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From the category archives: affordable care act

affordable care act

Trump's Executive Order on Healthcare is Bad Medicine

With all the skill of a surgeon wielding a machete, President Trump signed an executive order today that could undermine the affordability and quality of health insurance in America.  Republicans in Congress couldn’t enact their ill-considered legislation to repeal Obamacare, so the President hastily reached for his pen, despite admitting earlier this year that he had no idea “healthcare could be so complicated.”

The executive order instructs Trump’s cabinet agencies to look at ways to allow insurers to sell health policies across state lines.  The aim is to open-up association health plans (currently covering employees of various businesses and organizations) to people in the individual market.  These insurance policies would not be subject to Obamacare rules mandating coverage for pre-existing conditions or essential benefits, in theory making them cheaper – but also skimpier.  

These lower-cost, bare bones plans could siphon off younger and healthier enrollees, leaving older and sicker patients in the Obamacare exchanges and driving up their premiums. Ultimately, this could result in a death spiral for Obamacare, as we discussed on today’s Behind the Headlines Facebook Live broadcast. The administration’s own Centers for Medicare and Medicaid Services (CMS) says on its website:

Older Americans between ages 55 and 64 are at particular risk: 48 to 86 percent of people in that age bracket have some type of pre-existing condition. 

To some, the idea of selling insurance across state lines sounds appealing. (Republicans have been proposing this scheme in one form or another since 2005.)  Senator Rand Paul (R-KY) has been pushing it hard this year. But evidence – and history – indicate that the idea doesn’t work.  This Kaiser Health News video briefly and crisply explains why.

Not only does the selling-across-state-lines concept undermine important patient protections and drive up premiums for the most vulnerable, it has never proven viable for insurers or the insured.  According to today’s Hill newspaper:

A few states have opened their borders to out-of-state health insurers, and the response has been a uniform, “Thanks, but no thanks.”

One of Obamacare’s architects, Dr. Zeke Emanuel, told CNN today that, in addition to other concerns, association health plans have a “checkered history” and are especially vulnerable to fraud and scam artists. “Hundreds of thousands of people could be affected by fraud, unreimbursed medical bills,” he warned.  Emanuel also cautioned that patients with employer-provided insurance could see their rates rise “significantly.”

The biggest problem of all, though, is that Trump’s executive order may well be illegal.  The New York Times reports:

Several experts in healthcare and employment law said Trump’s plan could violate the U.S. Employee Retirement Income Security Act (ERISA), a federal law that governs large group plans that must be provided or maintained by employers or employee organizations.

In fact, a coterie of Democratic states attorneys general are poised to sue the administration if it enacts these harmful changes.

For all the Republicans’ talk of federalism, the executive order would actually weaken states’ power to regulate insurance markets, which is one of their primary responsibilities in the health care arena.

But as with the President’s trickle-down tax plan and other haphazard policies, history, precedent and data don’t seem to matter to this White House.  That’s especially troubling when – once again – the most vulnerable members of society will pay the price.


GOP Tax Cuts Could Cost Seniors in the Long Run

The GOP had scarcely emerged from the defeat of their latest Obamacare repeal legislation when they pivoted lightning-quick from healthcare to taxes.  The tax reform plan the party unveiled last week may ultimately endanger the well-being of older Americans more than the vanquished healthcare bill.  Here’s why:  The nonprofit Tax Policy Center estimates that the GOP tax plan will reduce federal revenues by a net $2.4 trillion in the next 10 years.  As the deficit grows, Congress will look to cut spending.  Republicans have already called for deep cuts to Social Security and Medicare, and would no doubt come after those programs looking for massive savings. Seniors’ earned benefits could be used as piggy banks to pay for reckless tax cuts that largely benefit the wealthy.

Americans for Tax Fairness put it his way:

"[The tax plan’s] eye-popping cost will lead to deep cuts in Social Security, Medicaid, Medicare, and public education that will leave working families in the cold."- Americans for Tax Fairness

… while House Democratic leader Nancy Pelosi predicted:

“Make no mistake: after Republicans’ tax plan blows a multi-trillion dollar hole in the deficit, they will sharpen their knives for Social Security, Medicare, Medicaid.” – House Minority Leader Nancy Pelosi 

Budget hawks (including President Trump’s budget director Mick Mulvaney and House Speaker Paul Ryan) have long dreamed of cutting Social Security and Medicare.  Once their tax plan balloons the deficit, they will have the perfect excuse for gutting those programs – even though Social Security and Medicare Part A are completely self-funded by workers’ payroll contributions; they contribute not a penny to the deficit.

In fact, the budget cutters’ knives are already sharpened. The 2018 House Budget resolution calls for nearly $500 billion in cuts to Medicaid over the next decade.  That would be devastating for the 1.4 million seniors who rely on Medicaid for long-term care, and millions of others who are dually eligible for Medicaid and Medicare.  The House budget resolution also includes nearly $500 billion in cuts to Medicare over the next ten years.  Under the House budget plan, Medicare would be privatized and the eligibility age raised from 65 to 67 (an effective benefit cut). If these changes are enacted, seniors will be left to fend for themselves in the private insurance market with vouchers that may not keep up with rising costs. 

Despite President Trump’s protestations that the GOP tax plan won’t benefit the rich, that’s precisely who would reap the biggest gains.  (Trump himself could save an estimated $1 billion in taxes!)  According to the Tax Policy Center’s analysis:

"Taxpayers in the top 1 percent would receive about 50 percent of the total tax benefit from the tax overhaul, with their after-tax income forecast to increase an average of 8.5 percent." – Tax Policy Center 

On the other hand, some in the middle class would see their taxes go up.  One in seven households earning between $48,000 and $86,000 per year would pay more in taxes next year; the proportion would double during the next decade.  For households earning $150,000-217,000 a year, one third would immediately pay more in taxes. 

Republicans claim that the tax cuts will pay for themselves through intense economic growth.  They have tried this before (Most recently, with the Bush tax cuts in the early 2000s), and it didn’t work out.  Instead, deficits swelled, reinforcing budget hawks’ instincts to cut programs for the most vulnerable members of our society, including and especially seniors.  One of the (repentant) architects of the failed trickle-down economics of the 1980s, Bruce Bartlett, put it best in a recent column for USA Today: 

"Tax cuts and tax rate reductions will not pay for themselves; they never have. Republicans don’t even believe they will, they are just excuses to slash spending for the poor when revenues collapse and deficits rise." – Bruce Bartlett, former Congressional economist

 

 

Throwing More Money at Wavering Senators’ States Doesn’t Improve Graham-Cassidy

To paraphrase W.C. Fields, it seems as if news of the death of the Graham-Cassidy bill is greatly exaggerated.  As veteran Kaiser Health News correspondent Julie Rovner tweeted this morning:

FWIW I will not believe health bill is really dead until I see it with an actual stake through it.

Her caution is well warranted.  Anti-repeal advocates breathed a sigh of relief last Friday when Senator John McCain (R-AZ) announced his opposition to the bill.  But opponents of Graham-Cassidy still need one more GOP vote to kill it before the September 30th deadline, and so far only McCain and Senator Rand Paul (R-KY) have announced as ‘No’s.  Some Hill-watchers are wary of Rand Paul’s position and predict he will flip to ‘Yes’ at the last minute, as he has done previously.  On the other hand, this weekend Sen. Ted Cruz (R-TX) threw cold water on Graham-Cassidy because he says it doesn’t go far enough in undoing Obamacare regulations:

"Right now they don't have my vote, and I don't think they have Mike Lee's either," Cruz said. "I want to be a yes."              –  Senator Ted Cruz

Seeing their Obamacare repeal bill appear to collapse before their eyes, Senators Lindsay Graham (R-SC) and Bill Cassidy (R-LA) have now sweetened the deal to try to buy off two wavering moderate Senators, Lisa Murkowski (R-AK) and Susan Collins (R-ME).   The Graham-Cassidy bill was changed over the weekend to give away tens of millions of dollars to two of America’s least populous states.  Alaska would net $3 million more in federal health spending than under current law from 2020-2026, and Maine $43 million.  Of course, when Graham-Cassidy’s block grants to states expire in 2026, both states will lose funding along with the other 48.   Steven Dennis of Bloomberg handicaps it this way:


These buy-offs may or may not bring Senators Murkowski and Collins over to the ‘Yes’ side.  Nor should they.  Both Senators have expressed deep concerns about other parts of the bill:  Sen. Murkowski for its elimination of protections for pre-existing conditions; Sen. Collins for its deep cuts to Medicaid.  And of course, these bribes for Alaska and Maine do not make the Graham-Cassidy bill any less egregious.  Every major group of stakeholders – insurers, doctors, hospitals, patients, and all 50 state Medicaid directors – have condemned this bill as a reckless assault on America’s health care system.  National Committee president Max Richtman lays out the case in testimony given to the Senate Finance Committee. 

The Republicans supporting Graham-Cassidy don’t seem to care as much about improving healthcare as they do about fulfilling a reckless campaign promise and scoring a legislative “win,” even though the vast majority of the American people would actually lose.  Premium subsidies would be eliminated, pre-existing conditions no longer protected, essential benefits gutted, and Medicaid decimated to the point where crucial services would be cut for seniors, children and the disabled.  One look at this chart from Kaiser Health News showing where most Medicaid spending goes makes it crystal clear who gets hurt if Graham-Cassidy becomes law.

Senators Graham and Cassidy, along with their enablers in the Trump administration, will continue to falsely claim that their bill protects people with pre-existing conditions, when by leaving it to the states to decide, there is no such protection at all.  If states seek waivers to pre-existing conditions, insurers can jack up rates for patients with diabetes, cancer, heart disease and other chronic illnesses to the point of unaffordability.

Instead of believing more pablum, or trusting that the Republican-led Senate will do the right thing, we must keep up the pressure on wavering Senators (especially Collins and Murkwoski) to vote ‘No’ when the bill comes to the floor later this week.  If we are to see a stake through Obamacare repeal, we must make sure to put it there ourselves. 

Two Paths Forward on Obamacare: One Reasonable, the Other Perilous

Newly back from summer recess, Senators are taking two divergent paths on healthcare after the Republicans’ spectacular failure to repeal and replace the Affordable Care Act (ACA).  For Americans who rely on the ACA for health insurance, one path is encouraging; the other, fraught with peril. 

On the encouraging side, the Republican and Democratic leaders of the House Education, Labor, and Pensions (HELP) committee are working on a bi-partisan plan to stabilize the ACA insurance markets, recognizing that the healthcare of millions of Americans hangs in the balance.  In fact, Senators Lamar Alexander (R-TN) and Patty Murray (D-WA) are up against a hard deadline.  Insurers need to know the level of federal support for the ACA marketplaces before they set premiums for 2018 at the end of September.

The legislation they devise will likely beef up cost-sharing payments to insurers who waive certain out-of-pocket costs for lower income patients, as well as re-insurance payments to help insurers cover high-risk populations.  While President Trump and hardline conservatives in Congress have indicated they would be content to let the Affordable Care Act languish, Senator Alexander wisely recognizes that the public will hold Republicans accountable if Americans lose healthcare.  In other words, the GOP will own the ACA, whether they like it or not. 

Unlike the Senate and House leadership during the repeal and replace debacle, the HELP committee has been holding hearings (imagine that!) to get input from outside of Congress on possible fixes to the ACA.  Last week, a group of Republican and Democratic governors of widely different ideologies sang from the same hymnal:  the ACA marketplaces must be stabilized.

Senators Alexander and Murray must finish their hearings, mark-up the bill, pass it out of committee, and hope that it reaches the Senate floor.  If Senate leadership feels the bill has bipartisan support, it may come to a vote.  Whether all of that can happen by the end of September is anyone’s guess.

On the discouraging side, Senators Bill Cassidy (R-LA) and Lindsey Graham (R-SC) just won’t let go of the repeal and replace agenda.  Undaunted by the GOP’s failure to get rid of the Affordable Care Act, Senators Cassidy and Graham are working on legislation to try, try again.  The Cassidy-Graham amendment is just as bad as - if not worse than - the failed Senate repeal bill last summer, and retains many of the most objectionable parts of the House-passed legislation.  Among other things, Cassidy-Graham:

*Ends the ACA’s Medicaid expansion  

*Cuts hundreds of billions of dollars in Medicaid spending

*Imposes per capita caps on Medicaid payments to the states

*Ends ACA subsidies and replaces them with inadequate block grants

*Leaves older and poorer Americans with no guarantee of affordable or adequate coverage

Were Senators Cassidy and Graham not paying attention when Americans at town halls across the nation expressed outrage at the GOP repeal and replace plans, including drastic cuts to Medicaid and more than 20 million people losing health coverage?  Did they not take seriously the Congressional Budget Office reporting on the negative impacts of repeal and replace on everyday Americans?  Apparently not. 

Fortunately for seniors – and all Americans who need healthcare – Senators Cassidy and Graham are running out of time.  Under Senate rules, their amendment cannot pass with a simple majority vote after the fiscal year ends on September 30th.  If they wanted to keep pushing for passage after that, they’d need 60 votes under regular order – a threshold they are not likely to meet.

Of course, it is premature for supporters of the ACA to declare victory.  We have seen seemingly dead repeal and replace bills suddenly spring back to life.  The legislative rollercoaster of last Spring and Summer are fresh in our memories.  Advocates and everyday Americans must keep the pressure on their elected representatives to work in a bipartisan fashion (like Sens. Alexander and Murray) to strengthen the Affordable Care Act– and reject repeal and replace once and for all.

Summertime No Time to Stop Protecting Seniors' Healthcare

Washington, D.C. is noticeably mellower with Congress beginning its August recess.  Our “worst-in-the-U.S.” traffic is noticeably lighter.  The sidewalks are emptier.  The news from Capitol Hill has slowed to a trickle.  But the summer doldrums are no time for advocates here in D.C. or the 50 states to let our guard down.  (We just discussed this on "Behind the Headlines" from Capitol Hill on Facebook Live.) 

Last week, we narrowly escaped the passage of healthcare legislation that would have been devastating for poorer, older, and sicker Americans. The heroism of three GOP Senators and a united Democratic party pulled us back from the brink by voting against the latest Obamacare repeal bill.  

Make no mistake, intense grassroots activism in Congressional districts across the country played no small part in the defeat of repeal legislation in both houses of Congress.  From New Hampshire to Nevada, everyday Americans challenged their elected representatives to protect their healthcare – and won in a heart-pounding showdown.  

In the end, only Senators Collins, Murkowski, and McCain had the courage to defy party leadership and do the right thing.  That’s a thin reed on which to hang future hopes.  If a single one of those votes had gone the other way, at least 22 million Americans would have been well on their way to losing healthcare coverage – and the Medicaid program would have been decimated.  In fact, it’s disappointing that some of the Republican moderates who seemed to oppose the various repeal bills voted yes in the end.  Perhaps it’s because Senator McCain’s no vote gave them cover.  But where is the courage in that?

While Senate Majority Leader Mitch McConnell says it’s time to “move on,” Speaker Paul Ryan signaled that the House isn’t done trying to repeal the Affordable Care Act.   Meanwhile, President Trump continues to threaten to cut off crucial cost-sharing payments, spooking insurers and threatening to drive up premiums.  As Phil Moeller pointed out in his column for PBS NewsHour, there’s a real danger that the majority party will re-attack Obamacare after August recess ends.  

With Capitol Hill’s largely silent and long-postponed summer vacations underway, there is little appetite for re-engaging in nasty policy fights. But when the leaders and their troops are rested, there is little doubt that [they] will be back at it again. – Phil Moeller, PBS NewsHour

This means that we in the advocacy community cannot simply relax this month – tempting as that may be.  Advocates and everyday activists must continue to deliver the message to our elected representatives that it’s time to stop trying to destroy the Affordable Care Act and work across the aisle to improve it, as National Committee President Max Richtman argued in The Hill newspaper this week.  We must maintain the drumbeat whenever and wherever we encounter members of Congress this summer:  at their district offices, by phone, by email, or around town.

Make no mistake:  the activism we saw last winter and spring made a difference.  Members of Congress heard their constituents loud and clear at contentious town halls.  Phone lines, fax lines, and email accounts were jammed. Congress heard us when we said “Hands Off Our Healthcare!”

But even after all that full-throated activism, several GOP moderates in the House and Senate still caved when it was time to cast crucial votes. We came dangerously close to losing the Affordable Care Act. If anything, we must step up our activism.  We must make the case for protecting the healthcare of seniors – and all Americans – even more vociferously, letting our leaders know in personal terms the true impact of changes to our healthcare coverage. But we must also demand that our elected representatives talk to us. Hold town halls, don’t cancel them.  Keep phone lines open instead of shutting them down.  Hear us instead of hiding. And if there are future votes to undermine our healthcare, we must insist that more GOP moderates stick to their stated principles instead of running with the herd.


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