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It’s Back: President Trump’s Budget Seeks to Revive Health Repeal

To: Interested Parties

From: Leslie Dach, Campaign Chairman, Protect Our Care

Subject: It’s Back: President Trump’s Budget Seeks to Revive Health Repeal

Date: February 13, 2018

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President Trump’s fiscal year 2019 budget proposal calls for the passage of the so-called Graham-Cassidy bill, the worst of the partisan repeal bills Congress considered last year. If you forgot – and who can blame you, there were a lot of repeal bills! – Graham-Cassidy was deemed “crueler and more cynical” than previous repeal proposals, in large part due to its draconian Medicaid cuts, and garnered just 24% approval before it died in the Senate without a vote. It was opposed by the American Medical Association, AARP, the American Cancer Society, insurers, physicians, faith leaders, nearly every medical and patient’s rights organization, a coalition representing all 50 state Medicaid directors, and Jimmy Kimmel – who analysts said had a “better grasp of health care policy” than the GOP senators who pushed the proposal.

Specifically, the Graham-Cassidy bill Trump wants to bring back would:

  • Take away coverage from 32 million Americans by 2027, with 15 million Americans losing their insurance and premiums increasing by 20 percent in the first year.
  • Gut Medicaid by imposing severe cuts and per-capita caps, forcing states to either raise people’s taxes or make draconian cuts to schools and other vital programs.
  • Raise costs on working- and middle-class families by eliminating financial assistance that helps pay for care. Graham-Cassidy ends premium subsidies, which help 9 million Americans pay for coverage, and Medicaid expansion, which has helped 15 million people get the care they need. These programs would be converted into a block grant and eventually zeroed out.
  • Remove protections for those with pre-existing conditions, with the Congressional Budget Office finding that many people with pre-existing conditions “might not be able to purchase coverage at all.”
  • Harm women’s health by preventing Medicaid enrollees from accessing preventive health and family planning services through Planned Parenthood.

In short, Graham-Cassidy would irreparably harm the American health care system, and the fact that President Trump still considers it a good option shows just how out of touch he is with the American people. The negative reaction to its inclusion have been swift:

New York Times Editorial Board: “It calls for (yet again) the repeal of the Affordable Care Act… Medicare and Medicaid, which benefit one-third of Americans, are targeted for cuts of hundreds of billions of dollars. If Congress adopted Mr. Trump’s proposal, millions of people would stand to lose health insurance.”

Planned Parenthood: “This year’s budget plan proposes sweeping changes that, if implemented, would radically reduce people’s access to health care and information through vital programs, especially for women. Whether or not Congress subscribes to the president’s priorities, the entire proposal is a blueprint for policymaking that the administration will no doubt use to advance its agenda.”

American Cancer Society Cancer Action Network: “Eliminating the health insurance marketplace subsidies and transforming Medicaid funding into a per-capita cap or block-grant structure could leave millions of Americans unable to access critical health services. Medicaid serves as an essential safety-net for more than 2.3 million Americans with a history of cancer, including one-third of all pediatric cancer patients at the point of diagnosis.”

American Lung Association: “Over the past year, Americans have been hit by repeated public health crises, from devastating wildfires and deadly storms to an influenza epidemic. President Trump’s budget proposal would simply make things worse.

Initial news coverage of the budget proposal also focused on the havoc it would wreak in the American health care system:

Los Angeles Times: “The White House is doubling down on the repeal effort, calling for massive cuts to healthcare assistance in its 2019 budget … Cuts of this magnitude – which parallel repeal legislation pushed unsuccessfully by GOP congressional leaders last year – would likely leave tens of millions more Americans without health coverage, independent analyses have indicated.”

Washington Post: “On healthcare for low-income Americans, Trump’s budget calls for cutting federal Medicaid funding by $250 billion over the next 10 years, as the administration envisions passing a law ‘modeled closely’ on a Senate Republican proposal that failed last fall to repeal the Affordable Care Act…  Experts say the overall reduction in government spending would cost millions of Americans their health insurance.”

Wall Street Journal: “The budget proposal includes $68.4 billion for the Department of Health and Human Services, a 21% drop from the funding level enacted last year. The proposal would also revive a repeal of the Affordable Care Act and cut spending on Medicare and Medicaid. It calls for enactment of a law to scrap the ACA and instead give block grants to states to establish their own health systems, a plan modeled after GOP legislation that failed to pass last year.”

CNBC: The new budget proposal also would seek a rollback of Obamacare’s expansion of Medicaid benefits to poor adults. Medicaid offers health coverage to primarily low-income people. Before Obamacare, most states either denied Medicaid coverage to people who did not have dependent children or set very low limits on how much a person could earn and still qualify for coverage.

Business Insider: “The budget contains cuts to funding for Medicare and other social safety net programs. During the presidential campaign, Trump repeatedly promised not to cut funding to these programs.”

USA Today: “The budget proposes repealing the ACA’s expansion of Medicaid and limiting the amount of money states receive for the jointly-funded health care program for the poor. It would also end after two years the private insurance subsidies for people who don’t get coverage through a government program or an employer, while giving states grants to develop their own programs.”

STAT News: “The proposals are a hodgepodge of relatively narrow policies that take aim at various parts of the Medicare and Medicaid programs. One would reduce the amount of money doctors and hospitals are reimbursed for hospital-administered drugs under Medicare Part B; another would let some states engage in more aggressive negotiation for drugs in their Medicaid programs. Others take aim at a drug discount program for hospitals and at seniors’ out-of-pocket spending.”

Since taking office last year, President Donald Trump and his Administration have carried out an unrelenting war on our health care with a goal of repealing the Affordable Care Act and gutting Medicaid. Trump has used his administrative powers to sabotage our health care and continue to beat the drum of partisan repeal of the increasingly-popular Affordable Care Act.

While the Trump Administration and Republicans in Congress want to keep up this war on health care in 2018, the American people are saying “Enough is Enough.” More than eleven million people signed up for coverage through HealthCare.gov despite all the sabotage efforts. The Affordable Care Act is more popular than it has ever been. And millions of people across the country made their voices heard at rallies, town halls and through calling their Member of Congress to fight these repeal efforts. The American people are right: enough IS enough – it’s time for President Trump and the GOP to end their war on our health care.

Trump Administration Targets Women in its War on Health Care

After yesterday’s revelations about the Trump Administration’s continuing attacks on women’s health care, Protect Our Care Campaign Director Brad Woodhouse released the following statement:

“The past 24 hours confirm that the Trump Administration’s war on health care is specifically targeting American women. Not only did President Trump release a budget that would defund Planned Parenthood and slash Medicaid, denying millions of women access to basic health care, but we also learned that Trump’s HHS last month instructed a Southern Poverty Law Center-designated hate group to write an official government letter that provides a roadmap for state Medicaid programs to restrict women’s access to the health care provider of their choice. These blatant attacks on women’s health care remain front and center in the Trump Administration’s ongoing war against the Affordable Care Act, Medicaid, and the entire American health care system.”

POLITICO, 2/12/18: “A conservative legal organization worked with the Trump administration to make it easier for states to defund Planned Parenthood.”

CNN, 2/12/18: “The Trump administration relied on a right-wing anti-abortion rights group to draft the letter it sent to states reversing Obama-era guidance that it’s against the law to terminate Planned Parenthood as a Medicaid provider … the Alliance Defending Freedom calls itself a conservative Christian nonprofit organization … but the Southern Poverty Law Center has labeled it a hate group for its attacks on LGBT rights.”

New Poll: Independent Voters Hold Major Concerns About Trump’s War on Health Care

A new Priorities USA poll finds that independent voters continue to hold major concerns about President Trump’s anti-health care agenda. The poll confirms that voters realize Republican health care sabotage is driving up insurance premiums and exacerbating the high health care costs burdening working families.

Priorities USA: Democrats Must Keep Focus on Economy and Health Care

“Donald Trump’s policies are adding to the economic burdens of average families by raising the cost of health care and driving up insurance premiums. And Trump has broken his promise to crack down on excessive drug prices. Instead, he has given the big drug companies huge tax breaks while allowing them to charge as much as they want, without any controls or negotiation. 60% of voters have major concerns, including 71% among independents.”

Coverage Roundup: Trump’s Budget Revives Health Care Repeal

As the dust settles around today’s surprise move by President Trump to revive the Graham-Cassidy plan to repeal the Affordable Care Act and gut Medicaid by including it in his annual budget blueprint, here’s a roundup of initial coverage:

Los Angeles Times: “The White House is doubling down on the repeal effort, calling for massive cuts to healthcare assistance in its 2019 budget … Cuts of this magnitude – which parallel repeal legislation pushed unsuccessfully by GOP congressional leaders last year – would likely leave tens of millions more Americans without health coverage, independent analyses have indicated.”

Wall Street Journal: “The budget proposal includes $68.4 billion for the Department of Health and Human Services, a 21% drop from the funding level enacted last year. The proposal would also revive a repeal of the Affordable Care Act and cut spending on Medicare and Medicaid. It calls for enactment of a law to scrap the ACA and instead give block grants to states to establish their own health systems, a plan modeled after GOP legislation that failed to pass last year.”

Washington Post: “On healthcare for low-income Americans, Trump’s budget calls for cutting federal Medicaid funding by $250 billion over the next 10 years, as the administration envisions passing a law ‘modeled closely’ on a Senate Republican proposal that failed last fall to repeal the Affordable Care Act…  Experts say the overall reduction in government spending would cost millions of Americans their health insurance.”

CNBC: The new budget proposal also would seek a rollback of Obamacare’s expansion of Medicaid benefits to poor adults. Medicaid offers health coverage to primarily low-income people. Before Obamacare, most states either denied Medicaid coverage to people who did not have dependent children or set very low limits on how much a person could earn and still qualify for coverage.

Business Insider: “The budget contains cuts to funding for Medicare and other social safety net programs. During the presidential campaign, Trump repeatedly promised not to cut funding to these programs.”

USA Today: “The budget proposes repealing the ACA’s expansion of Medicaid and limiting the amount of money states receive for the jointly-funded health care program for the poor. It would also end after two years the private insurance subsidies for people who don’t get coverage through a government program or an employer, while giving states grants to develop their own programs.”

STAT News: “The proposals are a hodgepodge of relatively narrow policies that take aim at various parts of the Medicare and Medicaid programs. One would reduce the amount of money doctors and hospitals are reimbursed for hospital-administered drugs under Medicare Part B; another would let some states engage in more aggressive negotiation for drugs in their Medicaid programs. Others take aim at a drug discount program for hospitals and at seniors’ out-of-pocket spending.”

New York Times: The budget once again calls for repealing and replacing the Affordable Care Act, an effort that has been tried and failed previously and which Republican leaders have largely abandoned as a priority.”

Trump Administration Continues War on Health Care with FY19 Budget Blueprint

After President Trump released a budget blueprint that would continue his Administration’s assault on the American health care system, Protect Our Care Campaign Director Brad Woodhouse released the following statement:

“With today’s budget, the Trump Administration is doubling down on its relentless war on  American health care. By asking Congress to revive the deeply unpopular Graham-Cassidy repeal bill that ended protections for Americans with pre-existing conditions, gutted Medicaid, ripped away coverage from millions, and raised costs for millions more, while also proposing drastic cuts to Medicare, Trump has chosen to ignore the American public’s overwhelming preference for a bipartisan path forward on health care. Instead, the Trump Administration continues its assault on the Affordable Care Act, Medicare, and Medicaid.

“As a deadly flu epidemic continues to sicken people across America, President Trump’s budget today shows that he remains worse than indifferent to our health care. Enough is enough: the sabotage, cuts, and repeal attempts must stop. Congress should declare this budget’s anti-health care proposals dead on arrival.”

BACKGROUND

Today’s Trump budget proposes a $1.7 trillion cut to Medicare and other mandatory programs and pushes Congress to repeal the Affordable Care Act and gut Medicaid by passing legislation modeled on Graham-Cassidy.

Backlash Against Proposed Medicaid Cuts Continues

As national backlash to the Trump Administration’s attacks against Medicaid continued, Protect Our Care Campaign Director Brad Woodhouse released the following statement:

“We continue to stand against the Trump Administration’s illegal plan to force people off their coverage. The American people want Congressional Republicans to stop stacking the deck against working Americans and for Congress to preserve Medicaid for generations to come.”

Kentucky Rushes to Remake Medicaid as Other States Prepare to Follow

New York Times // Abby Goodnough // February 10, 2018

LOUISVILLE, Ky. — With approval from the Trump administration fresh in hand, Kentucky is rushing to roll out its first-in-the-nation plan to require many Medicaid recipients to work, volunteer or train for a job — even as critics mount a legal challenge to stop it on the grounds that it violates the basic tenets of the program.

At least eight other Republican-led states are hoping to follow — a ninth, Indiana, has already won permission to do so — and some want to go even further by imposing time limits on coverage.

Such restrictions are central to Republican efforts to profoundly change Medicaid, the safety net program that has provided free health insurance to tens of millions of low-income Americans for more than 50 years. The ballooning deficits created by the budget deal that President Trump signed into law Friday and the recent tax bill are likely to add urgency to the party’s attempts to wring savings from entitlement programs.

House Speaker Paul D. Ryan, Republican of Wisconsin, said Thursday that addressing entitlement spending is “what you need to do to fully deal with this debt crisis,” though Senator Mitch McConnell, the Republican majority leader from Kentucky, said he has ruled out doing so this year.

As Kentucky pushes forward, many who work with the poor are worried that the thicket of new documentation requirements in Medicaid will be daunting for low-income people, who may have little education and struggle with transportation, paying for cellphone minutes and getting access to the internet. Not only that, they note, but the new rules will add the type of administrative costs and governmental burdens that Republicans tend to revile.

On a recent rainy Monday, Bill Wagner, who runs primary care clinics in poor neighborhoods here, listened tensely as a state health official explained how the state would enforce the complex and contentious new rules.

The 20 hours a week of work, job training or volunteering? Ten regional work force boards will monitor who complies, said the official, Kristi Putnam.

The monthly premiums of $1 to $15 that many will now owe? The managed care companies that contract with the state will collect them.

The “rewards dollars” that many will need to earn to get their teeth cleaned or their vision checked? They’ll be tracked through a new online platform, where Medicaid recipients will also be expected to upload their work, volunteer or training hours.

“I know it sounds a little bit complicated,” Ms. Putnam conceded as the group meeting with her, which has overseen efforts to enroll Louisville residents in health insurance in the Obamacare era, jotted notes. Someone heaved a sigh.

After four years of signing up thousands of people for coverage under the health law’s expansion of the Medicaid program, Mr. Wagner told the room, “We’re shifting our focus from helping people gain coverage to helping people keep it.”

The rationale of Gov. Matt Bevin and other supporters is that Medicaid was created for the most vulnerable citizens — those who aren’t only poor, but pregnant, elderly, children or disabled — and that for everyone else, working or otherwise engaging in their community will provide dignity and better health. About 500,000 Kentuckians have joined the Medicaid rolls under the Obamacare expansion, and the state estimates some 350,000 will be subject to the new work rules.

While the work requirement is unprecedented in the history of Medicaid, Mr. Wagner and others say they’re just as concerned about other new rules that will be confusing and hard to follow. For example, many adults who don’t pay their small premiums can be locked out of Medicaid for six months, unless they complete a financial or health literacy course. Others will lose access to dental and vision care.

Critics of the plan point to Indiana, which dropped about 25,000 adults from its Medicaid program from 2015 through 2017 for failing to pay premiums there. About half found other coverage, according to state surveys, typically through a job.

Mark Lee Coleman, a diabetic who was visiting a busy clinic run by Family Health Centers, the nonprofit network that Mr. Wagner heads, one recent morning, had heard next to nothing about the new rules. He needed refills on his medications; his blood sugar level had climbed so high without them that he risked falling into a diabetic coma. But first Mr. Coleman needed help figuring out why his Medicaid coverage had been canceled late last year, even before the new rules kicked in.

A counselor at the clinic called the state Medicaid office and found out Mr. Coleman, 49, had forgotten to report a change in income last July, when he switched from a higher-paying job at an Amazon warehouse to a less physically demanding job as a parts driver for Pep Boys, the automotive chain. After she helped him email a pay stub to the office, his coverage was set to be reinstated within a few days.

Once Kentucky’s new rules take effect this spring and summer, Mr. Coleman will also have to report a monthly tally of his work hours to keep his coverage.

Matt and Sarah Burress, and their children, at home in Mount Washington, Ky. Mr. Burress, who owns a small lawn care business and doesn’t work all winter, wonders how the new rules would affect seasonal, self-employed workers. Credit Aaron Borton for The New York Times
He now works 20 hours a week, but he has neuropathy, a numbness and tingling in his hands and feet, and sometimes has trouble walking. Should he cut back his hours, he’d either have to try to get classified as “medically frail,” which would exempt him from the work rule, or lose his coverage.

He hasn’t thought all that through yet. In concept, though, he supports work requirements — as do most voters, polls have found.

“That’s not bad, to tell you the truth,” he said. “If you’re working, that’s good for your health.

As he spoke, he gulped water from a bottle he kept refilling — his extreme thirst a sign of his health crisis. Kara Peers, a case worker at Family Health Centers, tried to gauge what other challenges he and his wife and four children might be facing that could interfere with his ability to manage his disease.

“What about food, sir?” she asked.

“Ah, we’re kind of low,” he replied.

“Utilities — are you able to pay the bill?”

“It can be tough.”

He left with a month’s worth of medications — three for diabetes, one for high blood pressure, paid for by the clinic — and the reassurance that his Medicaid would soon be reinstated. Melissa Mather, the communications director at Family Health Centers, said she worried that patients like him, who already stumble over Medicaid’s paperwork requirements, will be more lost under the new rules. She and Mr. Wagner are also worried about their homeless patients, who will be subject to the rules unless they meet the federal definition of “chronically homeless” and get an exemption.

“This is a very, very big concern from my perspective — talking about the complexity of these changes when a lot of the folks we deal with have lives that are in chaos already,” she said.

For now, there are more questions than answers, as state workers like Ms. Putnam hustle to iron out all the details, let alone explain them. Like Mr. Carter, Sarah and Matt Burress got Medicaid under the Affordable Care Act after going uninsured for years. The coverage may have saved Mr. Burress’s eyesight — though only 29, he was diagnosed with advanced glaucoma when he went for a routine eye check shortly after becoming insured in 2015.

Now he’s worried about keeping his coverage because he runs his own small lawn care business, working irregular hours with a hiatus that lasts all winter.

“We haven’t heard how it will work for seasonal self-employed workers,” said Ms. Burress, who works part time as an office manager. “Do his clients have to say, ‘Yeah, he mowed my grass this week?’ Part of it feels like they’re trying to catch you, by burying people in paperwork and making it a huge inconvenience.”

She added that she and her husband plan to remain on Medicaid only until his business starts turning a profit. “This was never meant to be our permanent fix,” she said, not the “dead-end entitlement trap” that Mr. Bevin rails against.

Most people on Medicaid do work, research has found; Those who don’t often are disabled, even though they may not qualify for Social Security Disability Insurance. Sheila Penney, 54, has cycled in and out of jobs for years with chronic depression and anxiety that started when she lost her father at 16. She has worked as a package handler, a boat reservations manager and even a health insurance enrollment counselor, helping patients at Family Health Centers sign up for Medicaid back in 2014.

But she has not worked at all for the last two years, focusing instead on getting her mental health problems under control and relying on her mother to pay her rent. Now she’s a plaintiff in a lawsuit filed last month to stop Kentucky’s new requirements from taking effect. With Medicaid, she is able to go weekly to a therapist and monthly to a psychiatric nurse practitioner who adjusts her medication, she said.

“I’m wanting to go back to work, but if I was told, ‘You have to go back,’ I do think that would step up my anxiety,” Ms. Penney said. “Volunteering would be less pressure, but you would still want to be consistent and reliable.”

Caring full time for a child or other family member can also count toward the work requirement, as can going to school full time, though neither will apply to Ms. Penney.

She expects she will find a way to pay the new premiums she’ll owe under the plan — $4 a month — but predicts it will mean going without other necessities at times. (She is poor enough under the new rules that if she fails to pay them, she will lose access to dental and vision coverage but not be dropped from coverage altogether.)

“I was at the store yesterday, looking in my wallet and going, ‘Do I have enough money for dog food?” she said. “The thought of taking on even one more expense feels overwhelming.”

For Kimberly Dandridge, who overcame breast cancer and addiction to crack cocaine earlier in her life, Medicaid is a bridge while she works toward a job that comes with benefits. Ms. Dandridge, 53, works 30 hours a week as an administrative assistant, and said she would have no trouble meeting the premium and work requirements — but could relate to those who might.

“I remember there was a time I was just down, in the gutter, so low and broken,” she said. “If people like that need medical attention, just let them get it.”

 

Momentum Builds Against Lifetime Limits on Medicaid Coverage

As critics speak out against the Trump Administration’s consideration of lifetime limits for people covered through Medicaid, Protect Our Care Campaign Director Brad Woodhouse released the following statement:

“One in five Americans has Medicaid coverage, most of them seniors, children, and people with disabilities. Every step the Trump Administration takes to roll back Medicaid coverage reveals that its true intention is to take away health insurance from Americans. But reactions to this week’s news about lifetime limits on Medicaid coverage make clear that this is an approach our nation rejects.

“The Affordable Care Act made it illegal for insurance companies to cut off care, preventing those going through extensive treatment like chemotherapy from having their coverage stopped. Allowing lifetime limits again would cast aside vulnerable Americans for no reason and under false pretenses – because despite the rhetoric coming from this Administration, studies show these proposals don’t incentivize people to work, they merely punish them for getting sick or having a disability and losing their job, or for working for a business that does not offer insurance.

“Implementing lifetime limits for those receiving coverage under Medicaid would work against the foundational goals of the program, which is why Americans are speaking up and fighting back.”

Another day, another stealth attack on Medicaid

Washington Post // Helaine Olen // February 8

Another day, another attack on Medicaid — and on the poor and working class.

According to a little-noticed McClatchy report this week, Arizona, Kansas, Utah, Maine and Wisconsin have appealed to the Trump administration to seek permission to put lifetime limits on Medicaid coverage for recipients they deem able-bodied. In other words, those five states want to time-limit or cap the total period of time an individual could receive Medicaid benefits over his or her lifetime.

There is no word on whether the administration will agree to this, but it is worth noting that it comes on the heels of its decision to allow Kentucky and Indiana to mandate that many of their able-bodied Medicaid recipients meet work requirements.

If successful, this push for lifetime limits will constitute another way to try to undermine the overall Medicaid program, including the Affordable Care Act’s coverage expansion. Arizona opted into the ACA’s Medicaid expansion, and voters in Maine approved a referendum to do the same, though that’s still up in the air. If the Trump administration signals that it will approve lifetime caps, other states that expanded Medicaid could follow. As a result, this could end up being a way to cut back on Medicaid both in states that didn’t expand the program as part of the ACA, and in states that did — further undermining the ACA’s historic coverage gains, just as work requirements will inevitably do.

As Jessica Schubel, a senior policy analyst at the Center on Budget and Policy Priorities, put it, the latest proposed change, when taken along with the work requirements, suggests the administration is “hell-bent on trying to keep people out of coverage.”

Direct attacks on Medicaid are not popular, as President Trump and Republicans learned last year during their efforts to repeal the Affordable Care Act. Polls have also found broad opposition to cutting Medicaid.

But that doesn’t mean Republicans are giving up. Both the work requirements and the proposed lifetime limits should be understood as using bureaucracy to facilitate a backdoor attack on Medicaid. As Rebecca Vallas, a vice president at the Center for American Progress, told me, work requirements ultimately are really about putting up “roadblocks and red-tape obstacles” in the way of access to health coverage. They discourage applicants from completing the process of getting benefits, usually to reduce spending by the states.

Work requirements — which have been championed by Seema Verma, the head of the Centers for Medicare and Medicaid Services — rest on a false premise.  It’s not true — despite myths claiming otherwise — that there are well-paying jobs out there for everyone who is willing and able to do them. Workers in the gig economy find temporary positions that come and go. Other low-wage workers can find their hours fluctuating enormously and with little notice. Medicaid is not simply there for people who are unemployed, or not a part of the workforce, but also as a support for people who are working, but not earning an adequate wage to afford health insurance.

Lifetime limits impose another hurdle on those who need Medicaid. Each state is proposing doing this in a different way. Utah’s proposed lifetime limit would be a total of five years. Wisconsinites would hit the limit at four years. In Kansas, at three years. Three of the states would count time working and not working while receiving Medicaid toward the limit, while two would only subject those receiving Medicaid while unemployed to the limit. Utah would only subject childless adults to it. All of these changes would be complex to navigate and, if they are green-lit, will not only push people out of the program when they hit the limits, but possibly discourage them from applying at all.

Medicaid lifetime limits and work requirements also function as cloaked attacks on the concept of universal health coverage. Medicaid functions as a guarantee of health coverage for people who do not have employer provided insurance, as well as the poor and working class. Lifetime limits — such as work requirements — throw more obstacles in the path of that idea, since they will, at some point, likely leave many without even that baseline access to health coverage.

If you believe universal health care is a right, lifetime limits are not the way to go. Caps on the time people can receive coverage would ultimately have the same effect as work requirements — a certain percentage of people who are ill, or will become ill, will not be able to easily access medical services when they need them.

Lifetime limits on Medicaid eligibility, like work requirements, take us backwards: they reestablish a principle that the ACA tried to abolish, albeit incompletely: that healthcare is not a right, but a privilege.

Protect Our Care Outlines Market Stabilization Must-Haves

As Congress begins to shape an omnibus after passing this morning’s spending bill, Protect Our Care Campaign Director Brad Woodhouse released the following statement outlining provisions that bill must include to stabilize the Affordable Care Act’s marketplaces and counteract cost increases caused by the Trump Administration and its Republican allies in Congress’s ongoing sabotage:

“If Congressional Republicans are serious about addressing the mounting mess they have created in the individual insurance market, they need to do far more than they are currently proposing. And the scale of those solutions must match the scope of the problems that Republican sabotage has created.

“While the Affordable Care Act marketplaces have shown remarkable stability in the face of this relentless sabotage, President Trump’s actions have already raised premiums this year, and the Republican tax bill will make things even worse next year by pushing premiums up double digits.

“A truly bipartisan market stabilization plan means making coverage more affordable,  not punishing people with pre-existing conditions, and not including anti-choice restrictions. The American people want affordable, high-quality health care, not even more restrictions on women’s health. And Republicans should not seek to revive high risk pools, failed experiments of the the past which would reverse the Affordable Care Act’s guarantees and once again allow states to segregate people with pre-existing conditions.

“The American people keep saying it loud and clear: enough is enough. It’s time for Republican lawmakers to do the right thing, leave politics at the door, reject their party’s war on health care, and develop real solutions to make coverage more affordable and accessible for more Americans.”

Policymakers Should Craft Reinsurance Proposals to Lower Premiums, Help More People
Center on Budget and Policy Priorities // Sarah Lueck // 2.8.18

The idea of reimbursing health insurers for some costs associated with their highest-cost enrollees, known as reinsurance, is gaining traction as policymakers seek ways to make states’ individual insurance markets more stable and reduce premiums. But some federal reinsurance proposals are likelier than others to reduce premiums, and reinsurance alone won’t help individual market consumers who qualify for subsidized coverage.

Reinsurance defrays insurers’ costs and reduces their risk, so insurers can reduce overall premiums compared to what they’d otherwise charge.

In the House, a bipartisan reinsurance bill from Reps. Ryan Costello and Collin Peterson is reportedly gaining support, including among insurers. It would provide up to $30 billion over three years for the Secretary of Health and Human Services (HHS) to allocate at his discretion. Meanwhile, Sen. Susan Collins is continuing to craft her bipartisan reinsurance bill (co-sponsored by Sen. Bill Nelson), which Senate Majority Leader Mitch McConnell promised to bring to the Senate floor. She’s proposing to make up to $10 billion over two years available to states, which they could then use to secure additional federal funding through waivers that HHS approves to let states experiment with new ways to deliver health care to their residents.

With reinsurance efforts potentially moving forward, policymakers should keep the following in mind:

Reinsurance funds should be targeted at reducing premiums, not diluted by other purposes. The Costello bill would let states use federal reinsurance for a number of purposes, not all of which focus on the individual market or on reducing premiums. For example, states could use the funding for “promoting participation” and “increasing health insurance options” in both the individual and small-group markets, or for promoting access to preventive services (especially dental and vision care) and maternity and newborn care, and preventing and treating mental or substance use disorders. While increasing access to these health services is important, it isn’t directly related to reducing premiums or stabilizing insurance markets. These provisions would probably also let states use federal funds to replace their own spending on activities they would have undertaken anyway — which would have no impact on individual-market premiums at all. The Costello bill also seems to let states create high-risk pools, an idea that House Speaker Paul Ryan has continued to talk up. But past high-risk pools worked by separating people with high-cost health needs into a different pool from less costly people. That approach has been tried and failed, and it shouldn’t be replicated. The Costello bill also includes new, unrelated policy dealing with abortion.

A federal reinsurance program is likely the fastest, most efficient way to mitigate premium increases in 2019. Insurers will have to finalize their decisions about individual-market premiums and about where they will offer plans by this fall, and they’ll begin making decisions well before that. And 2019 is shaping up to be a tough year in the individual market, particularly because the new tax law’s repeal of the Affordable Care Act’s (ACA) individual mandate to have health coverage or pay a penalty will take effect and because plans that don’t meet ACA standards are expected to proliferate under proposed Trump Administration regulatory changes. While a temporary reinsurance program is only a partial fix at best for the premium increases and other harmful effects of these changes, a federal reinsurance program could be implemented more quickly and efficiently than multiple state-level programs. The Collins-Nelson bill relies entirely on states to apply for funding. In a better approach, the Costello bill gives states the option to apply for funding and administer their own programs but includes a safeguard — to establish a federal program if states don’t act fast enough. The Costello bill, however, would also leave the amount that each state would receive up to the HHS Secretary’s discretion, creating unnecessary uncertainty and risk, particularly because the Trump Administration has been more focused on sabotaging the ACA-compliant insurance markets than shoring them up.

Provisions intended to offset reinsurance costs shouldn’t make people worse off. If policymakers seek to offset the federal cost of a reinsurance program through spending cuts or tax increases, those measures should not threaten the health of individuals. They should not, for instance, include cuts in other health care programs or changes that hurt modest-income people or those with pre-existing conditions.

Even well-designed reinsurance doesn’t make health care more affordable for low- or moderate-income people. Reinsurance reduces the sticker price of health insurance — i. e., the overall premiums that insurers charge. That means it benefits individuals and families who don’t qualify for premium tax credits that help low- and moderate-income people afford their insurance through the ACA health insurance marketplaces. That’s because the premium credits limit eligible people’s cost to no more than a given percentage of their incomes, so they pay about the same amount for coverage regardless of the sticker price. Most Americans who are uninsured and eligible for marketplace coverage could qualify for tax credits under current law. But some people who get tax credit — those with incomes up to four times the poverty level, or about $48,000 a year for an individual — also have trouble affording their premiums and out-of-pocket costs. Researchers estimate that modest improvements in the tax credits could meaningfully expand coverage. Increasing the tax credits or cost-sharing reductions (CSRs) for those already receiving them would also help shore up insurance markets and, if paired with reinsurance, broaden the benefits to all individuals and families buying health insurance on their own.

A bill that includes reinsurance funding and would reinstate CSR payments to insurers, such as the Costello bill, also should increase the tax credits or increase cost-sharing subsidies for people. Here’s why: As we and others have explained, the Trump Administration’s decision to halt CSR payments has had the effect of substantially raising tax credits, making coverage more affordable for many moderate-income consumers. (That’s because insurers raised premiums to account for the loss of CSR payments, which boosted the amount of federal premium tax credits available to eligible people.) Restoring CSR payments would reverse the tax credit increases and make coverage more expensive for this group. Thus, a bill funding reinsurance, restoring CSRs, and failing to increase tax credits or cost-sharing subsidies would make coverage more affordable for middle-income consumers but less affordable for many people at lower income levels.

 

This Week in the War on Health Care — February 5-9, 2018

While the budget showdown took up most of the oxygen this week in Washington, the Trump Administration continued its unprecedented assault on the American health care system.

Meanwhile, despite the relentless sabotage, 11.8 million people nationwide signed up for coverage through the Affordable Care Act marketplaces during this year’s open enrollment. Experts estimate that 1.1 million more could have signed up if Trump’s HHS hadn’t attacked outreach funding.

While most of us were focused on cars in space and the stock market, here’s a summary of what happened this week in sabotage – and how Americans are fighting back:

A NEW LOW IN THE WAR ON MEDICAID

On Monday reports emerged that the Trump Administration is considering a new low in their war on Medicaid: lifetime limits on coverage. The Affordable Care Act stopped insurance companies from imposing lifetime limits on coverage, freeing Americans from arbitrary limits on their care. The re-institution of these limits could punish Medicaid enrollees simply because their longtime employer doesn’t offer insurance or because they got sick or have a disability and lost their job, threatening the health and well-being of millions of Americans and leaving large swaths of the population with nowhere to turn.

And with Medicaid covering one-fifth of substance abuse treatment nationwide and playing a “central role,” in attempts to combat this crisis, this proposal could make things even worse.

MEANWHILE, SUPPORT FOR MEDICAID EXPANSION GROWS IN STATES

In stark contrast to the Administration’s near-constant attacks on Medicaid, medical professionals continue to assert the benefits of the popular program and states from coast to coast are moving forward with attempts to expand it.

In North Carolina, a children’s advocacy organization released a new report arguing that Medicaid expansion could reduce the state’s fetal and infant mortality rates, endorsing the bipartisan expansion proposal currently under consideration in the state legislature. Grassroots movements are underway in Nebraska, Utah, Missouri, and Idaho to put Medicaid expansion on state ballots in 2018. Just three weeks ago, Oregon voters supported a legislative package funding the state’s Medicaid program. And back in November, Maine voters overwhelmingly approved Medicaid expansion in the state.

All of which is to stay: people want expanded access to coverage. And if there were any doubts …

OPEN ENROLLMENT BLOWS EXPECTATIONS OUT OF THE WATER

Despite more than a year of sabotage from President Donald Trump, his Administration, and Congressional Republicans, 11.8 million Americans, including 2.5 million new enrollees, purchased 2018 health insurance through Affordable Care Act marketplaces – 96% of last year’s total. These Americans did so in the face of rampant obstacles put in their way, from a shortened sign-up period to the President declaring the law ‘dead,’ and did so for one reason: they want and need the quality, affordable coverage they can get from the Affordable Care Act . Here’s how health care experts and media outlets described this year’s open enrollment period:

NBC News: “Despite Trump, Obamacare Records Strong Enrollment.” [NBC News, 2/7/18]

Kaiser Family Foundation: 11.8 Million People Signed Up “Amid Steep Reductions In Federal Funding For Outreach In Navigators, An Enrollment Period Half As Long, And A Climate Of Political Uncertainty Surrounding The Law.” [KHN, 2/7/18]

Los Angeles Times: The Numbers “Suggest Surprising Strength In Many Markets Across The Country.” [Los Angeles Times, 2/7/18]

The Hill: The Numbers “Show The Obamacare Remains Stable In The Face Of ‘National Uncertainty.’” [The Hill, 2/7/18]

Associated Press: “Enrollment Remained Remarkably Stable Despite President Donald Trump’s Disdain For ‘Obamacare,’ And Repeated Efforts By The Republican-led Congress To Repeal The Program.” [AP, 2/7/18]

Washington Post: “Enrollment Was Surprisingly Resilient.” [Washington Post, 2/7/18]

Washington Times: “Interest In The Exchanges Outpaced Last Year On A Day-To-Day Basis.” [Washington Times, 2/7/18]

Bloomberg: “President Donald Trump Has Frequently Been Accused Of Trying To Undermine Obamacare, His Predecessor’s Signature Health Law. New Data Show That By At Least One Measure He Didn’t Do A Particularly Good Job Of It.” [Bloomberg, 2/718]

Larry Levitt, Kaiser Family Foundation: “If You Had Asked Me A Year Ago Whether Enrollment For 2018 Would Be Almost Equal To 2017, I Would Have Laughed At You.”  [AP, 2/7/18]

Mark Hall, Wake Forest University Professor Of Law And Public Health: “Despite The Trump Administration’s Effort To Undermine The Affordable Care Act, Its Basic Structure Remains Solid.” [Winston-Salem Journal, 2/7/18]

Trish Riley, National Academy For State Health Policy Executive Director: “This Shows Consumers Really Want And Need Coverage.”[Los Angeles Times, 2/7/18]

Allison O’Toole, MNSure Chief Executive: “We Had The Best Open Enrollment Period We Have Ever Had.” [Los Angeles Times, 2/7/18]

“Consumers Really Want Coverage”: Nearly 12 Million Americans Sign Up For Marketplace Plans Despite Rampant Obstacles

Meta Capitol

Despite more than a year of sabotage from President Donald Trump, his Administration, and Congressional Republicans, it was announced today that 11.8 million Americans purchased 2018 health insurance through Affordable Care Act marketplaces — 96% of last year’s total. These Americans did so in the face of rampant obstacles put in their way, from a shortened sign-up period to the President declaring the law ‘dead,’ and did so for one reason: they want and need quality, affordable coverage.

Overall, the open enrollment period this year was a resounding success that proved the skeptics wrong. Don’t believe us? Take a look for yourself…

NBC News: “Despite Trump, Obamacare Records Strong Enrollment.” [NBC News, 2/7/18]

Josh Peck, Former HealthCare.Gov CMO: “Without The Trump Administration’s Efforts To Undermine Enrollment, National Enrollment Would Have Exceeded 12.9 Million Enrollments Or Roughly 1.1 Million Additional People Would Have Enrolled.” [Get America Covered, 2/8/17]

Kaiser Family Foundation: 11.8 Million People Signed Up “Amid Steep Reductions In Federal Funding For Outreach In Navigators, An Enrollment Period Half As Long, And A Climate Of Political Uncertainty Surrounding The Law.” “11,760,418 people signed up for 2018 health insurance coverage on the ACA individual marketplaces, amid steep reductions in federal funding for outreach and navigators, an enrollment period half as long, and a climate of political uncertainty surrounding the law. The federal government also terminated cost-sharing subsidy payments to insurers in advance of the open enrollment period, leading to increases in premiums but also increased premium subsidies for many consumers that in some cases led to reductions in what they had to pay for coverage.” [KHN, 2/7/18]

Los Angeles Times: The Numbers “Suggest Surprising Strength In Many Markets Across The Country.” “Almost 12 million Americans signed up for 2018 health coverage through marketplaces created by the Affordable Care Act, according to a new tally that indicates nationwide enrollment remained virtually unchanged from last year despite President Trump’s persistent attacks on the 2010 health law. The new enrollment numbers — which include totals from California and other states that operate their own marketplaces, as well as states that rely on the federal HealthCare.gov marketplace — offer the most detailed picture to date of the insurance markets. And they suggest surprising strength in many markets across the country, with consumers steadily signing up for health plans even as Trump and his Republican congressional allies derided the markets as crumbling and unaffordable.” [Los Angeles Times, 2/7/18]

Bloomberg: “President Donald Trump Has Frequently Been Accused Of Trying To Undermine Obamacare, His Predecessor’s Signature Health Law. New Data Show That By At Least One Measure He Didn’t Do A Particularly Good Job Of It.” President Donald Trump has frequently been accused of trying to undermine Obamacare, his predecessor’s signature health law. New data show that by at least one measure he didn’t do a particularly good job of it. Enrollment in individual health-insurance plans under the Affordable Care Act fell 3.7 percent in 2018 to 11.8 million, from 12.2 million a year earlier, according to data compiled by the National Academy for State Health Policy, which calls itself a nonprofit, nonpartisan association of state health-policy makers. That’s a far smaller drop than some health-policy watchers had foreseen, after the Trump administration halved the enrollment season and cut marketing and enrollment-assistance efforts. Trump himself declared the law ‘dead.’” [Bloomberg, 2/718]

Trish RIley, National Academy For State Health Policy Executive Director: “This Shows Consumers Really Want And Need Coverage.” “‘This shows that consumers really want and need coverage,’ said Trish Riley, executive director of the National Academy for State Health Policy, which compiled the nationwide enrollment tally. ‘These are stable markets and a stable program,’ she said.”  [Los Angeles Times, 2/7/18]

Allison O’Toole, MNSure Chief Executive: “We Had The Best Open Enrollment Period We Have Ever Had.” “‘We had the best open enrollment period we have ever had,’ said Allison O’Toole, chief executive of Minnesota’s insurance marketplace, known as MNsure, which saw enrollment surge nearly 6% this year. Elected officials in Minnesota developed their own reinsurance system to help control premiums this year.” [Los Angeles Times, 2/7/18]

Washington Post: “Enrollment Was Surprisingly Resilient.” “With the Trump administration taking steps to undercut these marketplaces and congressional Republicans having spent much of last year trying unsuccessfully to dismantle large parts of the ACA, leaders of state insurance exchanges and other health-policy experts said that enrollment was surprisingly resilient.” [Washington Post, 2/7/18]

The Hill: The Numbers “Show The Obamacare Remains Stable In The Face Of ‘National Uncertainty.’” “Experts and advocates of ObamaCare had expected a bigger drop in enrollment, mainly due to attacks on the system from the Trump White House. The administration slashed the advertising budget for open enrollment by 90 percent and also cut funds for local groups that help people sign up for coverage.  Experts also worried that multiple attempts by congressional Republicans to repeal and replace the law could cause confusion and deter consumers from signing up… The final numbers released Wednesday, however, show the ObamaCare remains stable in the face of ‘national uncertainty,’ says the National Academy for State Health Policy (NASHP), the group that released the numbers. ‘For the first time we now have the full national picture of how the individual marketplaces did this year and it is a picture of remarkable stability,’ said Trish Riley, executive director of NASHP.” [The Hill, 2/7/18]

Associated Press: “Enrollment Remained Remarkably Stable Despite President Donald Trump’s Disdain For ‘Obamacare,’ And Repeated Efforts By The Republican-led Congress To Repeal The Program.” “Enrollment remained remarkably stable despite President Donald Trump’s disdain for ‘Obamacare,’ and repeated efforts by the Republican-led Congress to repeal the program. The Trump administration also cut the sign-up window in half, slashed the ad budget, and suddenly stopped a major subsidy to insurers, which triggered a jump in premiums.” [AP, 2/7/18]

Larry Levitt, Kaiser Family Foundation: “If You Had Asked Me A Year Ago Whether Enrollment For 2018 Would Be Almost Equal To 2017, I Would Have Laughed At You.” “‘If you had asked me a year ago whether enrollment for 2018 would be almost equal to 2017, I would have laughed at you,’ said Larry Levitt, who follows health law for the nonpartisan Kaiser Family Foundation. ‘So long as lots of people are still getting insurance it becomes much harder to take that away.’” [AP, 2/7/18]

Washington Times: “Interest In The Exchanges Outpaced Last Year On A Day-To-Day Basis.” “Based on its figures, the 11 states — plus D.C. — that ran their own exchanges matched last year’s signups. In fact, there was a tiny increase of 0.09 percent, compared to a 5.3-percent drop among the 34 states that solely relied on HealthCare.gov. Five states that run their own exchanges, yet use the federal website, saw a minuscule increase of 0.2 percent, according to the academy. Mr. Trump slashed the enrollment season in half this year, meaning consumers in HealthCare.gov states had to sign up by mid-December, though hurricane-battered areas got extra time. Interest in the exchanges outpaced last year on a day-to-day basis.” [Washington Times, 2/7/18]

San Diego Union Tribune: States “Generally Attributed The Reduction To The Trump Administration’s [Actions].” “States with larger enrollment declines have generally attributed the reduction to the Trump administration’s decision to cut back on marketing efforts and shorten the 2017 open-enrollment period which ended more than a month earlier than it did in California. Double-digit premium increases in many states are also blamed for decreasing enrollment in many locations. The president’s late 2017 executive order to eliminate special “cost sharing reduction” payments directly to health insurance companies are blamed for the price hikes.” [San Diego Union Tribune, 2/7/18]

Mark Hall, Wake Forest University Professor Of Law And Public Health: “Despite The Trump Administration’s Effort To Undermine The Affordable Care Act, Its Basic Structure Remains Solid.” “Mark Hall, a professor of law and public health at Wake Forest University, said the report ‘shows that, despite the Trump administration’s effort to undermine the Affordable Care Act, its basic structure remains solid. This is a testament to its fundamental soundness. In North Carolina, enrollment dipped, but not as much as some people feared.’” [Winston-Salem Journal, 2/7/18]