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.

“No”

  
Photo: Susan Walsh, AP
Photo: Susan Walsh, AP

Following a dramatic late night vote that saw Senators reject Majority Leader Mitch McConnell’s (R-KY) so-called “skinny” bill repealing the Affordable Care Act (ACA), lawmakers from both sides of the aisle are publicly calling for a fresh approach to reforming health care that embraces bipartisanship and transparency, and actively seeks solutions from experts who know health care best, including America’s 3.6 million nurses.

Sens. Susan Collins (R-ME), John McCain (R-AZ), and Lisa Murkowski (R-AK) joined with all 48 Senate Democrats to vote against legislation that would’ve stripped the individual and employer mandates introduced by the ACA, among other harmful provisions, and which was intended to pave the way for a conference committee of representatives from both chambers, who would be responsible for crafting a bill that both could pass.

But House Speaker Paul Ryan (R-WI) seemed unwilling to guarantee that his chamber wouldn’t just skip the conference process and pass “skinny” repeal itself, prompting McCain and others to publicly withhold their support early yesterday evening. While subsequent assurances from Ryan and Vice President Mike Pence were enough to win back the support of some of those Senators, McCain ultimately came to the same conclusion as his colleagues from Alaska and Maine, and voted no.

The nursing community showed up like never before in this fight, driving thousands of calls and e-mails to Congress. Hundreds traveled all the way to Washington, DC last month to deliver our message face-to-face with our legislators: The only way our country can truly reform our healthcare system is by working together. No more closed doors. No more dead-of-night deals. No more decisions made without a single nurse consulted.

While this victory is heartening, we know there are those who will continue pushing lawmakers and the administration to undermine our health system and harm those who have gained coverage as a result of the ACA. If you haven’t yet, please join our RNAction community to learn more and get the latest updates on how you can help ensure that our representatives in Washington continue to protect our care and put patients first.