Tagged Repeal And Replace Watch

2 Health Care Issues Collide On Capitol Hill And The Result Is Confusion


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Julie Rovner, KHN’s chief Washington correspondent, was interviewed on Here & Now by WBUR’s Robin Young Thursday. They discussed changes approved by Republican conservatives for the House bill to replace the Affordable Care Act — which would give states the option to loosen provisions in the health law requiring insurers to offer coverage to people with preexisting conditions and guaranteeing that policies cover essential health benefits — and the debate between the parties over whether the government will continue to fund subsidies that help pay for many out-of-pocket expenses for low-income people who purchase coverage on the health law’s marketplaces.

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5 Things To Know About The Health Issue That Could Shut Down The Government

Congress must pass a bill this week to keep most of the government running beyond Friday, when a government spending bill runs out. It won’t be easy.

The debate over a new spending bill focuses on an esoteric issue affecting the Affordable Care Act.

The question is whether Congress will pass — and President Donald Trump will sign — a bill that also funds subsidies for lower-income people who purchase health insurance under the law. These “cost-sharing reductions” (CSR) have become a major bargaining point in the negotiations between Republicans and Democrats, because the spending bill will require at least some Democratic votes to pass.

Here are five things to know about these cost-sharing subsidies: 

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How are these subsidies different from the help people get to purchase insurance?

There are two types of financial aid for people who buy insurance from an ACA exchange. People with incomes up to four times the poverty line, or $81,680 for a family of three, are eligible for tax credits to help pay their premiums.

In addition to that help, people with incomes up to two-and-a-half times the poverty line, or $51,050 for a family of three, get additional subsidies to help pay their out-of-pocket costs, including deductibles and copayments for care, as long as they purchase a silver-level plan. Insurance companies are required in their contracts with the government to provide these cost-sharing reductions to eligible people, then get reimbursed by the government.

Why are cost-sharing reductions suddenly front and center?

The fight dates to 2014, when Republicans in the House of Representatives filed suit against the Obama administration, charging that Congress had not specifically appropriated money for the cost-sharing subsidies and therefore the administration was providing the funding illegally.

A year ago, a federal district court judge ruled that the House was correct and ordered the payments stopped. However, she put that ruling on hold while the Obama administration appealed. That’s where things stood when Trump was inaugurated.

If the Trump administration drops the appeal, the funding would cease. However, Congress could also opt to approve funding the payments, which is what Democrats are pushing in the spending bill. 

What would happen if these subsidies are stopped?

At the very least, ending the cost-sharing reductions in the middle of the year would cause a serious disruption in the insurance market. The payments are estimated at $7 billion this year, and $10 billion in 2018. They cover about 7 million people, about 58 percent of those purchasing coverage on the exchanges.

Many experts have predicted that if the subsidies end, some or all insurers might leave their markets entirely, leaving consumers with fewer, or possibly no, choices.

But even if they stay, the Kaiser Family Foundation estimates that insurers would have to raise premiums on the marketplace silver plans by an average of 19 percent in order to offset that loss of government reimbursement. (Kaiser Health News is an editorially independent program of the foundation.)

Ironically, ending the subsidies would actually cost the federal government more money. Premium increases to make up for the lost payments would in turn trigger bigger tax credits for the broader population eligible for help paying their premiums. Those larger tax credits would cost the federal government an estimated $2.3 billion above what it would save on the cost reduction subsidies next year, KFF projected.

Who is pushing Congress to fund the subsidies?

In addition to Democrats in Congress who support the ACA, influential health-related groups are urging lawmakers to fund the cost-sharing reductions.

The coalition, which includes America’s Health Insurance Plans, the American Medical Association, the American Hospital Association and the U.S. Chamber of Commerce, points out that the uncertainty surrounding the future of the promised payments could not only disrupt this year’s insurance market, but next year’s as well.

“The window is quickly closing to properly price individual insurance products for 2018,” the groups wrote to Congress on April 12. Most insurers must decide whether they will participate in the health law’s market in 2018 by late June.

Most Americans don’t support cutting the subsidies as part of a GOP strategy to force Democrats in Congress to help pass a new health law. A recent poll reported 60 percent of those surveyed said the president “should not use negotiating tactics that could disrupt insurance markets and cause people to lose health coverage.” On the other hand, two-thirds of Republicans surveyed said Trump “should use whatever negotiating tactics necessary to win support for a replacement plan.”

What does the Trump administration think about this?

Good question. Trump and senior health officials have offered conflicting positions.

On April 10, unnamed officials told the New York Times and other outlets that the administration “is willing to continue paying subsidies” while the lawsuit remains pending, just as the Obama administration did. The next day, however, a spokeswoman for the Department of Health and Human Services disavowed that statement, saying that “the administration is currently deciding its position on this matter.”

The day after that, Trump himself said in an interview with the Wall Street Journal that he was holding back a decision on the payments as leverage. “I don’t want people to get hurt,” he said. “What I think should happen — and will happen — is the Democrats will start calling me and negotiating.”

By the following week, administration officials were dangling the funding for the cost-sharing reductions in the spending bill as a trade for Trump’s request for funding for a border wall. “We don’t like those [subsidies] very much, but we have offered to open the discussions to give the Democrats something they want in order to get something we want,” budget director Mick Mulvaney said on Fox News Sunday. “We’d offer them $1 of CSR payments for $1 of wall payments.”

Democrats, however, are not buying what the administration is selling. “The White House gambit to hold hostage health care for millions of Americans, in order to force American taxpayers to foot the bill for a wall that the president said would be paid for by Mexico is a complete non-starter,” Senate Minority Leader Chuck Schumer (D-N.Y.) said in a written statement.

Complicating matters further, it is far from clear that Republicans in Congress want to end the cost-sharing payments.

The subsidies are “a commitment made by the government to the insurers and the people,” House Energy and Commerce Committee Chairman Greg Walden (R-Ore.) said at a town hall meeting in his district, according to The Washington Post. “That needs to happen.”

Categories: Health Care Costs, Insurance, Repeal And Replace Watch, The Health Law

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Health Care Worries Pull Crowd To Conservative Ohio Rep’s Town Hall

LIMA, Ohio — Speaking over constituents’ often-hostile shouts and angry murmurs, one of Congress’ most conservative Republicans told a tense town hall meeting here Monday that less government regulation — not more — is the solution to their rising health care premiums.

“What we want to do is make sure we have the best health care system in the world and bring back affordable insurance plain and simple. That’s what I’m trying to do. That’s what we continue to focus on,” said Rep. Jim Jordan, the co-founder of the House’s conservative Freedom Caucus. Its firm opposition to the GOP’s plan to replace the Affordable Care Act forced party leaders last month to yank their bill from a vote on the House floor.

But on the eve of Congress’ return to Washington after a two-week Easter recess, Jordan offered no clues to his party’s next move on a health care bill or the prospects for a government shutdown if Congress fails to agree before the Friday deadline on a bill to provide short-term funding to keep it operating.

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More than 200 people attended the Ohio congressman’s 2 1/2-hour meeting, mostly pummeling him with questions and personal stories about their health care. Jordan heard from constituents with sick children, veterans who couldn’t access Veterans Affairs’ care and nervous families who feared what could happen to them if federal Medicaid funding is cut, among others.

Seated on black folding chairs in a windowless hall of the Lima Veterans Civic Center, many in the audience followed a practice that’s been common this year at congressional members’ town hall meetings — holding up red signs when they disagreed with Jordan and, less frequently, green signs when they agreed. Jordan, unruffled by opposition, drew laughs once when he referred to a woman in the crowd as “gentlelady,” in the formal way that male members of Congress sometimes address female members when the House is in session.

Tobias Buckell told the congressman the ACA’s mandate that insurers cover preexisting conditions had made it possible for both his wife, Emily, and him to have careers as freelancers — he as a science fiction writer and Emily as an e-book designer. Buckell, the father of twin 8-year-old daughters, told Jordan the only way he could risk that career choice was because he was able to buy insurance through the law’s exchanges. He has a genetic heart condition that he said had made him virtually uninsurable before.

“We’re going to be moved to a high risk pool, we’ll pay three times as much our current rate … how will that help me?” asked Buckell, 38.

Though the most vocal members of the crowd were largely in disagreement with Jordan’s views, a quiet minority in the front of the room shook their heads and waved green signs in agreement when the congressman responded to a question by saying he did not believe health care is a universal right.

(Rachel Bluth/KHN)

“I do not believe health care is a right. Rights are not given to us by the government, rights come from God, although Jim acknowledged that the American people have come to accept it as a right,” said Linda Gentry, a 66-year old constituent who works for an insurance company.

Of the 17 questions Jordan was asked, 13 related to health care. Lisa Robeson, the event’s moderator, estimated that around half of the 45 questions submitted in advance focused on the topic.

Jordan’s comments on the federal government’s role in solving the opioid crisis brought what might have been his audience’s most negative reaction of the night.

Ohio has been especially hard hit in recent years. It led the nation in opioid overdose deaths in 2015, according to the Kaiser Family Foundation, while Dayton, just an hour and a half south of Lima, topped a criminal justice group’s national ranking of America’s most drugged-out cities last year.

“I’m not convinced the federal government giving more money will solve the problem,” Jordan said. Instead of a “grand scheme” handed down from Washington, he suggested churches, schools and families are best equipped to handle the opioid epidemic – a remark that raised a sea of red signs across the room.

Jordan’s 4th District touches the northern part of the state near Lake Erie, and includes rural areas and suburbs of Columbus, the state capitol. He has been the district’s congressman since 2007 and he has little reason to be alarmed by contentious town halls. Jordan was reelected last November with more than 68 percent of the vote.

By the end of Monday’s town hall, some of Jordan’s constituents were divided on whether they’d heard what they came to find out.

“It’s clear to me that there is sort of a vague idea what the Republican replacement would be, and I don’t think we got a statement about that,” said Robert Kemp, 62, a health care economist that also rose to speak in favor of universal health care.

Barbara Mayer, 81, a retired teacher, didn’t mind the lack of specificity. She said it was unfair for people to demand comment on a measure that hasn’t been finalized yet.

“They’re quoting things about what Trump’s bringing out and it isn’t even public yet,” Mayer said. “People aren’t giving the new Congress a fair trial.”

Categories: Cost and Quality, Insurance, Repeal And Replace Watch, The Health Law

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Conservatives’ Goal To Relax Mandatory Health Benefits Unlikely To Tame Premiums

As House Republicans try to find common cause on a bill to repeal and replace the Affordable Care Act, they may be ready to let states make the ultimate decision about whether to keep a key consumer provision in the federal health law that conservatives say is raising insurance costs.

Those conservatives, known as the House Freedom Caucus, and members of a more moderate group of House Republicans, the Tuesday Group, are hammering out changes to the GOP bill that was pulled unceremoniously by party leaders last month when they couldn’t get enough votes to pass it. At the heart of those changes reportedly is the law’s requirement for most insurance plans to offer 10 specific categories of “essential health benefits.” Those include hospital care, doctor and outpatient visits and prescription drug coverage, along with things like maternity care, mental health and preventive care services.

The Freedom Caucus had been pushing for those benefits to be removed, arguing that coverage guarantees were driving up premium prices.

“We ultimately will be judged by only one factor: if insurance premiums come down,” Freedom Caucus Chairman Rep. Mark Meadows (R-N.C.) told The Heritage Foundation’s Daily Signal.

But moderates, bolstered by complaints from patients groups and consumer activists, fought back. And a brief synopsis leaked from the intraparty negotiations suggests that the compromise could be letting states decide whether to seek a federal waiver to change the essential health benefits.

“The insurance mandates are a primary driver of [premium] spikes,” wrote Meadows and Sen. Ted Cruz (R-Texas) in an op-ed in March.

But do those benefits drive increases in premiums? And would eliminating the requirement really bring premiums down? Health analysts and economists say probably not — at least not in the way conservatives are hoping.

“I don’t know what they’re thinking they’re going to pull out of this pie,” said Rebekah Bayram, a principal consulting actuary at the benefits consulting firm Milliman. She is the lead author of a recent study on the cost of various health benefits.

Opponents of the required benefits point to coverage for maternity care and mental health and substance abuse treatment as driving up premiums for people who will never use such services.

But Bayram said eliminating those wouldn’t have much of an impact. Hospital care, doctor visits and prescription drugs “are the three big ones,” she said. “Unless they were talking about ditching those, the other ones only have a marginal impact.”

John Bertko, an actuary who worked in the Obama administration and served on the board of Massachusetts’ health exchange, agreed: “You would either have very crappy benefits without drugs or physicians or hospitalization, or you would have roughly the same costs.”

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Maternity care and mental health and substance abuse, he said, “are probably less than 5 percent” of premium costs.

Of course, requiring specific coverage does push up premiums to some extent. James Bailey, who teaches at Creighton University in Omaha, Neb., has studied the issue at the state level. He estimates that the average state health insurance mandate “raises premiums by about one-half of 1 percent.”

Those who want to get rid of the required benefits point to the fact that premiums in the individual market jumped dramatically from 2013 to 2014, the first year the benefits were required.

“The ACA requires more benefits that every consumer is required to purchase regardless of whether they want them, need them or can afford them,” Ohio Insurance Commissioner Mary Taylor said in 2013, when the state’s rates were announced.

But Bayram noted most of that jump was not due to the broader benefits, but to the fact that, for the first time, sicker patients were allowed to buy coverage. “The premiums would go down a lot if only very healthy people were covered and people who were higher risk were pulled out of the risk pool,” she said. (Some conservatives want to change that requirement, too, and let insurers charge sick people higher premiums.)

Meanwhile, most of the research that has been done on required benefits has looked at plans offered to workers by their employers, not policies available to individuals who buy their own coverage because they don’t get it through work or the government. That individual market is the focus of the current debate.

Analysts warn that individual-market dynamics differ greatly from those of the employer insurance market.

Bailey said he “saw this debate coming and wanted to write a paper” about the ACA’s essential health benefits. But “I very quickly realized there are all these complicated details that are going to make it very hard to figure out,” he said, particularly the way the required benefits work in tandem with other requirements in the law.

For example, said Bertko, prescription drugs can represent 20 percent of costs in the individual market. That’s far more than in the employer market.

Bayram said another big complication is that the required benefits do double duty. They not only ensure that consumers have a comprehensive package of benefits but enable other parts of the health law to work by ensuring that everyone’s benefits are comparable.

For example, the law adjusts payments to insurers to help compensate plans that enroll sicker-than-average patients. But in order to do that “risk adjustment,” she said, “all of the plans have to agree on some kind of package. So if you think of essential health benefits as an agreed-upon benchmark, I don’t know how they can get rid of that and still have risk adjustment.”

Categories: Cost and Quality, Insurance, Repeal And Replace Watch, The Health Law


Florida Congressman Draws Jeers At Home For Backing Failed GOP Health Care Plan

LOXAHATCHEE, Fla. — A Republican congressman who in 2010 lost both legs after stepping on a roadside bomb in Afghanistan told an occasionally raucous town hall meeting here that he supports his party’s push to repeal the Affordable Care Act because Americans should be free to go without health care if they so choose.

“There are positives and negatives” in the health law known as Obamacare, said Rep. Brian Mast, who noted he gets his health care from the Veterans Health Administration. “I’m not going to pretend this is the easiest thing to work through.”

That was clear Saturday morning in the high school auditorium where about 150 constituents from Mast’s South Florida district west and north of West Palm Beach sometimes booed the congressman during the two-hour meeting. They held up red placards when they didn’t like what they heard and, less often, green ones when they did. Roughly half of the 35 questions that Mast took concerned health care.

No one spoke in favor of the GOP health bill that Mast was prepared to vote for last month. It was pulled by House leaders before a vote because of lack of support.

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Party leaders and the Trump administration are negotiating elements for a new plan to bring to Congress. At the same time, some Republicans back in their home districts for the Easter recess have endured similarly heated town hall meetings with constituents.

After his meeting, Mast told Kaiser Health News that his constituents’ lack of support for the GOP health bill shows the proposal needs more work before a vote. But he offered no solutions.

Many people at Saturday’s meeting asked why Mast wanted to gut the federal health law that helped them survive serious illnesses and sought to defund Planned Parenthood.

Susan Stutz, 48, of Port St. Lucie, said her health coverage under Obamacare is affordable and it has helped her and her sister get vital regular screenings for breast and cervical cancer. Both are at high risk for the diseases.

“If you take away the ACA without a realistic plan to replace it and defund Planned Parenthood, you take away my ability to know every six months if I have cancer,” she told Mast. “What am I supposed to do to stay alive?”

Rep. Brian Mast, who lost both legs while serving in the Army in Afghanistan, chats with Randi Solomon, a constituent who worries about losing her Obamacare coverage, at a town hall meeting in Loxahatchee, Fla. (Phil Galewitz/KHN)

Randi Solomon, 56, of Royal Palm Beach, said Obamacare coverage has helped her obtain back surgery and afford medications for asthma and high blood pressure. “I am really worried,” Solomon said.

Several women at the meeting asked Mast why he wanted to defund Planned Parenthood since federal law already banned federal funding of abortions. Mast replied that the nonprofit provides 300,000 abortions a year and that his concern is preserving the rights of unborn children.

Mast, 36, said he strongly supported retaining the health law provision that prohibits insurers from charging higher rates to people with preexisting illnesses. Unlike the current law, the GOP health plan would allow that benefit only for people who continuously maintain coverage.

“Preexisting conditions is something that I live with. … [It] touches our lives in personal ways, and that is never something lost on me,” said Mast, who has two prosthetic legs and spent the entire meeting in one spot leaning on a cane.

Even constituents who opposed Mast’s ACA opinions Saturday saluted his courageous service in the Army.

Mast was elected to represent the state’s 18th Congressional District after the two-term Democratic incumbent Patrick Murphy vacated the seat to run unsuccessfully for the U.S. Senate against Marco Rubio. The large district includes the wealthy haven of Jupiter Island and impoverished rural towns along Lake Okeechobee. Along with its many retirees, the region counts on tourism and agriculture as mainstays of its economy.

The town hall meeting took place about 15 miles northwest of where President Donald Trump spent the day at his West Palm Beach golf course.

Mast gained national publicity in March when he delivered an impassioned plea to his House GOP colleagues to unite to pass the GOP health plan, likening the effort to his military unit working together to beat the enemy combatants in Afghanistan.

Scott Webber, 62, of Hobe Sound told Mast that Obamacare provided affordable coverage for him and his wife and asked Mast how he could support the GOP bill when it received so little support in public polls.

Mast responded that Obamacare premiums are in a “death spiral” because too few young, healthy people have signed up, which has forced up prices. “I hope we can get to a point so you can have lower deductibles and lower premiums,” he said.

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