moderates have already put their markers down on the healthcare issues that concern them the most. Individual senators hold much more power in advancing the health bill than individual House members, and if Senate Republicans can’t find a balance among their caucus, the ObamaCare repeal effort could be doomed.
The Senate will only need 51 votes to pass the bill, but because of their slim majority, Republicans can only afford to lose two votes.
The centrist senators have several major concerns with the House bill, known as the American Health Care Act (AHCA), most notably its changes to Medicaid.
The Affordable Care Act allows states to expand Medicaid coverage to more people, funded mostly by the federal government. So far, 31 states and D.C. have done so.
Even as the healthcare bill was working its way through the House, moderate GOP senators hailing from states that took the Medicaid expansion objected to the proposed cuts to the program.
In early March, Republican Sens. Rob Portman (Ohio), Shelly Moore Capito (W.Va.) Cory Gardner (Colo.) and Lisa Murkowski (R-Alaska) sent a letter to Majority Leader Mitch McConnell (R-Ky.) objecting to the Medicaid cuts in the House bill. “We will not support a plan that does not include stability for Medicaid expansion populations or flexibility for states,” the lawmakers wrote.
The legislation has changed since then, but the Medicaid provisions have been largely left alone. The House bill would undo ObamaCare’s Medicaid expansion by 2020, and would cut over $800 billion from the program.
After the House passed the legislation last week, Portman, Capito and Sen. Dean Heller (R-Nev.) were quick to say they still opposed the bill because of the Medicaid provisions.
Capito on Monday said she would like to see some form of Medicaid expansion remain permanent.
“I have seen a lot benefits to the Medicaid expansion in our state, particularly in the mental health and opioid and drug abuse areas,” Capito told reporters. As for the people who have gained coverage through expansion, Capito said “you can’t just drop them off and wish them good luck. “
Moderates have also objected to the fact that the most recent estimates of an earlier version of the House bill would have resulted in 24 million fewer people having insurance coverage over a decade.
Sen. Bill Cassidy (R-La.) has crafted, along with Collins, a different ObamaCare replacement bill that would allow states to decide whether they want to keep ObamaCare or enact something different.
Cassidy has repeatedly objected to the House version of the legislation because he says it doesn’t fulfill President Trump’s promises to “lower premiums, maintain coverage and protect those with pre-existing conditions.” During a May 8 speech at the American Hospital Association, Cassidy said that while the AHCA may lower premiums, it does so by giving people “terrible coverage.”
Aside from coverage issues, abortion is also likely to cause some headaches in the Senate.
The primary group in the Senate working on the bill includes prominent conservatives like Ted Cruz (R-Texas) and Mike Lee (R-Utah), who are likely to insist that the Senate keep a provision from the House that largely strips Planned Parenthood of funding. But Collins has said any Planned Parenthood language is a non-starter.
Moderates are also likely to insist on making sure language is removed from the House bill that would prohibit the bill’s tax credits from being used to purchase coverage on insurance plans that cover abortion. That could be a major problem for conservatives, especially if the revised bill is to have any chance at passing the House again.
Senate Majority Whip John Cornyn (R-Texas) on Monday acknowledged the balancing act leaders will need to pull off. “Now it’s a question of building consensus within the Republican conference. All 52 Republican senators are going to be part of the process … because we’re going to need everybody.”
Cornyn also said he wasn’t concerned about losing votes if the Planned Parenthood language remained in the bill.
A Squeaker In The House Becomes Headache For The Senate: 5 Things To Watch
After weeks of will-they-or-won’t-they tensions, the House managed to pass its GOP replacement for the Affordable Care Act on Thursday by a razor-thin margin. The vote was 217-213.
Democrats who lost the battle are still convinced they may win the political war. As the Republicans reached a majority for the bill, Democrats on the House floor began chanting, “Na, na, na, na … Hey, hey, hey … Goodbye.” They claim Republicans could lose their seats for supporting a bill that could cause so much disruption in voters’ health care.
Now the bill — and the multitude of questions surrounding it — moves across the Capitol to the Senate. And the job doesn’t get any easier. With only a two-vote Republican majority and no likely Democratic support, it would take only three GOP “no” votes to sink the bill.
Democrats have made clear they will unanimously oppose the bill. “Trumpcare” is just a breathtakingly irresponsible piece of legislation that would endanger the health of tens of millions of Americans and break the bank for millions more,” said Senate Minority Leader Chuck Schumer (D-N.Y.).
And Republicans in the Senate have their own internal disagreements, too.
Here are five of the biggest flashpoints that could make trouble for the bill in the upper chamber.
HENRY KOTULA 