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Pre-existing conditions drive moderates’ concern over repeal bill
Moderate Republicans are largely withholding their support for the Obamacare repeal bill, arguing it would hurt people with pre-existing conditions
House Republican leaders hoped that the House Freedom Caucus’s endorsement of the latest Obamacare repeal bill would light a fire under enough moderates to get their whip count to the 216 votes needed to pass the measure. Instead, the holdouts are digging in, saying that the latest changes only moved the bill to the right and could put more Americans at risk of losing their health insurance.
“My concern has always been and what a lot of us talked about: people with pre-existing conditions, the elderly,” said Rep. Mario Díaz-Balart (R-Fla.). “How this makes the original bill better? Where is the part that is better for the folks I’m concerned about it? I’m not seeing it at this stage.”
Protections for people with pre-existing conditions have only been in effect for seven years, but proven to be one of the most popular and well-known features of the Affordable Care Act. Moderate Republicans are worried about stripping the safeguards without a reliable replacement. If the resistance from moderates holds, it would be enough to block Obamacare repeal in the House — or send the effort back to square one.
GOP leaders have been buttonholing moderates for two days, arguing that the latest changes — drafted by Rep. Tom MacArthur (R-N.J.) with consultation from the House Freedom Caucus — would ensure people with pre-existing conditions wouldn’t be priced out of a reconfigured market, pointing to high-risk pool requirements in state that choose to opt out of Obamacare provisions.
Backers of the repeal measure say the bill protects people with pre-existing conditions, arguing that people with coverage, for instance, can’t be priced out if they maintain it.
But buying into the plan would pose big political risks for centrists in swing districts. Voicing concerns about pre-existing conditions could prevent a tough vote on an issue that Democrats would surely spotlight in the 2018 election.
Several Republican sources say at least some moderates have climbed aboard, but they’re not inclined to say so publicly. House Appropriations Chairman Rodney Frelinghuysen (R-N.J.), who was widely panned by fellow Republicans for not supporting an earlier version of the repeal bill given his high-profile post, is expected to now support it, according to several sources.
Other than Frelinghuysen, there are no moderates who have publicly flipped to support the bill.
Republicans can absorb no more than 22 defections (depending on how many members are seated when the vote is held) from the 238-member Republican conference. The leaders still need fewer than 10 votes, according to several sources.
Rep. Ryan Costello (R-Pa.) said the latest changes to the bill didn’t bring him to a yes.
“Protections for those with pre-existing conditions without contingency and affordable access to coverage for every American remain my priorities for advancing healthcare reform, and this bill does not satisfy those benchmarks for me,” he said in a statement.
Rep. Barbara Comstock (R-Va.), one of the most vulnerable Republicans in 2018, said she is still a no. Rep. Carlos Curbelo of Florida is undecided— he’s still talking with leadership but claims no one is twisting his arm.
“They know better than to pressure me,” he said.
It’s not just traditional moderates who have qualms. Rep. Chris Smith (R-N.J.), who is very conservative on most social issues, is still a no.
Rep. Pete King (R-N.Y.) doesn’t want Obamacare’s Medicaid expansion repealed under the latest GOP plan, but told POLITICO he would vote to move the bill forward and assumes the Senate would restore Medicaid expansion. If the bill were to come back with Medicaid repealed, “it would be a problem,” he said.
The latest changes may have even eroded the support of moderates who backed the earlier repeal bill that was pulled in March. Rep. Adam Kinzinger of Illinois said he’s undecided. Rep. Steve King of Iowa, one of the House’s most conservative members, told reporters he’s undecided now, too.
Rep. Jim Renacci (R-Ohio), who supported the original repeal bill, is undecided but inclined to move the process forward.
“My biggest concern is that we’re changing things based on amendments written in backrooms and not everyone knows what is said and what’s part of the deal,” he said.
Some Republicans just don’t want to talk about it.
Rep. Darrell Issa of California paused to hear a reporter’s question on his vote, then kept walking.
4 key questions surrounding Obamacare repeal
House Republicans are mounting yet another effort to tear down Obamacare and remake the health care system — but the path to delivering on one of the GOP’s longest-standing priorities remains complicated and fraught with uncertainty.
House GOP leadership is working furiously to rally support for its Obamacare repeal bill amid threats of a government shutdown, rebellion within its ranks and dire warnings about the consequences for the nation’s most vulnerable Americans. The Trump administration and Republican leaders contend they’re drawing closer to a deal. Still, the situation is more fluid than ever. Here’s where things stand on the biggest outstanding questions:
Give it to us straight: Is the House going to vote on Obamacare repeal this week?
The official answer is no — at least not yet. The Republican leaders are working behind the scenes to win over enough lawmakers to get the 216 votes they need. They’re not there, and there’s little expectation that enough holdouts will flip in time for a Friday vote.
“We’re going to go when we have the votes,” Speaker Paul Ryan said this morning. “It takes time to do that.”
Republicans can only absorb 22 defections — and preliminary counts suggest there are more than that number either opposed to the bill or still undecided. Most are moderate Republicans still wary of provisions in the bill that would roll back Obamacare’s expansion of Medicaid and give states new opportunities to opt out of some of the health law’s core provisions.
The bill has changed a lot since it was first introduced. What would the latest version actually do?
The core elements of the GOP’s original American Health Care Act remain intact — the measure would eliminate big parts of Obamacare, such as its requirement that everybody purchase health insurance, and it would replace the law’s subsidies with a new set of tax credits to help pay for coverage. Those credits would be less generous than what’s offered under Obamacare, and the amount people would receive is based on their age.
The legislation also would overhaul Medicaid, rolling back its expanded coverage and capping its federal funding.
Originally, Republicans planned to keep several other major Obamacare provisions intact. But the changes proposed by the new Tom MacArthur amendment would let states apply for waivers to opt out of federal requirements that insurance plans cover a minimum set of benefits, and reopen the door to charging more based on a person’s health status under certain circumstances. States that take advantage of that flexibility would have to set up a high-risk pool or some other program to ensure that people would not be priced out of the market.
Those changes were essential to winning support from conservatives who complained that the original bill didn’t go far enough to repeal Obamacare. But that shift also threatens to alienate moderates, who were already nervous about leaving more people uninsured.
Who are these moderates? And what will it take to get them on board?
Many of the Republican holdouts belong to the Tuesday Group, the caucus of some 50 centrist House members. Their opposition was key to the GOP’s last-minute decision to abandon a planned vote on Obamacare repeal last month, and they’re still standing in the way. The moderates’ objections vary, but they essentially have one concern: That the repeal bill would leave far more people uninsured than there are with Obamacare.
So far, it looks like that concern hasn’t yet been addressed. The latest version of the bill would retain the phase-out of Obamacare’s Medicaid expansion and wouldn’t make the tax credits more generous. On top of that, the new state waivers could result in more people seeing higher premiums and fewer benefits. The AHCA’s proponents disagree, maintaining that the legislation would incentivize states to customize the health care system to residents’ needs. But it’s not clear that the argument has won over many centrists.
Exactly how many more uninsured are we talking about under the AHCA?
That’s not clear, and won’t be without an updated estimate from the nonpartisan Congressional Budget Office. The agency’s evaluation of the original bill predicted that 24 million more people would end up without coverage over a decade, than there are with Obamacare — losses that would come largely as a result of the restructuring of Medicaid.
But the legislation has changed several times since then, and the CBO hasn’t had an opportunity to take a second look. In fact, it may not do so until after the House votes, assuming that Republicans bring the bill to the floor in the next couple of weeks. The CBO told lawmakers’ offices that it won’t have time to fully reevaluate the revised bill, according to Democrats, and Republicans already under pressure to show progress on the bill don’t seem worried about plowing ahead without a new score.
How Medicaid Enrollees Fare Compared with Privately Insured and Uninsured Adults
Abstract
Issue: The number of Americans insured by Medicaid has climbed to more than 70 million, with an estimated 12 million gaining coverage under the Affordable Care Act’s Medicaid expansion.1,2 Still, some policymakers have questioned whether Medicaid coverage actually improves access to care, quality of care, or financial protection.
Goals: To compare the experiences of working-age adults who were either: covered all year by private employer or individual insurance; covered by Medicaid for the full year; or uninsured for some time during the year.
Method: Analysis of the Commonwealth Fund Biennial Health Insurance Survey, 2016.
Findings and Conclusions: The level of access to health care that Medicaid coverage provides is comparable to that afforded by private insurance. Adults with Medicaid coverage reported better care experiences than those who had been uninsured during the year. Medicaid enrollees have fewer problems paying medical bills than either the privately insured or the uninsured.
Can Obamacare Survive Another Round in the Congressional Boxing Ring?
The Affordable Care Act (ACA) has survived its biggest challenge to date with the failed attempt to repeal and replace by the GOP. But will it survive in the long run? Republican comments and President Trump’s many tweets would suggest the law is still doomed. It is hard to predict what will happen, but let’s examine some themes we are seeing so far to try to gain some insight:
One of the first things the GOP Congress wanted was to retract the cost sharing payments to insurers for low-income exchange plan members. Without these payments, insurers would lose even more money, driving many of them to not offer plans in the state exchanges. The jury is still out on whether the replacement bill’s failure will move the budget reconciliation process forward, but insurers have only two months to decide if they will provide a plan in the exchanges for 2018. If insurers do decide to stay in the exchanges, significant premium increases are very likely to help cover their costs. This will force many people who cannot afford the monthly cost to drop out of coverage. Either of these situations would push people back into the uninsured ranks where providers would lose that reimbursement revenue and drive up uncompensated care.
Loosening the individual mandate’s enforcement is another theme being discussed. New HHS Secretary Price has stated he plans to allow states to loosen the restrictions on waivers for the individual mandate. Combined with premium increases, this would allow people to opt out of coverage much more easily. The CBO report has stated 7 million people would have opted out of coverage if the American Health Care Act (AHCA) had been passed, since many people do not think they need it. Most of these people would be younger and healthier, creating higher costs for insurers, while driving up premiums and/or driving insurers to exit the exchange.
Secretary Price has also mentioned giving states the ability to set requirements to individuals to maintain Medicaid coverage, like applying for work. Studies have shown in the past this activity causes people to fall out of coverage. It is expected that this move would cause many to fall off the Medicaid roles and drive them to the uninsured ranks as well.
The federal deficit is upwards of $540 billion for 2017. And If the ACA does not change at all, then the federal government is expected to spend $1.2 trillion on Medicaid coverage alone through 2026. Previous CBO estimates indicate this would drive our yearly national deficit to over a trillion dollars in 10 years. The U.S. economy survives today because financial institutions buy treasury bonds to fund that deficit each year. But when deficits reach the heights predicted if the ACA remains entirely intact, and the national debt reaches a significant portion of our yearly GDP, bond sales could and likely will slow down. That means damage to the U.S. economy as it continues to stabilize post-recession.
A federal budget has been submitted that makes some spending cuts, but without the AHCA’s passage they pale when faced with the real problem of balancing our budget. This is not an indictment of policy to cover people with insurance, but simply a fact that our nation must find a way to balance our finances. There are many ways to cut cost, but the GOP seems fixated on cutting Medicaid spending as the key to accomplishing this.
We can only theorize what might become of the ACA, but looking at some of the themes and recent comments by the current administration, it would appear some things will change if not a complete revisit of the repeal and replace bill. Will those changes effectively kill the law since it will lack the ability to function as planned? Quite possibly, but only time will tell.
Change will happen. It will result in some sort of reimbursement cuts and very likely push more people back to the uninsured roles. Providers need to ready themselves, and start thinking about ways to improve productivity and reduce the cost to collect while increasing cash collections.
Shawn Yates serves as Director of Product Management for Ontario Systems, defining the company’s strategy for product and service offerings in the health care market. With over 20 years of experience managing self-pay receivables and collection operations for a top 20 health care system, Shawn’s background also includes working for a national outsourcing company helping clients manage their insurance and self-pay receivables, and Experian Health, the largest data and analytics company in the country.
Revised ACA Repeal-and-Replace Bill Likely to Increase the Uninsured Rate and Health Insurance Costs for Many
http://www.commonwealthfund.org/publications/blog/2017/apr/amendment-aca-repeal-and-replace-bill
News outlets report that House Republicans are close to agreeing on an amended version of the American Health Care Act (AHCA), their proposed repeal and replacement of the Affordable Care Act (ACA). The all-important legislative language for the revised bill is not yet available, nor are Congressional Budget Office (CBO) projections of its effects on coverage and the budget, so any analyses are necessarily tentative.
Nevertheless, the summaries leaked to the media offer insight on the amended bill. If accurate, those summaries suggest that the revised AHCA will significantly increase the numbers of uninsured Americans, raise the cost of insurance for many of the nation’s most vulnerable citizens, and, as originally proposed in the AHCA, cut and reconfigure the Medicaid program. The new amendment specifically allows states to weaken consumer protections by, for example, permitting insurers to charge people with preexisting conditions higher premiums.
What the Amendment Leaves in Place
The amended proposed bill does little to change many provisions of the original AHCA including:
- a phase out of the ACA’s Medicaid expansion;
- capped federal payments to states for their Medicaid programs;
- flat premium tax credits for individual market coverage that adjust for age but not income or premiums;
- the option for insurers to charge older people as much as five times what they charge young people;
- replacement of the ACA’s individual mandate penalties with a premium surcharge for those who fail to maintain continuous coverage;
- repeal of taxes that helped fund the ACA’s coverage provisions;
- state funding for reinsurance or other programs to stabilize the individual market.
The CBO estimated in March that the combined effects of these provisions would increase the number of people without health insurance by 24 million by 2026. Older Americans would be particularly hard hit by the bill, experiencing much higher premiums relative to the ACA and the greatest coverage losses.
What the Amendment Changes
The amendment offers states the option to apply for waivers to reduce ACA consumer protections that have enabled people with health problems to buy private health insurance. States could waive the ban on charging people with preexisting conditions higher premiums, as long as states set up high-risk pools for people with conditions like cancer or heart disease who could no longer afford coverage. States could also change the ACA’s required minimum package of health benefits for health plans sold in the individual and small-group markets.
Despite the fact the federal ban on preexisting condition exclusions would remain under the AHCA, as Tim Jost points out, insurers could reach the same end by not covering services like chemotherapy that sick people need, or by charging very high premiums for individuals with expensive, preexisting problems. In addition, waiving the ACA’s essential benefit requirement could weaken other consumer protections like bans on lifetime and annual benefit limits and caps on out-of-pocket costs.
While states that allowed higher premiums for people with health problems would be required to use a high-risk pool under the amendment, prior research has found that such pools operated by states before the ACA were expensive both for states and for people enrolled in them, and covered only a small fraction of the individuals who would have benefited. An amendment proposed earlier in the month would provide federal funds for a so-called “invisible risk-sharing” program, a hybrid between a high-risk pool and reinsurance for high claims costs, but the allocated funding would likely need to be much higher to have an impact on costs.
The number of states that would apply for these waivers is unknown, but it seems reasonable to expect that many states with governors and legislatures that have opposed the ACA would do so. For a substantial part of the country, therefore, the amendment could seriously undermine the ACA’s protections for people with preexisting health conditions.
Long-term care insurance facing major pricing shift
One of the biggest fears people have about retirement is getting sick and running out of money to cover their health issues.
So in comes long-term care insurance, which can cover the cost of nursing homes, assisted-living facilities and in-home care. Medicare — except in very limited situations — does not cover long-term care. Medicaid covers long-term care, but to qualify for the benefit, you have to be pretty poor.
If you need help with life’s basic activities — eating, dressing and bathing — it can be expensive and the cost of that care can decimate your savings.
The problem is that there have been some steep premium increases for long-term care insurance, and it has many people wondering if the insurance is worth it. Insurance companies have had trouble pricing the insurance. Initial premiums charged haven’t been enough to cover claims.
But how the insurance is priced may be changing significantly. Rather than keeping premiums steady for several years and then having to impose huge double-digit rate hikes, Genworth, one of the largest providers of long-term care insurance, wants to be have the ability to change premiums annually, reports Forbes contributor Howard Gleckman.
“In this design, unfortunately called the Annual Rate Sufficiency Model, buyers of new policies would likely see modest, single-digit rate hikes each year or two,” Gleckman writes. “If Genworth thinks it is likely to pay fewer claims than expected or if investment income is higher than projected, consumers might even see small rate reductions in some years.”
He goes on: “For years, some brokers told buyers that their premiums would never increase. But in reality, while carriers could not raise rates on individual policies, they could boost prices for an entire class of buyers. They often delayed those rate hikes — or were blocked by state insurance commissioners — for five years or more, until policyholders got hammered with increases of 40 percent and up.”
High-Risk Pools for People with Preexisting Conditions: A Refresher Course
During the recent effort to repeal and replace the Affordable Care Act (ACA), some members of Congress and the Trump administration seemed to be experiencing a certain nostalgia for high-risk pools, which operated in 35 states before the ACA was enacted. At a CNN Town Hall Meeting in January, Speaker of the House Paul Ryan responded to a question about coverage for people with preexisting conditions by saying:
We believe that state high-risk pools are a smart way of guaranteeing coverage for people with preexisting conditions. We had a really good one in Wisconsin. Utah had a great one . . . . What I mean when I say this is, about 8 percent of all the people under 65 have that kind of preexisting condition . . . . So, by financing state high-risk pools to guarantee people get affordable coverage when they have a preexisting condition, what you’re doing is, you’re dramatically lowering the price of insurance for everybody else. So, if we say let’s just, as taxpayers—and I agree with this—finance the coverage for those 8 percent of Americans under 65 in a condition like yours, they don’t have to be covered or paid for by their small business or their insurer who is buying the rates for the rest of the people in their insured pool, and you’d dramatically lower the price for the other 92 percent of Americans.
As high-risk pools and other changes to the ACA continue to be debated, it is critical to deconstruct statements such as these and remind ourselves of how high-risk pools really worked and how unaffordable they were. It is important to remember that high rates of uninsurance and lack of affordability for all buyers in the individual market existed before the ACA, even in states with high-risk pools. In addition, policymakers seem to substantially underestimate the number of Americans with preexisting conditions who might be forced to purchase coverage through a high-risk pool if insurers are allowed to deny coverage in the marketplace.
Reality Check
The reality is that high-risk pool coverage was prohibitively expensive and there is little evidence to suggest that the existence of such pools made coverage less costly for others in the individual insurance market. Without substantially more federal funding than currently proposed, these facts are not likely to change. People with preexisting conditions may have “access” to coverage, but most will not be able to afford it and those who can will face limited benefits and extremely high deductibles and out-of-pocket payments.
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.
Reversal: Some Republicans now defending parts of ObamaCare
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.
HENRY KOTULA 