Tax Reform and Spending Measures Threaten Healthcare for Millions – Including Children

  

Congressional Republicans threaten to put coal in the stockings of millions of Americans this holiday season, as they are poised to pass a massive tax bill – the Tax Cuts and Jobs Act – that promises to significantly reduce the number of Americans with health insurance. Meanwhile, House members have decided to play politics with the health care coverage of 9 million children, as they have placed a provision to re-authorize the Children’s Health Insurance Program (CHIP) into a spending measure that could potentially lead to a government shutdown.

The Tax Cuts and Jobs Act

The push toward final passage of a tax reform bill took a major step forward this week, as House and Senate Republican members of the conference committee  settled on a compromise version of the Tax Cuts and Jobs Act. Among its many provisions, the bill eliminates the Affordable Care Act’s individual mandate, which requires Americans to purchase health insurance or pay a financial penalty. As we have written before, the Congressional Budget Office (CBO) estimates that repealing the individual mandate would result in 13 million fewer Americans having health insurance. Such a reduction in coverage would result in negative health outcomes, higher costs, and a decreased focus on primary care and preventive services.

The bill also lowers the threshold for an individual to claim a medical expense deduction. More Americans will also likely find it necessary to take this deduction – without health insurance coverage, they will be much more likely to experience crippling medical expenses.  The bill allows individuals to deduct medical costs greater than or equal to 7.5% of an individual’s income; this is lower than the 10% threshold under current law. This is deceptive, however, as the threshold to claim the medical expense deduction will return to 10% in tax year 2019 and is only available to tax filers who itemize their deductions.

The likelihood for passage of the Tax Cuts and Jobs Act that came out of conference committee is still fairly uncertain. The conference committee held its only public meeting yesterday. The next steps in the process will be votes on the floors of the House and Senate. The timeline for these votes is not crystal clear, but the expectation is that both chambers will vote on final passage next week. Once this occurs – and assuming that the bill passes both chambers – it will head to President Trump’s desk, at which point he will sign it into law.

Children’s Health Insurance Program

Congress recently passed a continuing resolution to fund the government at current levels through December 22nd. This funding deadline, however, is fast approaching, and Congress will need to pass yet another spending bill by that date in order to avoid a government shutdown. House Republicans have already proposed such a measure, which would extend government funding through January 19th, and provide a crucial five-year extension of CHIP. A point of contention, however, is that the spending measure would fully fund the Department of Defense for the full year with a $73 billion funding increase over current spending levels. This is a non-starter for Congressional Democrats, who have demanded a dollar-for-dollar increase in spending for domestic programs for any spending increase in defense programs.

The funding situation for CHIP is truly dire. Federal spending authorization for the program ran out on September 30th; Congress has failed to act for over two months. While states have been using reserve funding to fill the gap, that excess funding will soon run out. Sixteen states – Washington, Oregon, Idaho, Nevada, California, Texas, Arizona, Colorado, Utah, Minnesota, Virginia, Pennsylvania, Florida, Massachusetts, Delaware, and New Hampshire – anticipate running out of funding by the end of January 2018. It is absolutely critical that Congress pass a CHIP reauthorization immediately; playing politics with the healthcare of 9 million American children is unacceptable.

We urge you to make your voices heard in Washington and to make it known that nurses demand comprehensive and quality care for all of the nation’s citizens, regardless of age or income level. Click here to tell your  representatives loudly and clearly that the Tax Cuts and Jobs Act is bad for Americans’ health and well-being and that CHIP is a crucial program for our children’s health.

 

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)

Graham-Cassidy is the worst healthcare bill yet

  
Photo: ABC
Photo: ABC

As Congress works its way through a packed September agenda, yet another attempt to repeal and replace the Affordable Care Act (ACA) is gaining momentum. Unfortunately, this legislation – like similar bills that have come before it – has chosen to leave nurses out of the process, and as a result would leave too many patients without the care they need.

As we’ve previously addressed, legislation sponsored by Sens. Bill Cassidy (R-LA) and Lindsey Graham (R-SC) would make drastic and dangerous cuts to the American healthcare system by repealing Medicaid expansion starting in2020, eliminating the critical Prevention and Public Health Fund, and creating high-risk pools for individuals with pre-existing conditions (effectively removing ACA-implemented essential health benefit protections for those patients), among other misguided policies.

The block grants to states that Graham-Cassidy would use to replace the ACA would also continue to shrink before, in 2026, disappearing entirely, leading to even more cuts. In other words, the legislation goes further than what was proposed this summer – which at its worst was projected by the Congressional Budget Office (CBO) to cause up to 32 million Americans to lose their coverage.

Meanwhile, the process surrounding the bill continues to fall well short of Sen. John McCain’s (R-AZ) repeated calls for a return to regular order. While the Senate Finance committee has planned a single hearing around Graham-Cassidy, the CBO will not have time to fully score the legislation, meaning it will remain unclear how many patients would have their care stripped away as a result.

Criticism of the bill is widespread: on Tuesday, Democratic, Republican, and independent governors from Alaska, Colorado, Louisiana, Massachusetts, Montana, Nevada, Ohio, Pennsylvania, Vermont, and Virginia released a letter announcing their opposition, writing that, “Only open, bipartisan approaches can achieve true, lasting reforms.”  And as with the so-called Affordable Health Care Act and Better Care Reconciliation Act, no Democratic senators have announced their support for Graham-Cassidy, with conservative Sen. Rand Paul (R-KY) also expressing skepticism that he’ll be a yes vote if and when it comes to the floor.

Regardless of the current whip count, which is constantly evolving, the stakes are too high to count on another dramatic late night vote that saves the day. Don’t wait: click here to be connected with your Senators and urge them to vote no on Graham-Cassidy. In the absence of real dialogue, nurses’ voices are needed now more than ever.