Don’t Look Now but Obamacare, the ACA, Repeal’s Last Gasp Attempt is Back on the Table!

drowning028And once again the GOP is about to try again to Repeal and Replace the Affordable Care Act also known as Obamacare. But there is a real feeling in both parties that they can work together in a bipartisan manner. Can you believe that in this climate of hate, anger and entitlement?

So, repeal of the Affordable Care Act is back on the agenda, with Republicans suddenly talking about a bill that, until recently, few people in either party had taken all that seriously.

The prospects for the new legislation are murky at best. The proposal has generated a ton of conversation in political and health policy circles in just the past week, with multiple outlets reporting that leadership is now thinking about floor action before Sept. 30. That’s the magic date when, because of parliamentary rules, Republicans lose their ability to pass repeal with just 50 votes. But much of the chatter is hype from supporters and it’s hard to know how much enthusiasm for the proposal actually exists.

Still, even if the bill’s political fortunes are difficult to pin down, the impact it would have as a law is crystal clear. By dramatically scaling back what the federal government spends on health care and undermining rules designed to guarantee insurance for people with pre-existing conditions, this new proposal would leave millions of Americans struggling to pay their medical bills and to get coverage.

It is, in other words, another shot at full repeal, although its GOP sponsors sometimes suggest otherwise ― and that’s one reason it has escaped heavy scrutiny until now. I predict that it will be A New Bill With The Same Old Devastating Effects On Coverage at best!

Sen. Bill Cassidy, R-La., says his last-ditch attempt to repeal and replace Obamacare is only a few votes shy of 50 and could pass before the fast-approaching Sept. 30 procedural deadline.

“We’re probably at 48, 49 votes and we’re talking to three more,” Cassidy told reporters at a briefing Friday morning. “I’m pretty confident we’ll get there on the Republican side.”

But Cassidy, a physician representing a state that expanded Medicaid under Obamacare, cautioned that he had not done a formal whip count. He is optimistic after presenting his bill during a lunch on Thursday of GOP senators. At one point, Sen. Dean Heller, R-Nev., told the group he was co-sponsoring the measure even though he’s been urged to “lay low” on health care while facing a tough reelection race back home, Cassidy said. Afterwards, several senators told him they’d vote yes on the bill. “I told my wife when I got home last night that yesterday may have been my best day as a senator,” Cassidy said.

Another of the bill’s sponsors, Sen. Lindsey Graham, R-S.C., is pushing the White House and GOP leadership to champion the bill, Cassidy said. President Trump released a statement earlier this week praising their efforts. “I sincerely hope that Senators Graham and Cassidy have found a way to address the Obamacare crisis,” Trump said.

The bill faces long odds, however, with Sen. John Thune, R-S.D., comparing passing it before the deadline to a “double-double bank shot” in pool. There’s also very little chance Senate Leader Mitch McConnell, R-Ky., would bring the measure to the floor unless it was guaranteed to pass, not wanting to repeat the spectacle when the Senate’s last attempt at repealing Obamacare failed dramatically in July.

The procedural vehicle that allows a bill to pass with just 51 votes is set to expire at the end of this month, adding urgency to the effort.

Sen. Rand Paul, R-Ky., announced Friday morning on Twitter he would not support the bill, which he called “Obamacare Lite.” If just two more GOP senators come out against it, the bill is dead, given that no Democrats support the measure.

“It would take an extraordinary lift to get that done before the deadline but I know there’s a lot of interest in our conference to get something done on that,” Thune, a member of the GOP leadership team, said Tuesday. “The clock’s ticking and it’s a pretty short window.”

The bill repeals Obamacare’s individual mandate, employer mandate and medical device tax. It then combines Obamacare’s different funding streams for states into one block grant that gives states more control over Medicaid and the insurance exchanges.

One result of the plan is that states that refused to take federal dollars to expand Medicaid under Obamacare, such as Texas and Virginia, would receive much more funding, which governors could use to cover more low-income residents. Other states, however, would lose billions of dollars of federal funds under the plan, most notably Massachusetts. (One outside analysis found 20 states would lose 35 to 60 percent of their funding compared to current law.) And Congress would have to vote to reauthorize the plan in 2026, or states would lose all of their funding.

“Graham-Cassidy does a much better job of distributing health care dollars fairly,” Cassidy said.

Paul tweeted Friday afternoon that the bill “redistributes money from Democratic states to republican states.”

The Congressional Budget Office (CBO) has not yet scored the bill, and the Senate parliamentarian would also have to examine it and make sure it’s eligible to pass under the special reconciliation procedure that only needs 51 votes. Vice President Mike Pence would likely be called in to provide the 51st vote if Cassidy and Graham are able to get to 50.

“Mitch [McConnell] has always said show me you can get 50 votes,” Cassidy said. “I’m meeting with senators. My staff is calling staff, whatever we can do to make sure we have 50.”

Senate HELP Wraps Hearings on Insurance Stabilization but is still unclear as to what shape a bipartisan bill could take. Shannon Firth pointed out in her article in MedPage that one of the things to take care of is this raising of premium subsidies for “young invincibles.” Give states more flexibility to design their own insurance products. Return funding to Obamacare navigators.

Those were just some of the suggestions from witnesses across the healthcare sector appearing Thursday at the fourth and last hearing of the Senate Health, Education, Labor and Pensions Committee, held over the past two weeks.

Panel members appeared determined to craft a bipartisan bill to stabilize the Affordable Care Act’s individual health insurance market, although its final shape remains uncertain.

“The easier part for the Democrats is more money. The easier part for Republicans is more flexibility and vice versa. So, we have to put those two together,” said Chairman Lamar Alexander (R-Tenn.).

Adding later, “Sometimes the last decisions are the hardest.”

Witnesses on both sides of the political divide agreed that continuing premium subsidies for low-income people is critical. Each also recommended either reinsurance or a high-risk pool to keep the sickest patients with high cost claims insured, though they disagreed about which was better.

Other suggestions for stabilizing the individual market tended to align with the ideas and the party of the senators who introduced the witness.

In introductory remarks, Alexander highlighted the three themes he’d gleaned from discussions with stakeholders, which he appeared to prioritize: continuing the premium subsidies, expanding “copper plans” (low premiums and high deductibles), and greater state flexibility. He underscored the same three tenets at a hearing two days earlier, though not all witnesses agreed.

Christina Postolowski, of the Denver-based group, Young Invincibles, was introduced by Sen. Michael Bennet (D-Colo.) recommended a federal reinsurance program and boosting premium tax credits for young adults.

A $50 increase in subsidies could draw 900,000 more young adults into the market, she said. Insurers have found this valuable market — young people tend to be healthier — harder to crack.

Postolowski also recommended against expanding so-called “copper” or catastrophic plans to all Americans.

With a median income for uninsured young adults around $20,000 and the average catastrophic plan offering a $9,000 deductible. “If something did happen … they’d be looking to pay almost half of their income,” she said later.

But Alexander said most insurance commissioners he’d spoken with, as well as Sen. Tim Scott (R-S.C.), a former insurance agent, have told him they think expanding copper plans will work.

Manny Sethi, MD, president of Healthy Tennessee, an orthopedic trauma surgeon, introduced by Alexander, noted that Tennessee ranks at the bottom of the list for most chronic care conditions but “[m]ore spending will not solve this problem.” One-third of the state’s budget is spent on healthcare, yet Tennessee’s market is near collapse, he said.

Sethi, who favored the GOP’s repeal-and-replace efforts, pressed the committee to allow states to create their own products, such as “catastrophic coverage for all.” Currently, such plans are only available to people 30 and under. For the long term, he supported greater transparency on prices, wellness incentives and health savings accounts.

Sen. Tammy Baldwin (D-Wis.) introduced Susan Turney, MD, CEO of Marshfield Clinic in Marshfield, Wisc., who has previously worked for the Medical Group Management Association.

Turney advocated for reinstating outreach funding and monies for navigators, both of which the Trump administration recently cut.

She also backed a reinsurance program similar to the ACA’s now-ended program, with new federal seed money. Without the earlier program, premium rates would have climbed 20% higher in 2014 and 12% higher in 2015, she said.

Another witness, Robert Ruiz- Moss, vice president of individual business at Anthem, whom Bennet also introduced, pressed for repeal of the health insurance tax. A moratorium on the tax ends at the end of 2017, and if it’s not repealed, patients could expect a 3%-5% premium increase, he said. He also encouraged the Committee to take steps to keep people continuously covered. The individual mandate is “too weak,” he said. Both Turney and Ruiz-Moss also stressed the importance of curbing patients’ out-of-pocket costs through CSR payments.

In her opening statement, ranking member Patty Murray (D-Wash.) said some of the proposed plans she’d heard over the last two weeks have been “unacceptable” but expressed optimism that a deal could be reached.

She proposed a reinsurance pool and multiple years of funding for premium subsidies. Alexander met her partway, supporting subsidy funding through 2018 for CSR payments, but opposing federal seeding for the reinsurance pool. “There’s not any money to give to anybody up here,” he said. Alexander also reiterated previous comments to the effect that the “1332 waiver” process should be streamlined, and that certain patient-protection “guardrails” should be part of any ACA replacement, and no dissent was heard from witnesses.

If the GOP would only give up on repeal and replace it could actually make healthcare more affordable. But can they relinquish their hold on the majority enough to actually make a difference? The Times editorial Board noted that time is rapidly running out before health insurers have to commit to the policies and premiums they’ll offer next year to roughly 20 million Americans not covered by an employer-sponsored health plan. Although those premiums are expected to jump 10% or more in many states, Congress can rein in that increase significantly — if it acts quickly. Doing so, however, will require Senate Republicans to stop flirting with yet another partisan proposal to “repeal and replace” the Affordable Care Act, and start focusing instead on steps to make coverage more affordable that can win broad support.                                                                                                                                            The good news is that leaders of the Senate Health, Education, Labor and Pensions Committee, who have a reputation for pragmatism and compromise, are trying to pull together a narrowly focused, bipartisan bill this week that would have a direct and rapid effect on premiums. Although the details are still being negotiated, the measure is likely to continue reimbursing insurers for at least a year — and preferably more — for some $7 billion that the ACA requires them to spend on lower out-of-pocket costs for low-income customers.

Although the law requires the federal government to make those reimbursements, some Republicans have labeled them a bailout for insurers, and the Trump administration has threatened repeatedly to cut off funding. Those threats have led insurers to seek premium increases of 2% to 23% in 2018 just to pay for the cost-sharing reductions, according to the Kaiser Family Foundation.

It’s irresponsible for Republicans even to flirt with the Cassidy proposal. That’s just one of the factors driving up premiums; others include the Trump administration’s indifferent enforcement of the ACA’s requirement that all Americans carry insurance, which encourages healthier adults not to sign up for coverage, and the unexpectedly large treatment costs incurred by those who do have policies. The Senate health committee’s bill may not address the rest of those issues directly. Instead, it’s likely to let states try to entice more healthy people to buy coverage by allowing insurers to offer less robust policies than the ACA requires, or by kicking in state dollars to help insurers.

A more direct approach would be to provide the sort of federal backstop that helps hold down premiums in Medicare’s prescription drug plans — such as reinsuring insurers against the cost of consumers with outsize medical expenses.

But even the Senate committee’s proposal would be better than one being floated by Sens. Bill Cassidy (R-La.), Lindsey Graham (R-S.C.) and Dean Heller (R-Nev.), which would replace the ACA’s insurance mandate and subsidies with a complex system of aid to the states, while also reengineering Medicaid to gradually reduce Washington’s share of its costs.

The Cassidy proposal has until Sept. 30 to pass by a simple majority, after which it would need an unattainable 60 votes to overcome a certain Democratic filibuster. It’s irresponsible for Republicans even to flirt with so major a proposal, let alone one so potentially damaging to California and other states with large Medicaid populations. Congress barely has enough time to pass a far narrower bill to shore up the non-group insurance markets in time to affect the 2018 premiums. Lawmakers should focus on that, and get it done.

Republicans seem to be targeting essential health benefits in bipartisan Obamacare talks as we see the Senate relitigating the GOP health care bill. Amanda Gomez wrote that while some Democrats pivot to single payer legislation this week, the immediate health policy agenda item is shoring up the 2018 Affordable Care Act (ACA) individual marketplace in time for September 27, the final deadline for insurers to decide if they’ll participate or not. The Senate’s Health, Education, Labor and Pensions (HELP) committee is resuming hearings Tuesday on how best to stabilize the marketplace this week, and one theme continues to dominate bipartisan negotiations: state flexibility.

Governors and state insurance commissioners testifying before the Senate HELP committee unanimously asked lawmakers to pay insurers for subsidies provided to low-income people, a more widely accepted request, and provide states more flexibility, a plea that’s not so clear-cut. If conservatives agree to include these cost sharing payments in the ACA stabilization bill, which is expected to be finalized by September 22, they need to get something in return.

“It’s pretty easy to be for extending cost sharing reduction payments. I mean, that’s just more money and we can argue about for how long it should be and that’s one thing,” said HELP committee chairman Lamar Alexander (R-TN). “We will have no chance of getting that unless we have, in addition to that, some restructuring of the market.”                                                                                                                                            The chairman spoke frankly about the political constraints of the bill. The success of this bill is contingent on Democrats making some concessions of their own. When Republicans talk about restructuring the marketplace, it’s clear they want to change two provisions within the current health law: allow older people to buy catastrophic plans, or cheap premium plans, and rework state innovation waivers. What’s unclear is whether Democrats are amenable to such requests. As for the latter tweak to the law, if reworking state innovation waivers means states can undermine the ACA’s ‘guardrails’ — which are meant to safeguard consumers from bare-bones plans — it’s hard to see how Democrats can cosign any stabilization bill.

“If we are talking about violating the guardrails that are in the ACA that provide protections for comprehensive coverage, for coverage numbers for benefits, then that’s something that Democrats are not going to agree to — it was something that was heavily litigated during the [repeal and replace] debate,” said health expert Topher Spiro during a bipartisan ACA event hosted by liberal Center for American Progress (CAP) and conservative American Enterprise Institute (AEI). ThinkProgress is editorially independent of CAP.

State innovations waivers, as outlined in section 1332 of the ACA, allow states to waive key provisions of the law as long as they do not jeopardize health coverage afforded to patients and the federal deficit is not increased. Under current law, states can already waive regulations, essential health benefits, which is when insurance companies must offer a basic set of benefits. Before the Department of Health and Human Services (HHS) can approve such waiver, they need to ensure no substantial losses in health coverage and affordability. Additionally, before a state can apply for a wavier, the state needs to pass legislation enacting the plan.

During repeal and replacement efforts, Republicans tried to amend the health care law by removing the coverage-related guardrails. (The Center for Health Policy at Brookings Institution has a good write-up on how the Senate GOP health bill looked to change 1332 waivers.) The Senate parliamentarian ruled that the GOP bill could not pass a bill that includes such waiver changes under reconciliation, which allows the Senate to pass a bill with a simple majority. If conservatives want any major tweaks done to section 1332, it’ll have to be done through regular order.

Stakeholders testifying last week have largely called for states to streamline the waiver application process. Insurance commissioners from Alaska and Pennsylvania asked Congress to change the waiver requirement that states need to pass legislation before enacting a plan. Additionally, insurance commissioners asked that Congress expedite the approval process. “The part that is stifling states right now is the six-month waiting period before they receive final approval,” Alaska’s Lori Wing-Heier told the Senate last week. In addition, former acting administrator of the Centers for Medicare and Medicaid Services turned advocate Andy Slavitt called for cutting the federal review time to a 90-day maximum.

“Expediting federal approval means less opportunity for public input and less time for the federal government to scrutinize waivers, particularly the effect on federal spending,” Kaiser Family Foundation Larry Levitt told ThinkProgress. “However, it wouldn’t fundamentally alter the protections for consumers. It would allow waivers to be more responsive to changing circumstances.” He added “eliminating the requirement for state legislative approval would give states with powerful governors more leeway.”

Chairman Alexander’s own state insurance commissioner, Julie Mix McPeak, asked that states be able to change the essential health benefits provision through waiver authority, a request about which she is adamant. Additionally, Governors John Kasich and John Hickenlooper during a bipartisan ACA stabilization event Friday hosted by AEI and CAP, called for states to have more wiggle room to waive ACA regulations, like essential health benefits and the individual mandate.

Republican Ohio Governor John Kasich asked that Congress allow states to define essential health benefits. “You shouldn’t have to comply with every one of those essential health benefits,” said Kasich. For example, he said, give someone who is 23 years old the option to purchase a plan that doesn’t include maternity coverage.

Democratic Colorado Governor John Hickenlooper agreed that the waiver’s administrative process was “a pain in the neck,” and that if states wanted to change, let’s say the individual mandate, states should have the ability to. When asked if the essential health benefits is too onerous on states, Hickenlooper said “it was a huge long process to get to those benefits and if we are going to change them, you are going to have to get to another huge long process to negotiate that out.” He added that stabilization talks should be narrow in scope.

Hickenlooper and Kasich have been praised by the left and right for coming together and working on bipartisan ACA legislation. Imagine both parties working together. Their take on whether the essential health benefits regulation has been burdensome is indicative of the ideological riff that will be hard to escape as Congress writes the ACA stabilization bill.

When discussing what provisions may make it into September’s health bill, it’s important to remember the objective of the bill: stabilize the marketplace. This largely means calming insurance companies and guaranteeing cost sharing payments, thereby ensuring they don’t leave the marketplace. It also means securing the market by making it more attractive to consumers. Conservatives have argued that the essential health benefits regulation drive up health costs.

Fewer benefits would mean cheaper insurance premiums. However, that’ll make for skimpier plans, consequently raising out-of-pocket costs. As Health Affairs expert Timothy Jost writes: “Removing maternity coverage from insurance coverage, for example, might lower premiums by $8 to $14 per month, but would dramatically raise the cost of coverage for women in child-bearing age, and possibly make maternity care essentially an out-of-pocket expense, costing potentially $30,000 to $50,000.”

A study authored by actuarial firm Milliman reported that the vast majority of health care costs are attributable to benefits that insurance companies nearly universally covered:

According to the HHS, prior to the ACA:

  • 62 percent of enrollees did not have coverage for maternity services.
  • 34 percent of enrollees did not have coverage for substance abuse services.
  • 18 percent of enrollees did not have coverage for mental health services.
  • 9 percent of enrollees did not have coverage for prescription drugs.

If reworking 1332 waivers means weakening the guardrails, then what becomes evident each passing day is that it’ll matter more and more where patients live than anything else.

So, there seems to be a weakening in the resistance armor of both parties and maybe they will improve the health care delivery system and how it is paid for. Except we still have the ignorant Senators like Rand Paul who want only to Repeal and Replace Obamacare. Are there enough votes to get something passed, which will benefit those that they serve, we the people? Remember also that there is a very narrow window in which to either rescue Obamacare or pass a new health care bill.

Good luck with that!!

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