A Budget to Nowhere

  

 

The good news is that the budget unveiled Monday by the Trump administration is dead on arrival. The two-year agreement reached by Congress last week makes this budget even less relevant than most presidential budgets, and more importantly the congressional spending deal funds a number of crucial health programs that were in danger of losing funds. The bad news is that the President’s budget seeks to normalize policy proposals that would either cripple or eliminate altogether a number of crucial federal programs that provide critical aid for nurses and their patients.

Nursing Workforce Development Programs covered under Title VIII of the Public Health Service Act would be particularly hard hit, with cuts of almost 65% at a time when nurses nationwide desperately need this funding to continue providing quality care. The budget slashes $145 billion overall, eliminating all but one program under Title VIII (the NURSE Corps Loan Repayment and Scholarship Program, which would be funded at $83 million). As a result of this drastic and misguided approach, the Nursing Community Coalition (of which ANA is a member) announced their strong opposition earlier today.

Even when the President’s budget takes one step forward by allocating new funds, it simultaneously takes two steps back, as with funding to combat the opioid crisis. While the budget proposal would allocate $13 billion, experts estimate that at least $32 billion is needed to address this lethal epidemic. This new funding would also come at the expense of the Centers for Disease Control and Prevention (CDC), which would lose $1 billion and suffer particularly deep cuts to programs aimed at reducing chronic disease, bolstering public health preparedness, and overseeing occupational safety and health.

Perhaps most alarmingly, the budget embraces the approach of the already-rejected Graham-Cassidy legislation to repeal and replace the Affordable Care Act. This approach would implement massive cuts to Medicaid and eliminate its state-based expansion (which 33 states to date have chosen to embrace). It would also end the subsidies that help a vast majority of Americans who obtained health coverage under the ACA-implemented marketplace pay for their premiums.

Rather than promoting a misguided and out-of-touch budget, ANA urges the administration to instead focus on more pressing priorities, including helping Congress reach an agreement on those affected by the Deferred Action for Childhood Arrivals (DACA) program, as well as efforts to stabilize the health insurance marketplace following the repeal of the individual mandate late last year. Too many of the ideas included in this budget have been rejected by bipartisan congressional majorities. Like those ideas, this budget should similarly be put aside.

Trump Administration Continues to Undermine Healthcare for Low-Income Americans

  

The Trump Administration has picked up in 2018 where it left off in 2017 by dealing two more blows to the American health care system. The Department of Labor (DOL) on January 5th published a proposed rule which would expand the ability of groups of employers to create Association Health Plans (AHPs), while today the Centers for Medicare & Medicaid Services (CMS) sent a letter to state Medicaid directors indicating support for states to implement work requirements for “able-bodied” adult Medicaid beneficiaries. These moves threaten to restrict access to critical and comprehensive healthcare services for low-income Americans, even as the healthcare coverage of 9 million American children hangs in the balance as Congress continues to drag its feet on a long-term re-authorization of the Children’s Health Insurance Program (visit ANA’s CHIP action page here).

Association Health Plans

As I wrote in a blog post in October, AHPs currently exist and are used primarily by small businesses to purchase group health coverage, but are regulated under the provisions of the Affordable Care Act (ACA) in the same way as coverage purchased on the individual health insurance market. DOL’s proposed rule seeks to make it easier for employers to create AHPs by:  1) allowing AHPs to exist for the sole purpose of offering healthcare coverage and 2) broadening the definition of “commonality of interest” to allow for larger AHPs. This would in effect treat AHPs as large group health insurance plans and allow coverage under AHPs to be sold across state lines under certain circumstances.

Expanding the use of 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.

While DOL notes that a non-discrimination provision within the proposed rule would prevent denying coverage on the basis of pre-existing conditions, AHPs could still select for younger, healthier individuals in other ways and could still charge higher premiums for older individuals, potentially leaving these individuals (who are statistically likely to be sicker) without a coverage option.

Furthermore, these insurance plans are ripe for instances of fraud, abuse, and insolvency. The Government Accountability Office (GAO) 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, while widely failing to meet state insurance laws and regulations. The GAO report found that some plans tried to duck state insurance regulations entirely. This type of 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 proposed rule, we also expect several lawsuits to challenge this based on the legality under current federal law and on the insurance across state lines aspect.

Work Requirements for Able-Bodied Adult Medicaid Beneficiaries

CMS sent a letter on January 11th to state Medicaid directors announcing its support for states to implement waivers introducing work requirements for non-elderly, non-pregnant adult beneficiaries who are eligible for Medicaid on a basis other than disability. CMS bases its support for work requirements on what it describes as the health benefits of community engagement, including work and work promotion.

This latest attempt by the Trump Administration to restrict Medicaid eligibility is, however, nothing more than a straw man argument. Medicaid expansion ipso facto provides healthcare coverage to working, low-income Americans. According to a December 2017 Kaiser Family Foundation issue brief, roughly 6 in 10 of the 22 million non-disabled adults receiving Medicaid benefits are employed either full- or part-time, while 8 in10 of these adults live in a working family. Most of these individuals work either for small firms or in low-paying industries which do not offer healthcare coverage and thus rely on Medicaid for such.

Further, among those adults who are not working, most report a major barrier to employment such as illness, disability, or care-giving duties. According to the same Kaiser issue brief, Medicaid expansion has not negatively impacted labor market participation; in fact, some research demonstrates that Medicaid coverage supports work.

As such, Medicaid work requirements would likely have little to no positive impact on employment and could even negatively impact both access to healthcare and employment prospects for these Medicaid beneficiaries. From an empirical standpoint, the basis for imposing work requirements on Medicaid beneficiaries seems to stem less from a desire to assist low-income Americans to access critical healthcare services while simultaneously supporting employment, but rather from a preconceived notion as to the characteristics of the individuals who benefit from Medicaid.

The American Nurses Association opposes any action – legislative or executive – which threatens the ability of Americans to access and receive high quality healthcare. This is particularly true when it comes to the most vulnerable Americans. If 2017 showed us anything, it is 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; this seems to be the modus operandi in 2018 as well.

We urge the Administration and Congress to work toward finalizing a long-term Children’s Health Insurance Program (CHIP) re-authorization, toward a market stabilization package including cost-sharing reduction payment funding, and toward strengthening the existing healthcare system – which has resulted in coverage for tens of millions more Americans since 2014 – and 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 regulations which align with our four core principles of health system transformation. These moves, however, represent a major step backward from achieving those principles.

Congress can’t keep kids covered as 2017 comes to a disappointing end

  

Congressional Republicans immediately followed their passage of a tax bill that will have a devastating impact on public health by voting for an irresponsible spending stopgap that needlessly jeopardizes the roughly nine million American children who rely on coverage from the Children’s Health Insurance Program (CHIP). While regrettable, this sequence of events was a fitting conclusion to 2017 on Capitol Hill, where majority lawmakers showed a persistent and troubling desire to limit Americans’ access to health care.

While the stopgap bill passed by the House and Senate will fund CHIP through the end of March 2018, it continues to create reckless uncertainty as state officials who manage the program are forced to run it on a month-to-month basis. Despite the widespread bipartisan support the program has historically enjoyed, congressional leaders proved unable to reach an agreement on the usual five-year long-term spending approval that CHIP has received in the past.

Republicans also chose to punt to 2018 on health marketplace stabilization efforts that are even more urgent in the wake of the tax bill’s passage. While the proposals from Sens. Lamar Alexander (R-TN) and Patty Murray (D-WA), as well as Susan Collins (R-ME) and Bill Nelson (D-FL) will not mitigate all the damage done by individual mandate repeal, they will help lessen the negative impact from President Trump’s unilateral and dangerous decision to end stabilization funding earlier this fall.

And though both measures would have an objectively positive impact on the health marketplace congressional Republicans seem intent on destroying, it remains unclear whether the measures – together or separately – could garner a majority of support in either chamber, particularly the House of Representatives where more conservative members enjoy increasing influence.

Despite these developments, almost nine million Americans reportedly signed up for coverage during this year’s Open Enrollment period that concluded on December 15, nearly matching last year’s total. This took place despite the administration’s efforts to limit enrollment, by cutting the sign-up period in half and slashing funding for promotional efforts to educate the public. The enrollment figures are a clear sign that Washington’s focus in 2018 must turn away from creating roadblocks to health care, and instead find new ways to help Americans get and stay covered.