Graham-Cassidy – R&R – Reachout and Rebuild

GOP Health Bill’s Changes Go Far Beyond Preexisting Conditions

David Posnett — Mon, 25 Sep 2017 20:48:06 +0000

KAISER HEALTH NEWS — REPEAL & REPLACE WATCH

By Julie Rovner September 22, 2017

Sen. Bill Cassidy (R-La.) speaks as Sen. Dean Heller (R-N.V.) and Sen. Lindsey Graham (R-S.C.) listen during a news conference on health care September 13, 2017. Senators Graham, Cassidy, Heller and Johnson unveiled a proposed legislation to repeal and replace the Obamacare. (Alex Wong/Getty Images)

The latest GOP effort to “repeal and replace” the Affordable Care Act is getting a lot of attention, even if its passage seems unlikely. But there is far more to the measure than its changes to rules regarding preexisting health conditions.

In fact, the bill proposed by Sens. Lindsey Graham (R-S.C.) and Bill Cassidy (R-La.) would disrupt the existing health system more than any of the measures considered so far this year, according to supporters and critics.

For backers of the bill, that disruption is a good thing. But others are appalled. As insurance industry analyst Robert Laszewski put it in a note to clients this week, “Would you rather lose your Republican Senate seat because you couldn’t pass an Obamacare repeal-and-replace plan or because you blew up the health insurance system?”

Some of those alterations have generated little discussion but would have major impacts. Here are four unheralded changes:

— The Bill Caps Federal Funding To Medicaid

Much focus has been placed on the bill’s funding formula, which would take money from states that expanded the Medicaid program for the poor. Less notice has been paid to the fact that this bill, like some other GOP options over the summer, would, for the first time, cap overall federal Medicaid funding. The federal government has provided an open-ended funding match since the program’s creation in 1965 — meaning the federal government has provided its share of whatever states spend to care for low-income children, pregnant women, seniors and people with disabilities. More than 70 million people are covered by Medicaid, including those added as a result of the ACA.

Republicans have been pushing unsuccessfully to limit the federal government’s funding of Medicaid to states since the 1980s.

State Medicaid directors — including both Republicans and Democrats — are alarmed at the idea that something of such magnitude could be done with so little debate or consideration. “Graham-Cassidy would completely restructure the Medicaid program’s financing, which by itself is three percent of the nation’s Gross Domestic Product and 25 percent of the average state budget,” said a statement from the group.

The Congressional Budget Office estimated in June that an earlier version of the cap would reduce federal Medicaid spending 35 percent by 2036. As a result, said CBO, states would “need to … decide whether to commit more of their own resources, cut payments to health care providers and health plans, eliminate optional services, restrict eligibility for enrollment, or adopt some combination of those approaches.”

“There won’t be enough money to do what’s authorized under current law,” said Jessica Schubel of the left-leaning think tank the Center on Budget and Policy Priorities.

— The Bill Gives Unprecedented Power To The Secretary Of Health And Human Services

Republicans complained bitterly about the power delegated by Congress to the secretary of Health and Human Services in the ACA. But conservative analyst Chris Jacobs pointed out that the Graham-Cassidy bill gives the HHS secretary more power still.

The bill creates a dizzyingly complex formula for the funds now being spent on the ACA, which is intended to draw money away from wealthier states (that mostly expanded Medicaid under the health law) toward poorer ones (that mostly did not). But there is a huge loophole, noted Jacobs. The bill gives the HHS secretary authority to change the formula on his or her own.

“That’s a trillion-dollar loophole that leaves HHS bureaucrats with the ultimate say over how much money states will receive,” Jacobs wrote.

And, he said, it’s the opposite of “federalism,” or giving states more authority, which the bill’s sponsors claim to be advancing.

“Draining the swamp shouldn’t involve distributing money from Washington out to states, whether under a simple formula or executive discretion,” he wrote. “It should involve eliminating Washington’s role in doling out money entirely.”

— The Bill Cuts Off All ACA Funding After 2026

The bill would lump together all funds being spent under the health law to help people pay premiums, out-of-pocket health costs and expand Medicaid to non-disabled adults and redistribute those funds to the states in the form of block grants. States could then use that money for almost anything health-related.

What few people have noticed, however, is that those block grants end abruptly after 2026. Originally, many thought this was because of congressional budget rules that limit new programs to no more than 10 years.

In fact, those rules only say that a program cannot add to the deficit after 10 years. The block grant is paid for by ongoing taxes generated from the ACA, so there is no budget requirement to end the block grant.

The reason seems to be a desire to require Congress to come back and revisit the program. A spokesman for Cassidy said the program “just has to be reauthorized in 2026 just like the CHIP program.” CHIP is the Children’s Health Insurance Program, also created in a budget bill in 1997. Congress was supposed to reauthorize that program by the end of September, although it looks as if lawmakers will miss that deadline, despite bipartisan support.

Others, however, worry that cutting the money off after 2026 means Congress could no longer use the current funding mechanism. Instead, lawmakers would have to come up with massive cuts to other programs or new tax increases if they wanted to continue providing the money for health care.

— The Bill Could Roil The Individual Insurance Market In Some States By Banning Abortion Coverage In Private Health Plans.

In keeping a promise to anti-abortion lawmakers, the bill would prohibit all private insurance plans receiving any federal funds from providing abortion coverage.

As part of a delicate compromise that got the ACA enacted in 2010, states were given the option to ban abortion coverage in plans on their health exchanges. Half of them did.

But some states, notably California, New York and Oregon require plans they regulate to offer coverage of elective abortions.

The problem is that the deadline for insurers to opt into coverage under the ACA is next Wednesday. If Congress were to pass the bill after that, it is unclear what would happen to those plans. In California, the requirement for abortion coverage is based on the state’s Constitution, so it would be possible that no plans could be offered to people who are eligible for federal help.

“There aren’t clear answers” to what would happen if the bill becomes law in its current form and takes effect in January, said Debra Ness, president of the National Partnership for Women and Families, a reproductive rights advocacy group. “I think it’s going to create chaos.”

Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.

Graham-Cassidy — The Last-Ditch Effort By Republicans To Replace ACA: What You Need To Know

David Posnett — Wed, 20 Sep 2017 15:31:43 +0000

By Julie Rovner September 19, 2017

Sen. Lindsey Graham (right), stands with Sen. Bill Cassidy (left), Sen. Dean Heller and Sen. Ron Johnson (second from right), as well as former senator Rick Santorum (center), to announce their legislation to repeal and replace Obamacare through block grants. (Jim Watson/AFP/Getty Images)

While the chances for this last-ditch measure appear iffy, many GOP senators are rallying around a proposal by Sens. Lindsey Graham (R-S.C.) and Bill Cassidy (R-La.), along with Sens. Dean Heller (R-Nev.) and Ron Johnson (R-Wis.)

They are racing the clock to round up the needed 50 votes — and there are 52 Senate Republicans.

An earlier attempt to replace the ACA this summer fell just one vote short when Sens. Susan Collins (R-Maine), Lisa Murkowski (R-Alaska) and John McCain (R-Ariz.) voted against it. The latest push is setting off a massive guessing game on Capitol Hill about where the GOP can pick up the needed vote.

After Sept. 30, the end of the current fiscal year, Republicans would need 60 votes — which means eight Democrats — to pass any such legislation because special budget rules allowing approval with a simple majority will expire.

Unlike previous GOP repeal-and-replace packages that passed the House and nearly passed the Senate, the Graham-Cassidy proposal would leave in place most of the ACA taxes that generated funding to expand coverage for millions of Americans. The plan would simply give those funds as lump sums to each state. States could do almost whatever they please with them. And the Congressional Budget Office has yet to weigh in on the potential impact of the bill, although earlier estimates of similar provisions suggest premiums would go up and coverage down.

“If you believe repealing and replacing Obamacare is a good idea, this is your best and only chance to make it happen, because everything else has failed,” said Graham in unveiling the bill last week.SIGN UP

Here are five things to know about the latest GOP bill:

1. It would repeal most of the structure of the ACA.

The Graham-Cassidy proposal would eliminate the federal insurance exchange, healthcare.gov, along with the subsidies and tax credits that help people with low and moderate incomes — and small businesses — pay for health insurance and associated health costs. It would eliminate penalties for individuals who fail to obtain health insurance and employers who fail to provide it.

It would eliminate the tax on medical devices.

2. It would eliminate many of the popular insurance protections, including those for people with preexisting conditions, in the health law.

Under the proposal, states could “waive” rules in the law requiring insurers to provide a list of specific “essential health benefits” and mandating that premiums be the same for people regardless of their health status. That would once again expose people with preexisting health conditions to unaffordable or unavailable coverage. Republicans have consistently said they wanted to maintain these protections, which polls have shown to be popular among voters.

3. It would fundamentally restructure the Medicaid program.

Medicaid, the joint-federal health program for low-income people, currently covers more than 70 million Americans. The Graham-Cassidy proposal would end the program’s expansion under the ACA and cap funding overall, and it would redistribute the funds that had provided coverage for millions of new Medicaid enrollees. It seeks to equalize payments among states. States that did not expand Medicaid and were getting fewer federal dollars for the program would receive more money and states that did expand would see large cuts, according to the bill’s own sponsors. For example, Oklahoma would see an 88 percent increase from 2020 to 2026, while Massachusetts would see a 10 percent cut.

The proposal would also bar Planned Parenthood from getting any Medicaid funding for family planning and other reproductive health services for one year, the maximum allowed under budget rules governing this bill.

4. It’s getting mixed reviews from the states.

Sponsors of the proposal hoped for significant support from the nation’s governors as a way to help push the bill through. But, so far, the governors who are publicly supporting the measure, including Scott Walker (R-Wis.) and Doug Ducey (R-Ariz.), are being offset by opponents including Chris Sununu (R-N.H.), John Kasich(R-Ohio) and Bill Walker (I-Alaska).

On Tuesday 10 governors — five Democrats, four Republicans and Walker — sent a letter to Senate leaders urging them to pursue a more bipartisan approach. “Only open, bipartisan approaches can achieve true, lasting reforms,” said the letter.

Bill sponsor Cassidy was even taken to task publicly by his own state’s health secretary. Dr. Rebekah Gee, who was appointed by Louisiana’s Democratic governor, wrote that the bill “uniquely and disproportionately hurts Louisiana due to our recent [Medicaid] expansion and high burden of extreme poverty.”

5. The measure would come to the Senate floor with the most truncated process imaginable.

The Senate is working on its Republican-only plans under a process called “budget reconciliation,” which limits floor debate to 20 hours and prohibits a filibuster. In fact, all the time for floor debate was used up in July, when Republicans failed to advance any of several proposed overhaul plans. Senate Majority Leader Mitch McConnell (R-Ky.) could bring the bill back up anytime, but senators would immediately proceed to votes. Specifically, the next order of business would be a process called “vote-a-rama,” where votes on the bill and amendments can continue, in theory, as long as senators can stay awake to call for them.

Several senators, most notably John McCain, who cast the deciding vote to stop the process in July, have called for “regular order,” in which the bill would first be considered in the relevant committee before coming to the floor. The Senate Finance Committee, which Democrats used to write most of the ACA, has scheduled a hearing for next week. But there is not enough time for full committee consideration and a vote before the end of next week.

Meanwhile, the Congressional Budget Office said in a statement Tuesday that it could come up with an analysis by next week that would determine whether the proposal meets the requirements to be considered under the reconciliation process. But it said that more complicated questions like how many people would lose insurance under the proposal or what would happen to insurance premiums could not be answered “for at least several weeks.”

That has outraged Democrats, who are united in opposition to the measure.

“I don’t know how any senator could go home to their constituents and explain why they voted for a major bill with major consequences to so many of their people without having specific answers about how it would impact their state,” said Senate Minority Leader Chuck Schumer (D-N.Y.) on the Senate floor Tuesday.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.