Senate, House Poised to Mark Up CHIP Funding Bills As States Prepare for Shortfalls

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Source: Fierce Healthcare

This week, Congress will mark up two measures to reauthorize funding for the Children’s Health Insurance Program, and for states, those efforts come not a moment too soon.

Federal funding for CHIP expired this past Saturday even though the Senate Finance Committee reached a bipartisan deal in mid-September to extend funding for five years.

Some say Republicans’ focus on passing an Affordable Care Act repeal bill was to blame for robbing the CHIP funding measure of momentum. “No one was even taking our calls,” Bruce Lesley, president of children’s advocacy group First Focus, told the Los Angeles Times.

With the Graham-Cassidy bill now tabled, lawmakers are once again focusing on CHIP. The Senate Finance Committee will mark up its bill on Wednesday, while the House Energy and Commerce Committee will do the same for its newly unveiled measure (PDF).

The House bill differs from its counterpart in the Senate in that it would send $1 billion in additional Medicaid funding to Puerto Rico, which is currently struggling to recover from the devastation wrought by Hurricane Maria.

Both bills, though, would end the enhanced federal medical assistance percentage (E-FMAP) after it expires. Under the Affordable Care Act, the E-FMAP increased the federal funding match for CHIP by 23 percentage points from 2016-2019.

Even as Congress gets back to work on CHIP, some state leaders are busy preparing for the possibility that their federal funding will run out.

Colorado officials, for example, say they have enough unspent federal aid to continue the program only through the end of January, The Denver Post reports.

Utah, meanwhile, is mulling moving CHIP-eligible children to Medicaid or the ACA exchanges if CHIP funding runs out, according to Politico. And Minnesota would face a $10 million federal penalty if it has to tap into its unspent federal allotment for 2017.

The Medicaid and CHIP Payment and Access Commission has estimated that all states will exhaust their federal CHIP coffers in fiscal year 2018 unless funding is extended. And just extending funding may not be enough, as a Kaiser Family Foundation issue brief points out.

“If Congress extends funding but does not include the 23 percentage-point increase in the federal matching rate that was provided in the ACA, most states will still face shortfalls, since many assumed continued funding with the enhanced match rate,” it notes.

Californians Back Obamacare And Dreamers, But NOT Single-Payer

Image result for poll imagesSource: Capital Public Radio

Majorities of Californians want to protect immigrant children brought to the U.S. illegally and improve the Affordable Care Act – but oppose the creation of a national single-payer health care system.

Those are the headlines from a newly-released Public Policy Institute of California (PPIC) poll.

There’s broad support in California for the children of immigrants who were brought to the U.S. illegally: 77 percent of likely voters – and even 57 percent of likely Republican voters – favor protections for “Deferred Action for Childhood Arrivals” (DACA) recipients.

“It’s always surprising in polling about national issues when you see consensus across party lines,” says PPIC’s Mark Baldassare. “It’s indicative of just what we also find in our poll, consistently, very strong support for immigrants and also for immigrant rights.”

Californians appear to be staking out positions on health care that are left of center – but not too far left.

The Affordable Care Act draws a 58 percent favorable opinion from likely voters, and the same percentage believes congressional Republicans should work with Democrats to improve health care. That’s compared to 20 percent of likely voters (and half of Republicans) who want the GOP to keep working to pass its own health care plan, and another 21 percent who want Republicans to leave health care behind and move on to other issues entirely.

“I think that overall, sentiment is, what we have (is) not perfect – can use improvements – but (it’s) better than the alternatives that we’re seeing out there,” Baldassare says.

Indeed, just 32 percent of likely voters – and only 45 percent of Democrats – favor a government-run “single-payer” national health care system. In contrast, 28 percent of likely voters (and 35 percent of Democrats) prefer that health care be provided by a mix of private insurance companies and government programs, and 37 percent of likely voters – including 73 percent of Republicans – believe it’s not government’s responsibility to provide health care at all.

“Most Californians support the government being involved in health care, providing a path for health care for Americans,” Baldassare says. “But when given the choice between the system we have and changing to a different system, people are divided.”

President Trump’s approval rating stands at just 27 percent. (Among likely voters, it’s 31 percent). He still has relatively strong support from his base, even in California: 69 percent of likely Republican voters say they approve of the job he’s doing. However, that’s down slightly from a high of 74 percent earlier this year. And it’s lower than his national approval rating among Republicans: Gallop’s daily tracking poll currently pegs Trump’s GOP support at 82 percent.

The president’s approval rating tracks with results when respondents were asked whether they favor or oppose building a border wall: 31 percent of likely voters and 69 percent of likely Republican voters support the wall. There’s even a direct correlation among Democrats: Nine percent approve of the president’s job performance, while 10 percent back the wall.

The poll also brought back some contradictory results.

For example, there’s mixed news for Democratic Sen. Dianne Feinstein, who’s considering whether to run for a fifth full term next year. While 54 percent of likely voters approve of her job performance, half say she shouldn’t run again. Of course, three-quarters of Republicans don’t want her to run, so perhaps that finding should be taken with a grain of salt.

And one of the poll’s more intriguing findings centers around termed-out Gov. Jerry Brown and the race to replace him in 2018. While Brown’s approval rating remains strong (55 percent), 49% of likely voters would rather see the next governor “mostly change” Brown’s policies to different ones. Just 43 percent favor the continuation of Brown’s agenda. Again, that’s inflated by 86 percent of Republicans wanting change. But independent voters also prefer change by a 56-39 percent margin. That suggests the “change” theme could come to dominate the 2018 gubernatorial campaign.

“I think it’s entirely possible that change means different things to different people on the political spectrum,” Baldassare says.

Republicans, who represent about a quarter of the electorate in California, generally oppose both Brown and Feinstein.

But for Democrats and independents, Baldassare says, “people are on the one hand happy with the leadership that they’ve seen in Sacramento but also wouldn’t mind seeing some change” next year in response to President Trump and the Republican Congress.

Sanders Slams GOP, Touts Universal Health Care in California

Image result for sanders and Medicare for all imagesSource: The New York Times

Sen. Bernie Sanders pilloried Republican efforts to overhaul the health care system and touted his own Medicare for all plan Friday before an effusive California audience that welcomed him on stage with chants of “Run, Bernie, Run!”

Sanders’ speech to the influential California nurses’ union in San Francisco came shortly after Republican Sen. John McCain announced he would vote “no” on the latest GOP effort to roll back President Barack Obama’s health care overhaul law. Sanders praised McCain for following his conscience, but he said the fight to preserve — and expand — access to health care is far from over.

“Tell (Republicans) they will pay a heavy political price,” he said. “While we have got to wage an all-out battle to defeat this horrific legislation, we have also got to understand, in terms of health care maintaining the status quo is not enough.”

The California Nurses Association was a particularly receptive audience for Sanders’ calls for a government-funded universal health care system. The union pushed aggressively this year to create such a system in California, only to see it shelved by Democratic Assembly Speaker Anthony Rendon who called it “woefully incomplete.”

Rendon’s move spurred marches and rallies at the Capitol. He has since pledged to study the issue and revisit it next year.

Sanders made no mention of the California bill, but his national legislation mirrors the California plan in many ways. His bill has attracted 16 co-sponsors, including California Sen. Kamala Harris, in a nod to the increasing openness of Democrats to get behind a single-payer system.

“Brothers and sisters, we understand that the fight for a Medicare for all, single-payer system is not going to be easy,” he said. “We’re going to be taking on the drug companies, the insurance companies. We’re going to be taking on the medical devices companies. But you understand and I understand that when the American people stand up together, we’re gonna win this fight.”

Earlier in the day Lt. Gov. Gavin Newsom, a candidate for governor, gave a full-throated endorsement for California’s bill and pledged to make universal health care a reality in the state if he wins the governorship in 2018. The nurses’ union endorsed his candidacy early.

“Because of your leadership, this state has never been closer to universal health care,” Newsom said. “I’ll make this crystal clear: If we can’t get it done next year, you have my firm and absolute commitment as your next governor I will lead the effort to get it done.”

Sanders’ proposal would hand government the responsibility of ensuring most Americans, with people no longer owing premiums and co-payments. Like the California proposal, it so far provides no details on how the plan would be financed. A single-payer system in California is estimated to cost $400 billion annually, and Rendon shelved the bill in part because it outlined no way to cover those costs. Sanders hasn’t provided details about what his plan would cost, but a similar measure he introduced during the 2016 campaign boasted a $1.4 trillion annual price tag.

Sanders remains a favorable choice among party activists to be the 2020 Democratic presidential nominee. He campaigned aggressively in California in 2016, but he lost the state to Democratic nominee Hillary Clinton by six percentage points.

He faced a more adoring reception Friday than top California Democrats have received lately in San Francisco. Sen. Dianne Feinstein took heat last month for calling for patience in dealing with President Donald Trump, while young immigrants shouted over House Speaker Nancy Pelosi last week for not pushing hard enough for comprehensive immigration reform. The criticism displayed continued angst among the Democratic party’s base about its direction as it tries to win back a Congress and White House controlled by Republicans.

The nurses’ union hasn’t shied away from criticizing the Democratic establishment. After Rendon shelved the single-payer bill, they displayed signs with a knife reading “Rendon” stabbed in the back of California’s grizzly bear.

Trust in Health Insurers Sinks to an All-Time Low

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Source: Modern Healthcare

Health system executives’ and physicians’ trust in health insurers has sunk to an all-time low, a new survey shows.

Health system executives level of trust in health plans dipped to a score of 52 out of 100 this year, compared to 54.1 in 2016, according to healthcare marketing and communications agency ReviveHealth’s 11th Trust Index report released Monday. Physicians gave health plans a score of 55.8 on the trust index, essentially unchanged from last year.

Consumers gave health insurers a score of 69, lower than their ratings for hospitals (74.2) and physicians (79.3).

The annual survey measures trust based on how honest, reliable and fair health system executives, physicians and consumers consider health insurers. It also looks at insurance executives’ level of trust in health systems and physicians.

For the major U.S. health plans included in the survey, health systems’ level of trust varied widely from 36.3 for the least-trusted insurer to 68 for the most trusted.

UnitedHealth, the nation’s largest health insurer serving 49.5 million members, scored the lowest. The Minnetonka, Minn.-based insurer has consistently been the least-trusted health plan since the survey began.

ReviveHealth would not provide the individual scores for each health plan.

Indianapolis-based Anthem’s score experienced the most significant decline year-over-year, and was almost as low as UnitedHealth’s, ReviveHealth CEO Brandon Edwards said. Anthem’s CEO is Joseph Swedish, former CEO of health system Trinity Health.

In a statement, an Anthem spokeswoman said the insurer “has a long history of working with providers to improve the accessibility, affordability and effectiveness of quality healthcare. We are advocates for our members and are committed to providing them with access to affordable, quality care.”

On the flip side, Cigna experienced the most growth and received the highest trust score of any other health plan. Anthem and Cigna have been locked in a legal battle over a $1.85 billion break-up fee that Cigna believes it is entitled to after their proposed merger fell through earlier this year.

The survey also asked respondents to rank Aetna, Humana and independent Blue Cross and Blue Shield plans. Edwards said the Blues plans’ scores have been steadily falling over the past few years, while Aetna and Humana’s scores haven’t budged much.

Aside from Anthem, insurers in the survey either declined to comment, were still reviewing the survey results or did not respond to requests for comment.

Meanwhile, insurers’ trust in health systems grew to 68.4 on the trust index, compared to 67.4 last year.

With health insurers’ trustworthiness at its lowest point, that hasn’t seemed to dent the plans’ bottom lines. Despite being the lowest in terms of trust, UnitedHealth added 2.5 million people to its membership total in the second quarter of this year, while growing revenue by 8%.

Lack of trust in insurance companies is unlikely to affect them financially because consumers have little choice in their insurance providers, Edwards said. In job-based insurance, where more than 150 million Americans access coverage, employers do the healthcare shopping. In the individual market, consumer choice has dwindled as health plans exit the exchanges due to financial losses and regulatory uncertainty.

When a Drug Coupon Helps You But Hurts Fellow Citizens

Image result for drug coupon imagesSource: The New York Times

It’s completely rational for you to use coupons to reduce the cost of your brand-name drug purchase.

But if the coupon is causing you to switch away from a generic drug with an overall lower cost, you may be playing a role in pushing up drug spending and premiums for others.

Let’s say that I needed the brand drug Effexor XR, used to treat depression and anxiety disorders. It would cost me at least $65 a month on my health insurance plan. It retails for about twice that amount, and the difference would be picked up by my insurer. But the generic version, Venlafaxine, would cost my insurer far less, and my co-payment would be only $10 per month.

My insurer and I would both save money if I purchased the generic. Pfizer, which sells Effexor XR, would lose a sale.

But Pfizer is fighting back. It offers an Effexor XR coupon card I could use at the pharmacy that would reduce my cost to as low as $4 per month. At that price, I would prefer the brand-name product. Why pay $10 for a generic when for $4 I can get the brand-name drug?

But for the insurer, unless it is getting a discount or a rebate from the manufacturer, the cost is about $130 minus the co-payment.

The company is by no means alone in this tactic. Many other drug manufacturers also offer coupon cards online for their brand-name products that compete with generics.

Such coupons are not new. But from 2007 to 2010, brand-name drugs with coupons grew as a share of retail drug spending, to 54 percent from 26 percent. The figure may well be even higher today, according to Leemore Dafny, an economist at Harvard Business School.

Though such coupons assist patients, they do nothing for insurers, for whom generics are still a better deal. And that’s the problem. By encouraging patients to switch from generic to brand drugs, coupons effectively impose higher costs on insurers. That ends up increasing premiums, and not for any particularly good reason. Generic drugs are generally regarded as equivalent to their corresponding brand products and are 80 percent cheaper, on average.

This is precisely why plans impose much higher cost-sharing for brand-name drugs than their generic equivalent. Doing so can help keep premiums down without harming patients. Perhaps in response, Americans are using more generics.

In 2006, 90 percent of prescriptions that were filled were for a generic equivalent to a brand-name drug, when such a generic was available. In 2012, that number had increased to 95 percent.

The circumvention of insurance plan designs by these coupons has long been suspected to contribute to drug spending and premium growth. A recent study examining data from 2007 through 2010 and published in The American Economic Journal: Economic Policy, puts some numbers to the phenomenon. Co-pay coupons increase use of brand drugs for which generics are available by 60 percent and spending by as much as 4.6 percent.

“Coupons raise spending in two ways,” said Ms. Dafny, an author of the study. “In addition to making more expensive brand drugs more attractive to consumers, it allows manufacturers to raise brand prices.”

For example, the $4 cost with the coupon holds the consumers’ prices fixed at a low level. That allows the manufacturer to raise the overall price without losing sales. This raises spending, too, but for the insurer.

In total, the coupons for drugs with generic competition are responsible for several billion dollars of additional drug spending per year, according to the study, which was also written by Christopher Ody with Northwestern’s Kellogg School of Management and Matthew Schmitt with the U.C.L.A. Anderson School of Management.

The coupons do so, by and large, without expanding the number of people using medications, just by switching which product they purchase — brand or generic. Drug manufacturers also offer coupons for drugs without generic competition, but they were not the focus of the study.

If drug coupons are problematic for insurers and drive up premiums, why don’t insurers reject them?

“They say they can’t ban them because they can’t tell when a coupon is being redeemed at the pharmacy counter,” Ms. Dafny said. But “public payers ban them, after all, and their enrollees pick up prescriptions at the same pharmacies.”

Medicare, for example, bans their use. But enforcement is incomplete, and by one estimate 6 percent of Medicare enrollees use coupons anyway. And Massachusetts has passed laws that ban co-pay coupons for brand drugs with generic equivalents.

The likelier explanation, Ms. Dafny says, is that denying consumers access to coupons would cause a backlash. In the short term, out-of pocket-prices would rise for the few: the consumers relying upon them. But in the long term, encouraging consumers to use generic drugs when available — which is what insurers are trying to do — would reduce drug spending and premiums for everyone.

CBO Projects Graham-Cassidy Would Reduce Spending And Coverage

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Source: Health Affairs

Late in the day on September 25, 2017, the Congressional Budget Office and Joint Committee on Taxation staff released their report on the Graham-Cassidy bill. Their analysis was apparently of an earlier version of the bill than the one released on September 24, 2017, but the provisions described and analyzed in the CBO report are virtually the same.

The CBO found that the Graham-Cassidy meets Senate budget reconciliation rules. It would reduce the deficit over ten years by at least $133 billion, the amount that the CBO concluded that the House American Health Care Act would reduce the deficit; each title of the bill would result in at least $1 billion in deficit reduction; and the bill would not increase the deficit in the four ten-year periods beyond the ten-year budget window. On the other hand, the CBO stated that, although it did not have time to come up with point estimates (which would take several weeks), “millions” would lose coverage under the bill.

Sources Of Coverage Losses

Coverage losses would be attributable to three main causes. First, large reductions in Medicaid funding would reduce Medicaid enrollment. Second, reduction in subsidies for the individual market would reduce enrollment in that market. Third, enrollment in all markets would be lower because of the repeal of the individual responsibility requirement. These losses would be only partially offset by new programs established through the block grants and higher enrollment in employer-sponsored coverage as individual market coverage became more problematic. Losses would be particularly large starting in 2020 when major changes to federal funding streams would begin, causing market disruptions and other implementation problems.

Sources Of Spending Reductions

The bill’s projected budget deficit reduction is mainly attributable to the relatively small size of the block grants, which at $1.2 trillion for the 2020 to 2026 period are $230 billion less than the amount in the CBO’s March baseline. These cuts would more than offset lost revenue from the repeal of the mandate penalties, but the CBO estimates that at least $150 billion of the $1.2 trillion would not be spent. Medicare spending reductions would add to the deficit reduction, although employers would expand coverage, reducing tax revenues.

The CBO projects that under Graham-Cassidy states that had expanded Medicaid would by 2026 receive about 30 percent less funding than under current law, and states that failed to expand Medicaid 30 percent more. Overall, funding would be reduced 10 percent from CBO’s 2016 baseline.

Projected Changes To State Insurance Regulations

The CBO projects that most states would change their insurance regulations as permitted by Graham-Cassidy because markets would become unstable if current insurance regulations remained in place without current subsidies and mandates. Without subsidies, states that maintained ACA market rules would see healthy people fleeing the market, premiums for people with preexisting conditions rapidly rising, and insurers withdrawing from the market.

But problems would also attend changes in market rules. CBO expects that some states would increase age rating ratios from the ACA’s 3 to 1 to 5 to 1 and reduce the scope of benefits to exclude expensive services that are used by few people, such as mental health care, habilitative and rehabilitative services, and certain drugs. Some states would allow insurers to set premiums based on health status. Coverage for people with preexisting conditions and for high-cost services would become much more expensive.

Graham-Cassidy would require states to provide at least small subsidies for purchasing individual market coverage in order to change market rules. But the CBO projects that states would lack the money and programs to otherwise maintain coverage in the individual market. The main effect of Graham-Cassidy would therefore be to reduce individual market protections.

The Future Of Medicaid Expansions And Medicaid Spending

The CBO predicts that some states that have expanded Medicaid would try to continue covering the expansion group. But by 2026, covering this population would take roughly the full amount provided to states in block grants, leaving little to support others in the individual market. Covering enrollees in the individual market would also be more difficult than simply retaining Medicaid, as states would have to establish new programs to cover them.

CBO projects that states that have not yet expanded Medicaid would likely use the block grant funds to establish high risk pools for high-cost individuals, pay providers for uncompensated care, or increase Medicaid payment rates or benefits for their traditional Medicaid population. (Graham-Cassidy allows states to use up to 15 percent of their block grant for their traditional Medicaid populations; up to 20 percent with HHS permission).

CBO projects that Medicaid spending would be cut by $1 trillion over the 2017 to 2026 period because of the elimination of Medicaid expansion funding and Graham-Cassidy’s Medicaid per capita caps or block grants. States would have little flexibility under the per-capita caps for redesigning their Medicaid programs. States might commit more of their own resources to funding Medicaid, but alternatively they could cut payments to providers and health plans (which are already low in many states); eliminate optional services; or restrict enrollment through work requirements or other means. These changes could reduce enrollment or enrollees’ access to care.

A Likely Too Short Implementation Period

The CBO acknowledges that the two-year timeframe in the legislation for states to develop the institutional capacity to use the block grants and to adopt new rules is too short. States would have to adopt legislation and administrative rules and establish systems for determining eligibility of individuals for subsidies, suitability of insurers for receiving those subsidies, enrolling individuals in coverage, and making required payments on a very short time frame. In some states there might be no insurers in the individual market until new market rules were clear and insurers had time to adapt to them.

During 2016, 8.4 million people with incomes between 100 and 400 percent of the federal poverty level received premiums tax credits, roughly half the enrollment of the individual market. States might try to cover these people through Medicaid-like programs, but to do so they would have to come up with substantial additional state funding.

A Bleak Political Outlook For Graham-Cassidy

The CBO report confirms much of what the critics of Graham-Cassidy have been saying for several days. In any event, the most important number connected with Graham-Cassidy is likely three: It is being reported that Senator Collins will not support Graham-Cassidy, and with Senators Paul and McCain as firm negative votes, there are now three Republicans opposed, leaving only 49 in favor even if not other GOP no votes emerge. The bill may well be dead.

Senate GOP Abandons Latest Effort to Unwind the Affordable Care Act

Image result for senate gop imagesSource: MSN

Senate Republicans decided Tuesday not to hold a vote on unwinding the Affordable Care Act, preserving the landmark 2010 law for the foreseeable future even as they suggested they may withhold crucial funding for it.

The move leaves the GOP — once again — short of fulfilling a signature promise, which some Republicans worried could inspire a backlash among their base heading into the 2018 midterm elections.

Several senators said they instead plan to move onto other issues now that the party’s latest proposal, authored by Republican Sens. Lindsey O. Graham (S.C.) and Bill Cassidy (La.), had failed to garner sufficient support

“Where we go from here is tax reform,” Senate Majority Leader Mitch McConnell (R-Ky.) told reporters after holding a closed-door policy lunch with members of his caucus.

Meanwhile, Republican lawmakers voiced little interest in shoring up the existing ACA insurance market, sowing apprehension among insurers and state officials just weeks before consumers must start enrolling in plans for next year.

While some GOP lawmakers expected consumers could experience major problems in the months ahead, they argued that the ongoing instability would backfire on Democrats and build momentum for the ACA’s eventual repeal.

“I personally think it’s time for the American people to see what the Democrats have done to them on health care,” said Senate Finance Committee Chairman Orrin G. Hatch (R-Utah). “They’re going to find they can’t pay for it, they’re going to find that it doesn’t work. . . . Now that will make it tough on everybody. Maybe that’s what it take to wise people up.”

Wednesday is the deadline for insurers to sign contracts with the federal government so that they can sell health plans on the ACA marketplaces for 2018. Many companies are hiking these rates by double digits, but they have suggested they would curb such increases if they had assurances that the federal government would provide cost-sharing reduction payments for all of next year. Those subsidies provide discounts to lower-income customers for their health plan’s deductibles and other out-of- pocket costs.

Republican leaders could call on Sen. Lamar Alexander (R-Tenn.) to revive negotiations with Sen. Patty Murray (D-Wash.) on a bipartisan package to stabilize the current insurance marketplaces. The pair had appeared to be reaching an agreement on a plan to guarantee the cost-sharing subsidies for at least a year in exchange for limited waivers to give states more flexibility in how they spend that money. Those talks stalled when Alexander stepped aside to allow GOP leaders to focus on securing votes for Graham-Cassidy.

“I would imagine that Senator Alexander is going to continue to work on that, and hopefully Senator Murray will as well,” said Sen. Roy Blunt (R-Mo.) Tuesday.

At the moment, the Trump administration is only covering cost-sharing payments on a month-to-month basis; a White House official confirmed Tuesday that it had made a payment for September. Asked what the president intended to continue making payments going forward, the aide said officials have not yet decided what to do.

Trump has suggested on several occasions that if a replacement bill does not pass Republicans should let the current system fail, forcing Democrats to negotiate.

It is unclear how much appetite there is for a stabilization bill among Republicans in the Senate, let alone in the House. Aides to House GOP leaders said they did not see a bill providing billions in ACA subsidies as viable in the lower chamber, and that House Speaker Paul D. Ryan (R-Wis.) had conveyed that to GOP senators.

Democrats, meanwhile, reiterated their interest in striking a deal Tuesday, with Murray saying that while “damage has been done” by delaying an agreement, “let’s pick back up right where we left off, and let’s do it right now.”

“The clock is ticking, Democrats are at the table, and I hope Republican leaders will now allow us to get back to work on lowering costs for patients and families and stabilizing the markets,” the senator said. “We don’t have a minute to spare.”

Some congressional Republicans — such as Rep. Carlos Curbelo (R-Fla.), who represents a swing district — echoed that call.

“I think the time for partisan health-care reform has passed, and we should focus on a bipartisan package that provides some regulatory relief, especially on the employer mandate,” Curbelo told reporters, “and also guarantees [cost-sharing subsidies] for the most vulnerable people.”

Lanhee Chen, a research fellow at the Hoover Institution, said in an interview that he had initially hoped the Graham-Cassidy bill would have allowed Republicans to move past their policy divisions on health care.

“I thought at least every Republican, or every conservative, would agree with the idea that when it came to health care, it would make sense to give states the freedom and flexibility to pursue a path that would work best for their residents,” said Chen, who also directs domestic policy studies at Stanford University’s public policy program. “That was a principle I was pretty certain could garner the vast majority of Republicans in the Senate.”

But even that sort of consensus seemed elusive, Chen said, and the fact that Republicans are rushing to pass the bill by the end of the month has produced “a flawed process” that has allowed some critics to sidestep more serious questions, such as the long-term sustainability of the Medicaid program.

Speaking to reporters Tuesday, Trump said he was “disappointed in certain so-called Republicans” who would not back the Graham-Cassidy bill.

The president declined the speculate Tuesday morning on whether he wanted lawmakers to actually vote on the measure, saying, “We’ll see what happens.”

“It’s going along and at some point, there will be a repeal and replace,” Trump added. “But we’ll see whether that point is now or whether it will be shortly thereafter.”

Two GOP senators — Rand Paul (Ky.) and John McCain (Ariz.) — already had come out last week against the measure and were not swayed by a new draft that emerged after the weekend. Monday evening, after the Congressional Budget Office projected that “millions” if Americans would lose insurance if the Graham-Cassidy bill was enacted, Sen. Susan Collins (R-Maine) announced that she could not support it.

Republicans hold a 52-to-48 advantage in the Senate; they can lose only two votes from their party and still pass legislation with the help of a tiebreaking vote from Vice President Pence.

A fourth Republican, Sen. Ted Cruz (Tex.), indicated through his aides Monday that he would not back the bill in its current form because it would not go far enough in repealing the 2010 law.

HHS Slashes Funding to Groups Helping ACA Consumers Enroll By Up to 92 Percent

Image result for hhs imagesSource: The Washington Post

Health and Human Services officials have informed grass-roots groups that assist with enrollment under the Affordable Care Act that their funding will be reduced by as much as 92 percent, a move that could upend outreach efforts across the country.

The groups, which fund organizations known as “navigators,” had been braced for the cuts since the Trump administration announced two weeks ago that it would shrink overall program funding by 41 percent and slash the department’s ACA advertising budget from $100 million to $10 million. At the time of the announcement, HHS officials said the outreach wasted taxpayers’ money.

But advocates of the navigator program, including congressional Democrats and some Republicans from rural states, said Thursday that the deep cuts would undermine work to help consumers get insurance coverage once open enrollment begins on Nov. 1. And the depth of some funding reductions, which were made official late Wednesday, raised questions about those state programs’ viability and the fairness of the administration’s method for deciding how much money each group gets.

“There is no way you can run what we had on $328,000,” said Sarah Sessoms of Insure Georgia, which was hit with a massive cut from the $2.2 million it received last year. The HHS email notice arrived at 11:53 p.m. Wednesday, and “I thought — it was disbelief — that something had to be wrong.”

Enroll Michigan executive director Dizzy Warren, whose group serves all of the state’s 83 counties though a network of more than two dozen groups, is contemplating shutting down within a matter of months now that its $1.2 million grant was slashed to $129,899.

“As you can imagine, this decimates our entire organization,” he wrote in an email. The collective effort there enrolled 16,290 Michiganders in health plans last year.

Navigator groups perform a range of services during the ACA’s annual enrollment season and throughout the year. They help individuals learn which health plans offered on state and federal insurance exchanges would best suit them, walk consumers through the sign-up process and conduct general outreach to communities about how to obtain coverage under the law. The program’s supporters argue that it is particularly critical during the upcoming six-week enrollment period, which is half as long as last year and comes after Republicans’ high-profile attempt to repeal the 2010 health-care law.

“I don’t know how the people who need this help are going to get it,” said Sessoms, adding that Insure Georgia is now exploring its options, including potentially legal ones.

HHS officials in the Trump administration have repeatedly questioned the value of paying navigators. They note that these groups received $62.5 million last year but signed up less than 1 percent of total enrollees. Seventeen of them enrolled less than 100 consumers each, according to the department, at an average cost of nearly $5,000 per enrollee.

“Navigators have been notified of their awards for the upcoming open enrollment period,” HHS spokesman Matt Lloyd, “and the next step is for the grantees to work … to align their activities to the awarded amount and accept the terms of the contract.”

Sen. Tammy Baldwin (D-Wis.), a member of the Health, Education, Labor and Pensions Committee said in a statement Thursday that the cuts reflected the president’s broader effort to undermine the ACA.

“This is nothing short of sabotage,” Baldwin said. “The Trump administration is actively creating chaos and making it harder for Wisconsinites in communities across the state to get covered. That’s just wrong, and it will further destabilize the market and can lead to higher costs for everyone.”

But some conservatives backed the administration’s action.

“The administration clearly has done a cost-benefit analysis in determining if the money that had been spent on the navigator program produced the needed results,” Grace-Marie Turner, president of the Galen Institute, said in an email. “Programs were significantly under performing in their cost per enrollee.”

Although Lloyd said the metric used to determine grant levels was the number of people a group had enrolled in ACA health plans, some organizations that reached past enrollment goals are facing major cuts while others were not touched.

The Kansas Association for the Medically Underserved, where officials said all targets had been met, received full funding, as did Planned Parenthood of St. Louis. Yet Karen Pollitz, a senior fellow at the Kaiser Family Foundation, said New Jersey’s Center for Family Services had its grant go from $805,000 to $291,000 “despite the fact that they exceeded all of their numbers.”

“There doesn’t seem to be a pattern,” she said. “It looks like this could drastically cut back on the availability of in-person assistance in a lot of the heavily impacted states.”

At the Missouri Association of Area Agencies on Aging, which spread nearly $920,000 in navigator money among seven agencies across the state last year, executive director Catherine Edwards learned early Thursday morning that amount would be cut by 62 percent to just under $350,000.

Take Care Utah, a network of nonprofits with roughly 90 navigators, enrollment specialists and insurance brokers, suffered a 61 percent cut, from $740,000 to $289,584. Its director, Randal Serr, noted that Utah had the country’s third-highest increase in federal marketplace enrollment last year, behind Hawaii and South Dakota.

“We will have to make some tough decisions, there’s no way around it,” he said in an email.

At this point, navigators are scrambling to rework their approach for this fall’s enrollment period. As recently as May, federal officials had told Edwards that her association in Missouri could expect to receive a similar grant as last year. Having prepared a budget based on its 2016 award, she now is wondering how she can proceed with the digital and social media campaign planned, especially if many individual navigators are at risk of being laid off.

“At what point does it become ineffective to do any of that?” she asked.

Even before the emails began popping up in organizations’ inboxes, HHS’s abrupt announcement about an overall drop in funding had created havoc for enrollment helpers around the country. It came at the exact time of year when their work becomes intense, ramping up for the always feverish enrollment season, and left them with no money to spend during the first two weeks of September because their previous grants had expired as of Sept. 1.

According to notices sent to organizations late Wednesday, these groups now have just two weeks to send HHS a revised budget and work plan, which federal officials then must approve. They will be allowed to use 10 percent of their award to cover costs they have incurred since Sept. 2, and the reimbursement will be restricted to certain expenses.

HHS informed recipients that their award figures “are considered private and confidential and should not be shared.”

In addition to enrolling consumers, navigators typically advise consumers on how to provide proof of health coverage when filing their taxes; how to find a primary doctor and how to address issues related to premium payments and insurance billing. They also work with employers on fulfilling their obligations under the ACA.

“They don’t count all the other ways we help people,” Serr emailed from Utah. “This is completely a political decision, and not a decision made by people who do this for a living.”

While congressional Democrats have been most critical of the administration’s plan to cut navigator cuts, some GOP officials have warned it could hurt their constituents as well.

Lori Wing-Heier, director of the Alaska Department of Commerce, Community and Economic Development’s insurance division, testified on Capitol Hill last week that in some remote parts of the state “there’s not an insurance broker or a consultant to be found.”

“We are very concerned that it will have a major impact on our enrollment,” Wing-Heier told the Senate hearing. “This would be devastating, to our population.”

Funding for the state’s two navigator groups, Alaska Primary Care Association and United Way of Anchorage, were cut by 24 percent and 27 percent, respectively.

Dems Call for Action Against Cassidy-Graham ObamaCare Repeal

Image result for senate democrats imagesSource: The Hill

Democratic senators are reigniting their calls to fight against another Republican health-care push that aims to repeal and replace ObamaCare after reports surfaced that President Trump and GOP leaders are working to garner support for legislation introduced by Sens. Bill Cassidy (R-La.) and Lindsey Graham (R-S.C.).

Prominent upper-chamber lawmakers like Sens. Elizabeth Warren (D-Mass.), Dianne Feinstein (D-Calif.) and Chris Murphy (D-Conn.) are taking to Twitter to make impassioned calls for voters to speak up and demonstrate their opposition to the bill.

“Drop what you are doing to start calling, start showing up, start descending on DC,” Murphy tweeted Sunday.

“I’m alarmed,” Sen. Brian Schatz (D-Hawaii) tweeted, while linking to a Politico report that describes the GOP leadership’s back-door push to find support for the legislation.

The measure, put forward by Republican Sens. Bill Cassidy (La.), Dean Heller (Nev.), Ron Johnson (Wis.) and Lindsey Graham (S.C.), aims to give more power to states by converting ObamaCare funding for subsidies — which help people afford health-care coverage and pay for Medicaid expansion — into a block grant to states.

While Senate Majority Leader Mitch McConnell (R-Ky.) has withheld full-throttled support by telling Cassidy and Graham to find the necessary 51 votes on their own, Cassidy says leadership is asking the Congressional Budget Office (CBO) to prioritize its analysis of the measure in an effort to get it to the floor.

“We’re told that CBO was told by our leadership to make this a priority above all other priorities,” Cassidy said Friday, while predicting that he can get enough votes. “Mitch has always said, ‘Show me you can get 50 votes.’ ”

Employer Groups Targeting a Number of Healthcare Reforms in Congress

Image result for employer groups imagesSource: Employee Benefit News

Employer associations are regrouping after Congress failed to repeal and replace major elements of the Affordable Care Act this summer, and they have a number of priorities on their agenda.

Congress is now back in session following the August recess, and there are several deadlines that will bring attention back on the issue in the near term. The Senate has until the end of the month to pass an ACA replacement bill using a process known as budget reconciliation, which requires just 50 votes. Lawmakers also are working to shore up the individual market before Sept. 27, when insurers must finalize the plans they will sell on the exchanges for 2018. Funding for the Children’s Health Insurance Program also expires on Sept. 30.

Beyond that time frame, employer groups are likely to continue to press for a broad range of tweaks that could potentially be taken up as standalone bills or included in packages of must-pass legislation later this year.

Here are some of the biggest legislative priorities for employer associations this fall and what the efforts could mean for employer-sponsored care.

Roll back ACA taxes: Supporters of employer-sponsored healthcare are expected to continue their fight to repeal or delay several ACA taxes this coming fall.

The Cadillac tax, which imposes a 40% excise tax on high-cost plans, remains a particular area of focus for employers. Other taxes that will be targeted include the health insurance tax and the medical device tax.

Obamacare taxes are making healthcare more expensive for employers and employees alike, says James Gelfand, senior vice president for health policy at the ERISA Industry Committee, a national association that advocates for large employers on health, retirement and compensation public policies.

“It’s super important that we eliminate taxes that are raising costs both for us and for them,” he says.

Limit the impact of 1332 Waivers: Employers also want to ensure that any changes to how so-called 1332 waivers are issued don’t have knock-on effects for employer-sponsored care. The waivers allow states to modify certain ACA health insurance requirements, such as essential health benefits and tiers of coverage, and several bills debated this summer included steps to streamline the process for states to obtain the waivers.

It’s an issue that could indirectly affect employer-sponsored care down the line, and it’s one that employer groups will be watching closely. The Employee Retirement Income Security Act currently bars states from passing any laws that would impact employee benefits, including employer-sponsored healthcare.

“Proposals such as providing states more flexibility, which we definitely support, could eventually lead to the erosion of ERISA, if states become accustomed to implementing their own health plans,” says Chatrane Birbal, senior advisor for government relations at the Society for Human Resource Management.

Employer groups say that they are broadly concerned the application of state-by-state variations in healthcare on the exchanges could potentially affect employer coverage in the longer term.

“Our feeling about this is that granting more flexibility to states is fine, as long as it’s focused on individual markets and potentially the small employer market,” says Jim Klein, president of the American Benefits Council. “For large, multi-state employers, the notion that there could be any erosion of the federal ERISA preemption is very troubling. I don’t think there’s necessarily any direct intention to adversely affect large, multi-state employers, so we’re just working with Congress to ensure that doesn’t happen inadvertently.”

Modify the definition of full-time work: Employers plan to continue to advocate for reforms that would raise the bar for when insurance must be offered to workers. The ACA defined full-time work at 30 or more hours, which employers have argued raised their costs, because they had to extend health benefits to additional people.

“It makes sense to set the bar at 40 hours, and if a particular retailer wants to offer coverage at a lower level, it can do so,” says Neil Trautwein, vice president of health care policy at the National Retail Federation.

Reduce reporting requirements: Efforts to fix the ACA’s reporting requirements for employers were largely blocked in the Senate this summer, because the issue could not be considered as part of budget reconciliation. Larger employers must report information about whether they offer coverage to full-time employees, whether that coverage meets certain minimum requirements and its cost.

Standalone bills that focus on streamlining employer requirements are likely to be introduced again this fall.

“We’d love to fix the dysfunctional ACA reporting system,” Trautwein says.

Improve health savings accounts: Gelfand says that employers are continuing to push for a broad array of changes to health savings accounts, including reforms that were not considered over the summer under budget reconciliation rules. Those might include efforts to allow use of HSA funds on concierge care or on a broader array of health activities, like the purchase of gym memberships or activity trackers, in addition to the changes that were introduced as part of earlier bills, such as raising the cap on contributions.

Stabilize individual markets: Many lawmakers are now focused on trying to advance a more limited package of reforms with bipartisan support that would also help shore up the state exchanges.

The Trump administration agreed to pay certain cost-sharing reduction subsidies to insurers for the month of August, but has yet to guarantee that the payments will be made through the rest of the year without congressional authorization. Cutting off those payments could significantly destabilize the exchanges in a number of states.

The issue is another that does not impact employer-sponsored plans directly, but numerous business and employer groups have spoken out in favor of shoring up the individual markets going forward, because of the indirect impacts.

“To the extent that there’s greater instability and more uninsured [in the absence of the CSR payments], the rest of us, whether that’s individuals or companies, end up getting cost-shifted,” Klein says. “We think this needs to be stable and funded.”

It’s also possible that any legislation addressing the subsidies could ultimately include other reforms beneficial to employers, including some of the items outlined above.

Last Updated 10/4/2017

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