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.

Trump Administration Moves Create Major Uncertainty In Healthcare System

  

The Trump administration has toyed for months with the idea of withholding cost-sharing reduction (CSR) payments to insurance companies participating in the individual insurance marketplace implemented by the Affordable Care Act (ACA). This has injected a great level of risk into the healthcare system which has in turn created a lot of uncertainty and confusion. These CSR payments are intended to help low-income individuals with income between 100% and 250% of the federal poverty level pay for co-pays, co-insurance, and deductibles. The ACA limits to a percentage of their income the amount of cost-sharing these individuals pay. For instance, an individual with an annual income of $17,000 might only have a $125 deductible compared with a $2,500 deductible for someone with a $25,000 annual income under the same insurance plan. (See a detailed description of CSR payments here). The federal government makes CSR payments to insurance companies to balance out the difference between what the individual pays and what the insurance company charges (fortunately, the Trump administration today stated that it will make CSR payments for August).

The Congressional Budget Office (CBO) on August 15th released an analysis on the impact that withholding the CSR payments would have on insurance premiums and insurance coverage. According to the CBO report, insurance premiums for individual insurance coverage would increase by 20 percent in 2018 and by 25 percent by 2020, while 5 percent of people would live in areas that would have no insurers in the non-group market in 2018.

Furthermore, withholding CSR payments would increase the federal deficit by $194 billion from 2017 through 2026, largely as a result of higher federal premium tax credit payments. Higher federal deficits would also put pressure on existing federal healthcare and social services programs, including Medicaid, and would further threaten the ability of the federal and state governments to provide health care services to the nation’s vulnerable populations.

In addition to the chaos and uncertainty the Trump administration is causing with respect to CSR payments, it is also making moves to undo some of the progress made under the ACA toward achieving quality outcomes and a higher degree of care coordination. A recent rule proposal published on the website of the Office of Management and Budget would eliminate the mandatory implementation of the bundled payment models for cardiac care coordination and cardiac rehabilitation, as well as implement changes to the comprehensive care joint replacement model. These advanced payment models promote care coordination and place an emphasis on patient outcomes and quality of care; elimination of these models would be a detriment to patients and nurses alike.

Stable payment systems and innovative payment models which emphasize care coordination and patient outcomes will better enable nurses to provide quality care and ensure that patients are able to receive the best quality of care in a timely fashion and with better outcomes. As such, the American Nurses Association strongly supports both the federal CSR payments and the implementation of the aforementioned advanced payment models.