President’s Latest Attempt to Destabilize Healthcare

  

This morning, despite ongoing bipartisan efforts to stabilize the individual insurance market following the failure of Congress to pass legislation to repeal and replace the Affordable Care Act, President Trump signed an Executive Order (EO) allowing for the creation of new association health plan (AHP) options for small employers and individuals. AHPs currently exist and are used primarily by small businesses to purchase group health coverage, but are regulated under the provisions of the ACA in the same way as coverage purchased on the individual health insurance market. Today’s EO in effect treats AHPs as large group health insurance plans and allows coverage under AHPs to be sold across state lines.

Treating AHPs in this way exempts them from important provisions covered under the ACA. As a reminder, the ACA includes provisions on insurance plans sold on the individual market which:

  • Require plans to cover 10 Essential Health Benefits including reproductive and maternal health services and preventive services;
  • Forbid insurers from charging more to individuals due to pre-existing conditions;
  • Limit the amount insurance companies can charge to older individuals based on age.

The American Nurses Association opposes any action – legislative or executive – which would put at risk the ability of Americans to access and receive high quality healthcare. This is particularly true when it comes to the most vulnerable Americans. It has become increasingly clear that this administration is more concerned with scoring political points and reversing gains made in healthcare than it is about actually ensuring high quality healthcare coverage for all Americans.

As a result of this EO, AHPs would be permitted to offer coverage that does not include the 10 Essential Health Benefits required to be covered under insurance plans offered through the ACA exchanges. AHPs would also be allowed to charge different prices to consumers based on age and health – including charging more for individuals with any host of pre-existing conditions.

This EO allows AHPs to sell insurance coverage which offers fewer benefits at variable prices depending on an individual’s health. This would certainly be an attractive option for someone who is young, healthy, and does not anticipate needing to use a high volume of healthcare services. The flipside is that this would have a negative impact on older adults and individuals with pre-existing conditions.  The cruel irony with this plan is that these individuals would likely be stuck with plans in the individual marketplace, as they would not be able to afford the coverage offered under AHPs – which would likely not provide coverage for necessary care.

Furthermore, these insurance plans are ripe for instances of fraud, abuse, and insolvency. The Government Accountability Office in 1992 issued a report which slammed similar small business insurance arrangements and noted that they left hundreds of thousands of enrollees with millions of dollars in unpaid claims and widely failed to meet state insurance laws and regulations. The GAO report found that some plans tried to duck under state insurance regulations entirely. This type of wild, wild west approach to insurance coverage does not offer the comprehensive level of coverage at a low price that the Trump administration claims. Based on the provisions of this EO, we also expect several lawsuits to challenge this based on the legality under current federal law and on the insurance across state lines aspect.

In essence, this latest gambit by the Trump administration is another attempt to undermine the system put in place by the ACA at the expense of some of the most vulnerable Americans. Combined with the administration’s move last week to weaken the ability of Americans to access sexual and reproductive healthcare services – particularly contraceptives – covered under the ACA, this represents a significant effort to endanger the healthcare of all Americans.

We urge Congress and the Administration to continue to work toward market stabilization and to strengthen the existing system – which has resulted in coverage for tens of millions more Americans since 2014 – and to put an end to these attempts to sabotage Americans’ healthcare for political gain. ANA is committed to working with Congress and the administration on legislation and policy which aligns with our four core principles of health system transformation. This Executive Order, however, represents a major step backward from achieving those principles.

(Photo: Doug Mills/The New York Times)

Senate Republican Healthcare Push Ends in Defeat (Again)

  
Photo: Al Drago, New York Times
Photo: Al Drago, New York Times

Senate Majority Leader Mitch McConnell (R-KY) has chosen not to hold a vote on the Graham-Cassidy-Heller-Johnson bill to repeal and replace the Affordable Care Act. With a September 30th deadline to pass healthcare legislation with a simple majority of votes, opposition from at least 3 members of the 52-member Republican caucus, united Democratic opposition, and no viable alternative plan, the Senate Republican push to repeal and replace the ACA is effectively dead (for now).

The American Nurses Association would like to express its immense gratitude to all of our members, constituent and state nursing associations, organizational affiliates, and partner advocacy groups for all of your work in helping to defeat this latest attempt to gut the American healthcare system. Your calls, emails, and letters to your elected officials, as well as your physical presence at rallies and hearings, ratcheted up the pressure on these officials and made it known loud and clear that this legislation would have had an enormously adverse impact on the ability of your patients to receive high quality healthcare.

Quite simply, the Graham-Cassidy-Heller-Johnson bill was bad public policy. Its provisions would have: ripped away coverage from Americans receiving care under Medicaid expansion and limited federal funding for the Medicaid program overall; eroded protections for individuals with pre-existing conditions; made it easier for states to remove the 10 Essential Health Benefits requirements; slashed federal funding for healthcare services; defunded the Prevention and Public Health Fund; and defunded Planned Parenthood for one year. The non-partisan Congressional Budget Office, in the very limited time it had to do an analysis, concluded that millions of Americans would have lost their healthcare coverage under this bill. In addition, many experts noted that states would have had only two years to implement drastically different healthcare systems with no federal support to speak of – a nearly impossible task.

ANA would also like to offer our tremendous thanks to the members of Congress who opposed the Graham-Cassidy bill. In particular, the 48-member Democratic caucus once again showed its grit and resolve by standing united against this bill in favor of the best interests of its constituents. ANA would also like to thank Sen. Susan Collins (R-ME) and Sen. John McCain (R-AZ) for demonstrating their resolve in the face of tremendous pressure from their caucus to pass repeal and replace legislation. These senators should be commended for putting the best interests of their constituents ahead of their party and standing opposed to this legislation.

As we have seen before, the failure of one repeal and replace proposal does not automatically mean that the healthcare system is safe. It is very likely that the Trump administration will continue to undermine the ACA through regulatory and other policy measures; we have already seen this in their assaults on value-based purchasing regulations, their brinksmanship with respect to cost-sharing reduction payments, and their refusal to undertake a robust ACA enrollment strategy crucial to connecting Americans with individual health insurance coverage. Senate Republicans are also already discussing language for the FY 2019 budget which would allow them to once again use reconciliation to repeal and replace the ACA.

ANA believes that the current healthcare system created by the ACA can and should be improved upon. However, any healthcare reform proposals should be done in a bipartisan manner, through regular order, and should offer pragmatic solutions to real problems faced by Americans. Of immediate importance are the reauthorization of the Children’s Health Insurance Program (CHIP) – which runs out of funding on September 30th – the stabilization of the individual insurance market, which received several bipartisan hearings in the Senate Health, Education, Labor, and Pensions Committee, and the implementation of a robust enrollment campaign for the ACA’s individual insurance market. These issues are straightforward, would advance ANA’s principles of health system transformation, and, most importantly, ensure that more Americans are able to receive high-quality healthcare.

The fight over healthcare reform is not over. While another repeal and replace bill has gone down to defeat, there will be further attempts to undermine the gains realized under the ACA. For these reasons, we urge you to continue to press your elected officials – local, state, and federal – to commit to ensuring healthcare reform in alignment with ANA’s principles of health system transformation. For now, however, let’s take a deep breath and celebrate stepping back from the brink of what would have been a disastrous transformation of the healthcare system.

September Heats Up on the Hill as Congress Turns Back Toward Healthcare

  

As expected, Capitol Hill has turned out to be a beehive of activity in the month of September. With government funding, the debt limit, and hurricane relief funding taken care of, Congress is increasingly turning its eye back toward healthcare reform. Democrats and Republicans have each introduced new healthcare reform bills (which, shockingly, go in drastically different directions), and several House and Senate committees have held hearings on healthcare reform. On a positive note, there seems to be a significant shift toward bipartisan cooperation on healthcare reform (at least with respect to the individual insurance market) since the dramatic collapse of the Senate Republicans’ efforts to repeal and replace the Affordable Care Act in the early morning hours of July 28th.

Senators Lindsey Graham (R-SC) and Bill Cassidy (R-LA) Unveil Yet Another Repeal and Replace Plan

Republican Senators Lindsey Graham (R-SC) and Bill Cassidy (R-LA) introduced a “new” healthcare reform bill this morning – which, it should be noted, is a very long shot for even seeing a vote on the Senate floor. At this point, the ACA repeal and replace effort feels like the movie Groundhog Day, in that we keep seeing the same proposals over and over again. The Graham-Cassidy bill – also supported by Sens. Dean Heller (R-NV) and Ron Johnson (R-WI) – is not substantially different from any of the other repeal and replace bills we have seen from House and Senate Republicans. It repeals Medicaid expansion in 2020; it eliminates the $1 billion Prevention and Public Health Fund; it creates high-risk pools for individuals with pre-existing conditions; it defunds Planned Parenthood for a year; it puts a per-capita cap on Medicaid funding and gives states the option to convert their Medicaid programs into block grants (see ANA’s policy primer on block grants); and it ends premium tax credit assistance and cost-sharing subsidies and puts greater control of healthcare spending in state hands. As with all other repeal and replace proposals to date, the current proposal fulfills none ANA’s 4 principles for health system transformation. Under Senate rules, the Senate must vote on this measure (if it comes to a vote) by September 30th in order to pass with a simple 51 vote majority. We hope that it does not come to that.

Senator Bernie Sanders (I-VT) Goes (Medicare For) All-In on Single-Payer

On the other side of the aisle, Sen. Bernie Sanders (I-VT) has introduced his Medicare for All Act of 2017. As the name implies, this plan would extended Medicare eligibility to all Americans and transform the American healthcare system into a government-run, single-payer system. This bill – which has the support of 16 Democratic co-sponsors (though notably no endorsement from party leadership) – would phase in Medicare eligibility by age over 4 years, eventually extending eligibility to Americans of all ages. The Medicare for All Act of 2017 would do away with the country’s current system of employer-based insurance coverage and, it should be noted, significantly increase the amount of money the U.S. government spends on healthcare services. The chances of it passing, however, are non-existent, given that Democrats are in the minority in the Senate and the House, and do not control the White House. Still, the introduction of the Medicare for All Act of 2017 does shift the conversation toward a single-payer healthcare system to a significant degree.

Children’s Health Insurance Program Reauthorization Shows Progress

The Children’s Health Insurance Program (CHIP) provides healthcare coverage to low-income children whose families do not qualify for Medicaid; it is a crucial source of healthcare coverage for roughly 9 million children each year. CHIP funding is generally reauthorized every few years. The current CHIP authorization is set to expire on September 30th, placing the healthcare coverage of 9 million children at risk. Fortunately, Sens. Orrin Hatch (R-UT) and Ron Wyden (D-OR) of the Senate Finance Committee announced yesterday that they have reached a deal to extend CHIP for five years and would transition CHIP to its traditional federal-state partnership and provide additional protections for low-income children and flexibility for states (full legislative language will be released in the coming days).

Senate Health, Education, Labor, and Pensions Committee Holds Hearings on Insurance Premiums

The Senate Health, Education, Labor, and Pensions (HELP) Committee held hearings on September 6th, 7th, and 12th, focused on stabilizing premiums and helping individuals in the individual insurance market in 2018. The committee also has another hearing scheduled for September 14th on the same subject. Panelists during these hearings have included state insurance commissioners and governors, and the hearings have focused on affordability and state flexibility. The Senate HELP Committee is led by Chair Lamar Alexander (R-TN) and Ranking Member Patty Murray (D-WA) and has begun to move forward in a bipartisan way to stabilize the individual insurance market with the goal of protecting consumers from huge price increases.  

With so much activity happening on Capitol Hall, it can be difficult to keep it all straight. ANA encourages you to engage with your senators and representatives and make clear to them that any healthcare reform effort must align with our principles of health system transformation: universal access to a standard package of essential health benefits for all citizens and residents; utilization of primary, community-based and preventative services while supporting the cost-effective use of innovative, technology-driven, acute, hospital-based services; the economical use of health care services with support for those who do not have the means to share in costs; and a sufficient supply of a skilled workforce dedicated to providing high quality health care services.